HEALTH DAY
More and more, doctors get asked which dental orthotics can solve snoring and sleep apnea problems.
- Where do these orthotics come from? How do they work?
- What are the indications?Are they efficient?
- Will RAMQ reimburse the costs in case of apnea?Snoring
- Case 1: The snoring patient
- Case 2: The patient that failed with a nCPAP
- Where to refer these patients?
A BRIEF HISTORY
Charles Samelson, a Chicago psychiatrist, invented the first dental device against snoring and apnea in the late 1970s. Dr. Samelson was trying to fix his own snoring problem. His wife, a pianist, complained that the noise generated by snoring interfered with her “musical ear” and gave her fatigue during the day. Dr. Samelson produced beeswax molds of his tongue, which kept the airway open during sleep by pulling on the tongue by suction. Soon, beeswax was replaced by latex, and research was undertaken at Rush University Medical School. In 1982, the results were presented to the same scientific meeting where Dr. Colin Sullivan introduced the CPAP or nCPAP (Nasal Continuous Positive Airway Pressure), in his article published in the New England Journal of Medicine in 1981. The continuous positive airway pressure technique is the application of air pressure through a sealed mask on the nose by means of a compressor.
DEVICE EFFECTIVENESS
The success rate with wearing dental orthotics varies according to several criteria. If it’s a snoring patient, some studies have shown success rates up to 95%. Thus, in 95% of cases, snoring is eliminated completely or is reduced to an acceptable level. In the case of patients with obstructive sleep apnea, the success rate is lower. It would be between 50% and 80% depending on the study. This variance is due to criteria considered a success factor, or other selected or excluded criteria that differ from one study to another. For example, European studies include thinner individuals compared to American studies that accept higher-weight candidates. And we know that the weight, not body mass index, influences directly the response to treatment with dental orthotics. Thus, the implication is that the thinner a candidate, the lower his apnea-hypopnea index, the smaller his neck circumference, and the more his lower jaw is retruded, the better his chances are of being successfully treated with dental orthotics. The patient’s sex is also an important prognostic factor, as women respond better than men to treatment with an oral splint. Also, a patient breathing well through the nose has better chances to tolerate orthotics. It is important to note that very good responses to treatment were obtained for some patients whose prognosis was medium or low. Furthermore, a study by Dr. Allan Lowe of the University of British Columbia compared the effectiveness of a nCPAP treatment with that of an oral splint. Taking into account adherence to treatment that is far greater with dental orthotics compared to nCPAP, Dr. Lowe has determined that effectiveness was comparable.
HOW IT WORKS
Depuis 1982, une multitude d’appareils ont été introduits pour le traitement de l’apnée. En fait, plus de 80 modèles différents sont présentement sur le marché. Si chaque modèle est différent, le principe de base est le même : exercer une traction sur les tissus autour des voies respiratoires pour les dégager et permettre ainsi un meilleur passage de l’air. Si l’appareil du Dr Samelson tirait sur la langue, la plupart des nouveaux modèles s’accrochent sur la mandibule et la tirent vers l’avant en s’appuyant sur le maxillaire supérieur.DEVICE COST
Although one can fairly assess prognosis of treatment with a dental orthotic from factors described above, it is impossible to determine with certainty whether its use will be successful. This is the main problem with this device, since the patient has to pay between $ 1,000 and $ 2,600 without knowing whether the treatment will give desired results. So far, only the French State covers this type of device, but it seems that Medicare in the United States is about to defray the cost of treatment. Many private insurance companies cover expenses for the device. The medical portion of a patient’s insurance provides coverage while dental insurance does not usually cover this type of care. The insurer will often cover the nCPAP or oral splint depending on the patient’s choice. In general, it is estimated that the treatment is successful if there is a normalization of obstructive events per hour for the apneic patient. However, we now realize that even in the absence of an appropriate reduction in the number of episodes of apnea and hypopnea per hour of sleep, there is a daytime sleepiness reduction and an improvement in the patients’ quality of life, factors that until recently, had less weight in evaluating the success of an apnea treatment.SNORING
Snoring occurs when the vibration of respiratory tissues produces sound when a person is sleeping. Although snoring is firstly a social problem, studies tend to show that it is much more than an annoyance. In terms of sound, research indicates that a snorer can produce sounds up to 69 decibels. We know that a jackhammer produces sounds ranging from 70 to 90 decibels, so it’s not surprising that spouses of snorers sleep an average of one hour less per night than spouses of non-snorers. Interestingly, Sleep Journal published a study in 2008 that tells us that for serious snorers, the risk to suffer from hypertension increases by 40%, by 34% to have a heart attack, and by 67% to have a stroke, compared to people who do not snore. These results suggest clinicians should take snoring a lot more seriously. A patient shows up for consultation complaining of a snoring problem. Although he mentions not to suffer from this condition, his wife asked him to sleep in a separate room and fishing buddies say they are quite annoyed by the snoring noise. He wants to get a dental orthotic for snoring and asks for your opinion. He does not suffer from high blood pressure and fatigue, factors that might suggest a sleep apnea problem.
Can he go to the dentist?
Although the patient seems in perfect health, the procedure is to send him to a sleep specialist for evaluation. Very often, this brief evaluation will give a negative diagnosis, but it is not uncommon that the patient suffers from sleep apnea, in which case the treatment may be different. An ENT evaluation would also be desirable, especially if the patient has significant anomalies in the throat tissues or a nasal obstruction. In some cases, intervention may be practiced. Moreover, recommendations of the Canadian Thoracic Society are clear to the effect that it is in the patient’s interest to be evaluated by a physician before obtaining an intra-oral dental device. Thus, a dentist who sees a patient in consultation for snoring should first be referred to a physician for evaluation before producing such a device. In cases where the patient is just a snorer, he could be sent to the dentist for an orthotic against snoring. The latter will explain what the treatment is, and the probable number of visits. If the patient is interested, models of his teeth are made and an orthotic is produced. During the next appointment, the orthotic is set in the mouth and the patient is given a timetable for the gradual advancement of the splint (and the mandible). The more the mandible is pushed forward by the device, the better the chances of resolving the snoring problem. However, a very gradual progress is recommended since a movement done too quickly could cause pain in the jaw. A patient walks into your office and tells you that he has been diagnosed with obstructive sleep apnea. He’s been using a compressor for some time now and is dissatisfied. Also, he’s tired because he doesn’t use it much. He thinks that the side effects associated with wearing a mask prevents his sleep to the point where he’s even more tired with the compressor than without. He has heard of dental orthotics and asks your advice.
SHOULD WE SEND HIM DIRECTLY TO THE DENTIST?
We must first ask the patient if he has contacted the doctor who prescribed the compressor, or the private company that sold him the compressor. Sometimes a simple adjustment or a revision of the compressor operation instructions will allow the patient to fully benefit from using the device. However, if the patient contacted the physician or met with the representative of the nCPAP company and they cannot help, it is quite appropriate to go to a dentist who makes mandibular advancement splints. All dentists can offer this service, but given the relatively small number of orthotics made, only a few dentists have a sufficient volume of patients referred by physicians to be interested in acquiring expertise in the field. Initially, the treatment of an apneic patient is much like that of the snorer. Made similarly for the latter, the device is designed to advance the mandible to clear the airway. It can often be the same device used by the dentist. Monitoring an apneic patient is often longer and more complex than monitoring a snorer. It is not uncommon for the apneic patient to stop snoring at the first control appointment, but that he still suffers from apnea. The orthotic is then gradually advanced until the patient feels much better or that he has reached maximum tolerable advancement. A monitoring oximetry can then be made to determine if the patient has decreased the number of apnea episodes to an acceptable level. In the case where the oximetry test is not acceptable, one should continue the advancement of the orthotic as far as possible. If the test appears successful, it is time to return the patient to a sleep specialist for a reassessment. Experience gained by the author during research at the Quebec University Institute of Cardiology and Pneumology determined that if oximetry is a valuable technique for the evaluation of the patient’s condition, a physician competent in the field must analyze it, because the results can be quite different from what would be obtained using a more accurate assessment technique. Once adjustments are completed, the dentist should see the patient for annual follow-ups. Most dental devices have a three to five year lifespan: this period can vary between individuals.
CONCLUSION
Despite constant effort by the medical community to find, diagnose and treat sleep apnea, epidemiological studies estimate that the vast majority of sleep apneics are not yet diagnosed. It can therefore be expected that physicians encounter even more apneic patients in their practice. With the new Canadian Thoracic Society guidelines, doctors will have to meet a growing number of apneic patients who will use dental orthotics in the treatment of sleep apnea and snoring. They will also see patients using a compressor wanting to switch to dental orthotics. It is therefore imperative that physicians have some knowledge of dental orthotics and their indications to direct patients adequately. Article from Medical News, Vol. 9 No. 22, November 4, 2009.
BIBLIOGRAPHY
- Fleetham J, et al. Canadian Thoracic Society Guidelines: Diagnosis and treatment of sleep-disordered breathing in adults. Can Respir J 2007, 14, 31-36.
- Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 2006; 244-262.
- Moses A., What’s New in Oral Appliances for Snoring and Sleep Apnea. Sleep Diagnosis and Therapy 2007; V2 N6, 19-24.
- Kushida CA, Morgenthaler TI et al. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliance: An Update for 2005. Sleep 2006; 240-243.
- Hoffstein V., Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath 2007; 11:1-22.
- Hoekema A, Stegenga B, De Bont LG., Efficacy and comorbidity of oral appliances in the treatment of obstructive sleep apnea-hypopnea: a systematic review. Crit Rev Oral Biol Med 2004; 15: 137-155.
- Moses AJ, Alvarez MA., A New Look at an Old Device. Sleep Review 2003; 6.
- Dunai A et al. Cardiovascular disease and health-care utilization in snorers: a population survey. Sleep 2008; 31:411-416.
- De Almeida FR et al. Effects of mandibular posture on obstructive sleep apnea severity and the temporomandibular joint in patients fitted with an oral appliance. Sleep 2002; 25:507-513.
- Naismith SL et al. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med 2005; 1:374-380.
