Presentation by Dr Robbie Schaack DDS at the University of Washington Medical Center, December 2014.

1. The Dentist’s Role in Treatment
of Sleep Disordered Breathing
Robbie Schaack DDS

2. Pathophysiology
Diagnosis
Treatment Options
Major Types of Oral Appliances
The Dentist's Treatment Protocol

3. Obstructive Sleep Apnea
complete collapse/blockage of upper respiratory tract
Central Sleep Apnea
brain temporarily stops sending signals to the muscles that
control breathing
Mixed/Complex Sleep Apnea
become central apneas when treated with CPAP or oral
appliance

4. What is Sleep Apnea?(click)

5. (1) Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal
size and shape changes in three dimensions. Angle Orthod. Jan 2005;75(1):15-22.

6. Hypertension
CHF
Acute MI
Coronary Artery Disease
Stroke
Sudden death
Diabetes
Obesity
Bruxism (14)
Memory & Cognitive Problems
Motor vehicle accidents
and many more!
(3,4,5,6)

8. cause of sound -
symptom, not a problem in
and of itself
should be taken seriously,
sign of a very serious
underlying problem
Partners lose 1.5 hrs of
sleep/night

9. 1 in 5 adults have mild OSA
1 in 15 adults have moderate to severe OSA
Prevalence (43 million) equal to that of asthma (20
million) and diabetes (23 million) combined
80% of those with OSA remain undiagnosed!

11. — Male gender
— Obesity (BMI >30)
— Diagnosis of hypertension
— Excessive use of alcohol or sedatives
— Upper airway or facial abnormalities
— Smoking
— Family history of OSA
— Large neck circumference (>17” men; >16” women)
— Endocrine and metabolic disorders
(8)

12. deviated septum
enlarged nasal turbinates
thickened soft palate
large uvula
large tonsils
retrognathic mandible
disproportionate size of
structures in relation to
pharyngeal opening

13. Screening
• Patient health questionnaire
• Epworth Sleepiness Scale
Diagnosis
• Polysomnogram
• Portable monitoring/home studies (in conjunction)

14. Overnight sleep study
conducted at certified sleep
center or hospital
Monitors many body functions
including brain (EEG), eye
movements (EOG), muscle
activity or skeletal muscle
activation (EMG) and heart
rhythm (ECG), respiratory
airflow, pulse oximetry

15. Total number of apneas & hypopneas per hour of sleep
AHI = 0–5 Normal range
AHI = 5–15 Mild sleep apnea
AHI = 15–30 Moderate sleep apnea
AHI > 30 Severe sleep apnea
Apnea: complete cessation of breathing
Hypopnea: partial obstruction of breathing
*for at least 10 seconds (20-40 seconds on average)

16. Behavioral therapies
• mild to severe OSA, in conjunction with other therapies
Oral appliances
• first line of therapy in mild to moderate OSA and second line of treatment in patients with
severe OSA who do not tolerate CPAP
Continous positive airway pressure (CPAP)
• first line of therapy in mild, moderate, and severe OSA
Upper airway surgery (nasal surgery, uvulopalatopharyngoplasty)
• noncompliant, or after failure of nonsurgical therapies

17. weight loss
avoiding alcohol and tobacco
sleeping on your side
oropharyngeal exercises (10)

18. (11) Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo playing as
alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. BMJ
2005;332:266–270.

19. “gold standard”
effective vs mild, moderate, and severe OSA
Compliance ~50%
Side Effects:
• nose irritation
• nasal congestion
• headaches
• stomach bloating and discomfort
• sore or dry mouth
• runny nose
• sinusitis
• nosebleeds
• irritation and sores over the bridge of the nose
• discomfort in chest muscles.

20. (12) Okuno K, et al. The effect of oral appliances that advanced the mandible forward and limited mouth opening in patients with obstructive

21. Thornton Adjustable Positioner (TAP)
Adjustable PM Positioner
SomnoDent
ResMed Narval
Silent Night
Tongue Retaining Device
and many more!

22. heat sensitive acrylic
two piece adjustable appliance that hooks
together
only appliance that can be adjusted easily by
the patient or practitioner while in the mouth
allows the patient to fine-tune their treatment
position at home to achieve desired results
suitable for heavy bruxers
may take longer to adapt with assembly
protruding between the lips at the front of the
tongue.

23. heat sensitive acrylic
Expansion screws are
located on the right and left
buccal areas to allow space
for the tongue and anterior-
posterior positioning of the
mandible.
permits some (4mm) lateral
and protrusive movement

24. patented fin-coupling component,
which allows normal mouth opening
and closing.
a part can be added to make the
device adjustable.
Permits normal mouth opening
Allows speech and drinking
Provides full lip-seal
covered by a two year
manufacturer''s warranty.

25. varying sizes of straps/connectors
Patented physiological articulation: most MRDs hold the lower
jaw in a forward position. With Narval CC, the force of retention
works along the occlusal plane to retain the mandible in a
protruded position rather than pushing it, thus relieving stress
on the TMJ. The elevated articulation point allows the
connectors to be parallel with the patient's jawline, which
complements the physiological articulation
minimize the problems of patient discomfort by decreasing bulk,
eliminating invasion of tongue space and enabling freedom of
mandibular movement
Lateral flexibility eliminates “locked-in” sensation and offers
freedom to talk discernibly or drink a glass of water while
wearing it
CADCAM Technology offers more customization, accuracy,
and a greater mechanical strength
ResMed guarantees that if your Narval™ CC breaks under
normal use within 3 years, we will repair or replace it free of
charge. (digital images of models are stored)

26. initial treatment of snoring
mild OSA when other
treatments are ineffective or
not desired.
soft or hard frame material is
available

27. flexible polyvinyl material adapted to the
general contours of the teeth and dental
arches
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
Since the mandible is not rigidly or firmly
held by the appliance, freedom of
movement is possible during use.
Option for patients with edentulism, perio
disease, or TMJ dysfunction

28. Studies reveal prefab devices to be: (13)
less comfortable
less effective vs snoring and reducing AHI
Failure rate 69%
success rate with the custom-made oral
appliance 100% higher than with pre-
fabricated devices
Side effects such as TMJ disorder,
worsened sleep apnea, bruxism and shifting
of the tooth position may outweigh the
benefits
(13Vanderveken, O. M., A. Devolder, et al. (2008). "Comparison of a
custom-made and a thermoplastic oral appliance for the treatment
of mild sleep apnea." Am J Respir Crit Care Med 178(2): 197-202.

29. 1st Line Treatment
Mild to moderate OSA (AHI 5–30) for patients who:
- Prefer MRDs over CPAP
- Are inappropriate candidates for or fail CPAP
- Fail behavioral measures treatment
Primary snoring for patients who do not respond or are not appropriate candidates for behavioral
measures treatment
2nd Line Treatment
Severe OSAS (AHI>30) in case of lack of compliance with CPAP
*Patients who travel

30. Short teeth
Insufficient undercuts to retain the device
Insufficient teeth per arch and quadrant (eg, ~4 minimum per quadrant)
TMJ pain - assess
TMJ osteoarthritis
Periodontal disease
pending extractions or prosthodontic treatments
intraoral ulcers
NOTE: Mandibular repositioners have been successfully used in edentulous patients over dentures in certain cases where the
dentures have had adequate retention. Mandibular repositioners have also been successfully used in patients with
compromised periodontal status or TMJ function. In these cases, however, the clinician needs to be especially careful in design
and follow up.

31. Possible Side Effects
More common/Minor:
• dry mouth
• excessive salivation
• Tooth or jaw discomfort
• temporary change in the bite (when removed in the morning)
Less Common: (primarily with non custom made/OTC oral appliances)
• TMJ pain
• permanent bite changes (teeth move)
Although it may take up to a week to get used to wearing these at night, most patients experience relief the first night.

32. 1. Medical assessment must be made by a physician before oral
appliance therapy (OAT) is initiated. (1-4)
A. the dentist refers the patient to the physician for a complete
medical evaluation and diagnosis to determine the absence or
presence, and severity, of sleep-disordered breathing (SDB)
Following diagnosis, the dentist may provide OAT as appropriate
with a prescription provided by a physician that has had a face-to-
face evaluation. The treatment of primary snoring does not require a
physician’s prescription; or
B. The physician refers the patient directly to the dentist for OAT
as appropriate.

33. 2. The diagnostic sleep study is interpreted by
a medical sleep specialist, who provides a copy
of the interpretation to the dentist for review.
The reviewed copy of the interpretation shall be
maintained in the patient record.

34. 3. The dentist performs a complete clinical
examination
• determine current health and prognosis of oral tissues that
might be affected by OAT.
• recent radiographic survey
• dentist recommends the choice of appliance (1, 2, 5, 6, 7, 8)
• disclose and discuss relevant fees with the patient
• explains the rationale for OAT to the patient
• record all appropriate documentation

36. 4. The dentist communicates the proposed
plan for OAT to the patient’s physician, and
appropriate health care providers, and the
dentist regularly provides the patient’s physician
and other health care providers with progress
and follow-up notes, as well as other pertinent
information.(1,2)
5. The dentist shall provide the patient with a
copy of the consent form prior to appliance
delivery.(9)

37. 6. Delivery: dentist meets with the patient for an
initial calibration and adjustment.
After this initial calibration, the dentist may obtain
objective data (portable sleep monitoring at
home) during an initial trial period to verify that the
oral appliance effectively improves upper airway
patency during sleep by enlarging the upper airway
and/or decreasing upper airway collapsibility.
If necessary, the dentist makes further adjustments
to the device during a final calibration to ensure that
optimal fit and positioning have been attained.(10-13)

38. 7. Following the final calibration, the dentist refers
the patient back to the physician for a medical
evaluation and assessment of OAT outcomes.
To ensure satisfactory therapeutic benefit, an
order may be written for the patient to undergo an
overnight sleep test with the oral appliance in
place.
If the treatment is sub-therapeutic, the physician and
dentist collaborate to discuss: the possibility of
further calibration, validated alternative treatments,
or combining positive airway pressure (PAP) therapy
with OAT. (11-13)

39. 8. Patients diagnosed with primary snoring may
be treated without objective, follow-up data;
however, the patients should be reevaluated at
least annually.

40. 9. Follow-up every 6 months for the first year and at least annually
thereafter.
• verify appliance efficacy; ensure resolution of symptoms such as
snoring and daytime sleepiness
• occlusion stability
• check the structural integrity of the device
• inquire about patient comfort and adherence to therapy
• screen for possible side effects
• If the patient’s annual assessment reveals symptoms of worsening
OSA or the potential need for additional adjustments to the device,
then the dentist shall communicate this information to the patient’s
physician.(1, 2, 5, 14-16)

41. 10. Knowledge of various appliances is
strongly recommended, as no single appliance
is effective for treatment of all patients.
Dentists who treat SDB are encouraged and
have a responsibility to routinely pursue
additional education in the field and to comply
with all applicable state and federal regulations.
(6, 7, 8, 17, 18)

42. Dentist —> Sleep Physician —> Sleep Study —> Rx
—> Dentist —> Oral Appliance —> Follow-up
Not complicating!

43. Billed as medical code to medical insurance instead of dental.
Custom dental appliances for sleep apnea are covered by most medical
insurance companies and Medicare.
Total fees collected from patient/insurance per case: $2000-3000
• initial evaluation and consultation
• impressions
• laboratory fabrication
• delivery
• follow-up

44. Literature References:
(1) Kyung SH, Park YC, Pae EK. Obstructive sleep apnea patients with the oral appliance experience pharyngeal size and shape changes in three
dimensions. Angle Orthod.
Jan 2005;75(1):15-22.
(2) 2. Young et al. J Am Med Assoc 2004
(3) Kuniyoshi et al. (July 2008). "Day–Night Variation of Acute Myocardial Infarction in Obstructive Sleep Apnea". Journal of the American College of
Cardiology 52 (5): 343–346. doi:10.1016/j.jacc.2008.04.027.
(4) Claudio L. Bassetti, Milena Milanova, Matthias Gugger (6 March 2006). "Sleep-Disordered Breathing and Acute Ischemic Stroke: Diagnosis, Risk
Factors, Treatment, Evolution, and Long-Term Clinical Outcome". Stroke 37: 967–972. doi:10.1161/01.STR.0000208215.49243.c3.
(5) Horstmann et al. Sleepiness-related accidents in sleep apnea patients. Sleep 2000
(6) Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An
Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 4, Functional and Economic Impact of Sleep Loss and Sleep-
Related Disorders. Available from: http://www.ncbi.nlm.nih.gov/books/NBK19958/
(7) Young et al. The occurrence of sleep-disordered breathing among middle-aged adults. New Engl J Med 1993 Apr 29;328(17):1230-5.
(8) http://www.polarmed.no/us/assets/documents/product/narval_cc/1015550_dental-practitioner-guide_us_eng.pdf
(9) "Obstructive Sleep Apnea Syndrome (780.53-0)". The International Classification of Sleep Disorders. Westchester, Illinois: American Academy of Sleep
Medicine. 2001. pp. 52–8. Retrieved 2010-09-11.
(10) Kátia C. Guimarães, Luciano F. Drager, Pedro R. Genta, Bianca F. Marcondes, and Geraldo Lorenzi-Filho "Effects of Oropharyngeal Exercises on
Patients with Moderate Obstructive Sleep Apnea Syndrome", American Journal of Respiratory and Critical Care Medicine, Vol. 179, No. 10 (2009), pp. 962-
966.
(11) Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome:
randomised controlled trial. BMJ 2005;332:266–270.
(12) Okuno K, et al. The effect of oral appliances that advanced the mandible forward and limited mouth opening in patients with obstructive sleep apnea: a
systematic review and meta-analysis of randomised controlled trials.. J Oral Rehabil. 2014 Jul;41(7):542-54. doi: 10.1111/joor.12162. Epub 2014 Mar 21.
(13) Vanderveken, O. M., A. Devolder, et al. (2008). "Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep
apnea." Am J Respir Crit Care Med 178(2): 197-202.
(14) Bader G, Lavigne G. Sleep Bruxism; An overview of an oromandibular sleep movement disorder. Sleep Med Rev 2000;4:27-‐43 • Camparis CM, et al;
Sleep Bruxism and TMD: Clinical and polysomnographic evaluaEon. Arch Oral Biol 2006;51:721-‐728

45. AADSM Treatment Protocol Reference List:
1. Kushida CA, Morgenthaler TI, Littner MR, et al. American Academy of Sleep Medicine Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances:
An Update for 2005. Sleep. 2006; 29(2):240-3.
2. Epstein LJ, Kristo D, Strollo PJ Jr., et al. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical Guidelines for the Evaluation, Management and
Long-term Care of Obstructive Sleep Apnea in Adults. J Clin Sleep Med. 2009; 5(3):263-76.
3. Comparative Effectiveness of Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Tufts Evidence-based Practice Ctr., July 2011. AHRQ publication No. 11-EHCO52 80-99 and 2-
5.
4. Chan ASL, Lee RWW, Cistulli P. Dental Appliance Treatment for Obstructive Sleep Apnea. Chest. 2007; 132:693-699.
5. Marklund M, Stenhuld H, Franklin KA. Mandibular Advancement Device is in 630 Men and Women with Obstructive Sleep Apnea and Snoring. Tolerability and Predictors of Treatment
Success. Chest. 2004; 125:1270-1278.
6. Lawton HM, Battagel JM, Kotecha B. A Comparison of the Twin Block and Herbst Mandibular Advancement Splints in the Treatment of Patients with Obstructive Sleep Apnea: A Prospective
Study. Eur J Orthod. 2005; 27:82-97.
7. Gagnadoux F, Fleury B , Vielle B et al. Titrated Mandibular Advancement Versus Positive Airway Pressure for Sleep Apnoea. Eur Respir J. 2009; 34:914-920.
8. Lam B, Sam K, Mok W et al. Randomized Study of Three Non-surgical Treatments in Mild to Moderate Obstructive Sleep Apnea. Thorax. 2007; 62:354-359.
9. AMA Physician Resources: http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-hysicianrelationship-topics/informed-consent.page.
10. Collop NA, Anderson WM, Boehlecke B et al. Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical Guidelines for the Use of Unattended Portable Monitors
in the Diagnosis of Obstructive Sleep Apnea in Adult Patients. Portable Monitoring Task Force of the AASM. J Clin Sleep Med. 2007; 3(7):737-747.
11. Campbell AJ, Reynolds G, Tengrove H, et al. Mandibular Advancement Splint Titration in Obstructive Sleep Apnea. Sleep Breath. 2009: 13:157-162.
12. Almeida FR, Parker JA, Hodges JS et al. Effect of a Titration Polysomnogram on Treatment Success with a Mandibular Repositioning Appliance. J Clin Sleep Med. 2009; 5(3):198-204.
13. Holley AB, Letteri CJ, Shah A. Efficacy of an Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome.
Chest (online). 2011; 140(6):1511-6.
14. Almeida FR, Lowe A, Sung J et al. Long-term Sequellae I of Oral Appliance Therapy in Obstructive Sleep Apnea Patients: Part 1. Cephalometric Analysis. AJODA. 2006; 195-204.
15. Almeida FR, Lowe A,Otsuka R et al. Long-term Sequellae I of Oral Appliance Therapy in Obstructive Sleep Apnea Patients: Part 2. Study-model Analysis. AJODO. 2006; 205-213.
16. Ghazal A, Sorichter S, Jonas I et al. A Randomized Prospective Long-term Study of Two Oral Appliances for Sleep Apnoea Treatment. J Sleep Res. 2009; 18:321-328.
17. Petri N, Svanholt P, Solow B et al. Mandibular Advancement Appliance for Obstructive Sleep Apnea: Results of a Randomized Placebo-controlled Trial Using Parallel Group Design. J Sleep
Res. 2008; 17:211-229.
18. Vandervecken OM, Devolder A, Marklund M et al. Comparison of a Custom-made and a Thermoplastic Oral Appliance for the Treatment of Mild Obstructive Sleep Apnea. Am J Respir Crit
Care Med. 2008; 178:187-202.

46. Robbie
Schaack
Doctor of Dental Surgery
www.linkedin.com/in/robbieschaack