The steps in getting an oral appliance start with the recognition that something is wrong.  This recognition varies from person to person, but may include, among others, a feeling of daytime fatigue or sleepiness along with the presence of loud, bothersome snoring.   Very often a bed partner is necessary to bring the problem to light. Often, discussing these symptoms with your physician will result in your being referred to a sleep lab for an evaluation.

 

The vast majority of our referrals come from physicians, sleep lab technicians or facilities where CPAP masks are fitted.  Some patients contact our office directly, wanting relief of their snoring but who have not been to a sleep lab to rule out sleep apnea.  For these patients, we always preform a home sleep test  to rule out the presence of sleep apnea before providing treatment for snoring relief.

 

If if is evident from the home sleep study that sleep apnea is present, we immediately refer that patient to a sleep lab for a medical diagnosis.  We cannot treat a sleep apnea patient without a medical diagnosis nor can the patient receive medical insurance reimbursement for oral appliance therapy without a medical diagnosis.

 

Once a diagnosis is made and pre-verification is obtained from the insurance company, we schedule a consultation.  We strongly recommend that the bed partner be present at the consultation since they often have insights that no one else has.  We carefully review the medical history and the sleep study results to make sure that the patient fully understands the disorder as well as specifically how the disorder is impacting their health.  At this consultation, all of the available treatment options are explored.  

 

Once the decision is made to pursue treatment, an appointment is scheduled.  If a screening home sleep study has not been obtained, one is now done to provide a base-line by which progress is measured.  At the “work-up” appointment, a panoramic x-ray, as shown below, is taken to help rule out the presence of any dental condition that would prevent treatment.  This x-ray is taken digitally and requires an extremely low dose of radiation.  An examination of the teeth, gums and jaw joint is done, again, to rule out any condition that would interfere with treatment.  It is important to note, that this examination is not to substitute for a routine dental examination.   Since most of our patients are referred by the medical community and already have their own dentist, our focus is to manage the sleep disorder that is interfering with the patient’s life.  

 

 

 

At this same appointment, impressions or molds of the teeth are obtained for use by the laboratory that fabricates the oral appliance as well as certain jaw movement records necessary to properly fit the appliance.  Models of the teeth that are derived from the impressions are shown here.

 

Three weeks after the “work-up” appointment the oral appliance has been custom made by the dental laboratory and a time is scheduled to be fitted with the appliance. The appliance is carefully adjusted to fit snugly on the teeth and, yet, be extremely comfortable. The most common comment that we get is “This isn’t as bad as I thought!” The appliances are surprisingly comfortable and patients have very little difficulty adjusting to them.

 

The patient shown in this photo has just tried in her oral appliance for the first time.  Notice that with the lips closed, there is very little evidence that the appliance is in her mouth.  

 

Oral appliances function by moving the lower jaw forward during sleep.  Moving the lower jaw forward also brings the tongue base forward and assists in opening the airway during sleep.  A great deal of our success in creating a comfortable process for patients is choosing a “starting position” of lower jaw advancement that our patients can very comfortably tolerate.  For some of our patients, this starting position is all that is necessary to provide complete relief of symptoms while others require further adjustment of the appliance.

 

 

 

Shown here is the oral appliance that is in the mouth of the above patient.  With this appliance in place, it is easy to take a sip of water or to engage in some conversation with a bed partner.   Obviously, if this is long conversation, the appliance is better out of the mouth!

 

 

 

Shown below is a demonstration model of the SomnoDent appliance that is commonly used in our office.  The area circled in red is the part that is adjusted to modify the jaw position.

 

 

At right is a close up of the adjustment screw.  If a bed partner reports that snoring is still present or if daytime sleepiness or fatigue are not relieved, the patient is shown how to make nightly adjustments by turning this screw.  When the screw is turned on the appliance, the lower jaw is very slightly moved forward.  This process of nightly turning the adjustment screw is continued until symptoms are improved.  Occasionally the patient reports jaw soreness.  If this happens, the screw is turned back until soreness disappears.  Once the soreness disappears, further advancement is usually possible.

 

Usually after a month or two, symptoms have disappeared or a maximum, comfortable jaw position is reached.  At this point, we initiate another home sleep study to verify effectiveness of the appliance.  It is extremely important to note that the elimination of daytime symptoms or a report by a bed partner that snoring is stopped is not an assurance that sleep-breathing problem is under control!  It is quite possible that a patient can perceive that his disorder is completely controlled because of a return of energy and the elimination of daytime sleepiness and, yet, have considerable sleep apnea present.  It is vital that follow-up testing be done to verify effectiveness of treatment.

 

The medical literature tells us that statistically, those with mild sleep apnea have an 81% chance of complete treatment with an oral appliance.  However those with moderate sleep apnea have their chance of complete success drop to 56%.  In the severe category, 25% of patients will have complete treatment using only mandibular repositioning with an oral appliance.  While an oral appliance is not a complete guarantee of success, the results compare extremely well for patients who are not able to wear CPAP all night every night.  For a better understanding of this statement, go here.

 

At The Center for Sound Sleep, our operating mission is to help provide the highest level of sleep health for our patients based on the therapy that they are willing to use. Virtually all of our patients start with us because they have actively chosen oral appliance therapy over surgery or CPAP.  If oral appliance therapy is not completely successful, we have treatment options remaining that can continue to enhance our patient’s sleep health.  

 

While surgery as a stand alone therapy is rarely completely successful, oral appliance combined with surgery can be extremely effective for those patients who do not have complete relief with oral appliance therapy alone. While a large number of patients cannot tolerate CPAP by itself, combining oral appliance therapy with CPAP can reduce CPAP air pressure to the point that CPAP is now tolerable.  Oral appliance therapy can also be used in a way to eliminate the CPAP mask having to be strapped to the patient’s head by connecting a CPAP nasal interface to the oral appliance as shown at right and below.