by David B Schwartz, DDS, D.ABDSM
When it comes to ice cream flavors I like chocolate, my wife likes vanilla, my kids like mint chip, you get the point. We have many choices in everything that we do in life as well as dental sleep medicine and until we have conclusive evidence that one oral appliance works better in our hands than another, we will be left selecting the appliances for our patients based on a variety of factors. One size does not fit all in this appliance-eat-appliance world.
We might select a device based on the preferred choice that our friends use, one that was advertised in the latest periodical, or one which was featured in a weekend course on dental sleep medicine. Our choice quite possibly could be based on whether the patient will be reimbursed an adequate amount from their insurance in order to appropriately reimburse us. Those of us who deal with Medicare know all too well that the appropriate appliance may not be the ideal appliance for our Medicare Demographic or conversely that the Medicare approved appliances are not best for our patients. Should profit be a consideration? Should we make all our patients the least expensive appliance to maximize our gains? How do we make decision based on individual patients and their needs?
Each feature unique to a device is not only a selling point but also the industry’s attempt to offer enhancements that make it more appropriate for your patient and more attractive to us. Along with these enhancements comes our individual preference for design and specific comfort features. The laboratory may include add-on values such as digital storage of the models, free shipping, including a morning repositioner with the case, and lowering the cost to influence the economics of what we do. I hope to share with the reader the process I use in selecting an oral appliance to treat my patients.
Imagine your big screen television goes on the fritz. You wind up at ABC electronics store and look at the huge wall that is completely covered in HD, LED, LCD, 3D, UHD and curved televisions. Where do you begin? At the left side where the prices are lower and quality, size, and features are limited or the right side where enhancements are plentiful and screen sizes seem equal to a movie theatre, with prices to match? Or do you rely on the salesperson to help guide you through these steps? We are playing the role of the consummate salesperson where our job is to guide our patients to a reasonable choice and help them understand why we are selecting a particular appliance and the advantages it offers them.
My decision process starts with the examination. My dental exam leads me towards the first of several algorithmic and logical decision pathways. For example, if there are normal teeth in quantity and quality present, I have the most choices. I can select a flex material, vinyl material, hard acrylic or thermo acrylic, I can choose Cad/Cam milled, or 3D printed. If teeth are compromised due to the presence of large restorations and the future dental needs will be higher than average, I tend to select hard acrylic as the material of choice as it allows chairside or lab modification when the dentistry is completed or is in the process. Temporary crowns are a perfect example when a chairside modification allows continuous OA therapy during restorative treatment.
Another major issue I pay particular attention to is, does this patient have any TMJ concerns? Examples are history of trauma to head neck or face, clicking, locking or limitation of movement/range of motion? If the patient has had a history of TMD or current symptoms, first we have to decide if we really want to treat them or should we encourage the patient to try CPAP therapy. Every dentist will have different comfort levels depending on their training and expertise.
Depending on what TM dysfunction I diagnose, I usually add an anterior discluding element or ramp onto the sleep appliance. I tend to steer away from rigid dorsal designs that do not allow lateral movement unless I can add that feature. This can be done in hard acrylic or the softer combination material. I may chose to make for instance a Narval appliance for these patients but then add an NTI device by utilizing a lingual strap design with special instructions to the laboratory. Your treatment choices may vary; these are examples of what my protocol is in certain situations.
In the same light as TMD what do we use for those patients who are bruxers?
This is a very difficult discussion as we all have our theories regarding bruxism and sleep and the best way to handle it. Will the sleep appliance alone alleviate the bruxism drive by opening the airway? Or should we utilize the materials of our device to allow for these forces to be effectively handled?
I like to preemptively provide some adaptive mechanism to help these patients. It might be the utilization of a flex type material to absorb more pressure while grinding and clenching or the use of an anterior discluding element described in the previous paragraph. For the heaviest of bruxers, I will utilize a SUAD or the Narval with an NTI (yes two separate devices) to decrease the activity of the muscles of mastication.
How do I handle patients that have obligate oral breathing patterns?
Many of my patients have nasal obstruction that is seasonal and related to allergens or humidity. Others have physical obstructions that require treatment by our Otolaryngology colleagues to correct airflow. It does not make sense to fit one of these patients with an anterior restrictive type appliance such as the TAP series of devices. Many of my patients find that inability to open too restrictive; it makes it difficult for them to be compliant with the device. While the TAP is a great choice for patients who have nasal patency, it becomes a concern for those patients who have anterior recession, significant crown and bridge history on the front teeth or proposed treatment in that region.
Do you utilize the same appliance for a patient who opens wide enough to fit an apple in his mouth versus a grape?
For the large-mouth individuals or those you see that have a very short mandible, a micrognathic appearance or are severely Class II with immediate retrusion when opening, I typically choose a rigidly fixed appliance to keep the maxilla and mandible tightly held together. An appliance such as a TAP comes to mind first. Certainly adding elastics to a dorsal appliance to hold the jaw together is a good option too. Similar types of retention would be the EMA, Narval, PM Positioner.
What do you use for patients who have had periodontal problems or anterior grafting procedures?
For many of us doing oral appliance therapy for sleep apnea treatment, the mere mention of periodontal disease and bone loss eliminates the use of an oral appliance as a treatment option. Patients have to be evaluated with regards to their specific periodontal concerns. If I feel that the concerns are negligible, than I will proceed with the use of an oral appliance. In a patient with anterior bone loss, I will rarely use a TAP appliance as this puts an undo amount of stress onto those front teeth. My choice for these patients is the Narval by ResMed, which eliminates the pressure on the front teeth by the design of the appliance itself. I will also consider a hard acrylic appliance and a dorsal type mechanism, as this will keep movement of the anterior teeth to a minimum while splinting the teeth like a retainer. I encourage these patients to maintain their preventive care frequency and home care. In severe cases, they can have the anterior teeth splinted with extra-coronal retention prior to fabrication of a device.
One aspect of appliance selection that is often overlooked pertains to the physical ability of the patient to place, remove and adjust the appliance. This can be due to age, arthritis, tremor, diminished mental capacity or other issues. Many years ago, a Vietnam Veteran that came to me as a patient humbled me. He was limited physically as a triple amputee, losing two arms and a leg in the conflict. He was desperate to treat his apnea and CPAP was not an option. His arm prosthesis was the old hook-and-claw type. The ability to use his arms was severely limited to rudimentary movements with minimal fine skills. Was a TAP appropriate? A two-piece dorsal? PM Positioner? Clearly his case was a challenge and after much discussion and a few appliances later, we ultimately selected a modified PM Positioner that had an extension handle on the maxillary arch to allow him the ability to place and remove the device. The adjustments were done by his wife or by me and after a few weeks he was happy to have relieved his sleep issues. The point is that we had some trial and error associated with his treatment, but I learned that not one appliance can be used to treat everyone. There is no magic pill and we have to use our skills, experience and creativity to select appliances for our patients.
Is it wrong to select an appliance based on profit – making a business decision that influences a clinical one?
(Picture me with a long dramatic pause in my breathing as I begin to discuss this.) We all have concerns about profit and yes, when you do several hundred of these devices in a year, the difference between a $500.00 appliance and a $300.00 appliance makes a significant improvement to the bottom line. For those of us treating Medicare patients a lower cost alternative is already designated by the rules of which appliances we may use. In my practice, our insurance contracts specify an amount; the lab cost is already factored in. If for example the contract reimbursement is $600.00, it is hard to justify the higher cost appliance for that patient. If the contract disallows balance billing, we have to select a device that is effective and also fits within our patients insurance coverage. I liken this to generic drugs versus name brand drugs or equivalent benefit drugs. By comparison, imagine if you will a prescription for Celebrex, an effective Cox 2 inhibitor. This is a wonderful class of drug but is also expensive and many insurers do not cover that due to the high cost. Usually the doctor, or more commonly the pharmacist, will recommend an alternative medication such as Naproxen, which is equivalent on the pain but may lack the protection against stomach irritation. The patient may have the option to pay for the Celebrex but ultimately it is their choice. It is my opinion that we have the right to choose an appropriate appliance based on the cost benefit to our patient and to us.
There are many factors that go into choosing an appropriate appliance for our patients. To attempt to classify all of them is daunting. It is our job and duty to do so with consideration of the many details that come with treating patients as individuals, with unique dental concerns, physical limitations, wishes and desires. We run a professional business, also, with its obligations. Sorry I could not give you an algorithm to make the choice clear for each person you see; I hope you have been inspired by this essay to think about those details and make the choices for your patients easier.