Dental Sleep Medicine: Beyond Oral Appliance Therapy

Sleep disordered breathing continues to plague millions of Americans.  Our traditional way of managing patients has been inconvenient, intrusive, and ultimately offered solutions most patients simply don’t want (CPAP or surgery). Between the high cost and inconvenience of in-lab sleep studies, and the aversion that most people have to the idea of sleeping with a CPAP device or having “half their throat ripped out”, most people with sleep apnea have never even been diagnosed. Perhaps more telling is the fact that most people who have been diagnosed currently go untreated!
AdjunctiveCare_Pillar_fig1With real-world CPAP compliance rates as low as 35%, many patients simply need better treatment options. Over the past 10 years, dental sleep medicine has played an increasingly vital role because Oral Appliance Therapy (OAT) has proven efficacy and is better tolerated than CPAP. More and more dentists are educated about what sleep apnea is and help their patients with custom oral appliances. In fact, independent healthcare business analysts Frost and Sullivan recently reported that they anticipate a five-fold increase in the number of dental devices made in the US over the next 5 years.
But is OAT all we have to offer? As a dentist, what can you do for your patient who can’t tolerate OAT? What about those who refuse to wear a dental device? Or those patients for whom OAT offers partial, but incomplete relief? What else can we do for these patients?
The Pillar Procedure is another tool you can use to better meet the needs of your snoring and sleep apnea patients.
First approved by the FDA in 2002, the Pillar Procedure has been used to treat over 50,000 patients with snoring and mild-to-moderate sleep apnea. The Pillar Procedure is a minimally invasive technique, performed chair-side, that works by inserting small woven sutures into the soft palate (see diagram). Performed under local anesthesia in about 10 minutes, it has been shown to significantly reduce snoring (bed-partner satisfaction rates average around 80%),1,2 and to effectively treat mild-to-moderate sleep apnea (approximately 80% of patients experience significant reduction in AHI).3,4
Stiffening the soft palate has been a primary method of procedural sleep apnea treatment for over 40 years. The Uvulo-Palato-Pharyngo-Plasty (UPPP) was first introduced in the 1970s as a treatment for OSA, and remained the standard surgical treatment for many years. Over the years, the technique has been modified numerous times, but even now remains an extremely invasive and painful procedure. In contrast, the Pillar Procedure does not require the removal or destruction of any soft tissue. The Pillar Procedure stiffens the soft palate by stimulating a foreign body reaction. In response to the placement of the palatal implants, the patient’s natural fibrotic response stiffens the soft palate, thereby decreasing palatal flutter. So instead of an invasive, painful surgical procedure, it is a simple, essentially painless chair-side procedure that allows patients to immediately return to normal diet and activities.
OK, but what does the Pillar Procedure have to do with dentistry? Simple, as a dentist, you can perform the Pillar Procedure. While most Pillar Procedures performed to date have been done by ENT physicians, the FDA authorizes trained dentists to perform this procedure. Eager to offer their patients more than just OAT, an increasing number of dentists are adding the Pillar Procedure to their practices. In the dental setting, the Pillar Procedure has been shown to augment the efficacy of OAT, reducing the amount of protrusion required to achieve a desired end point. The theory is that the two techniques work synergistically, because airway stabilization is accomplished both retro-palatally and retro-lingually. It also allows a dentist to help patients for whom OAT is not an option.
AdjunctiveCare_Pillar_fig2Performing the procedure: The patient is typically given ibuprofen 800 mg po, and then asked to rinse with an antiseptic solution immediately prior to the procedure. The palate is anesthetized topically, and then injected with approximately 3 cc of a short acting local anesthetic (with epi). The implants are then placed approximately 2 mm apart and parallel, with the first implant inserted along the midline raphe. The entry point for the delivery device is the junction of the hard and soft palate, allowing the implants to be placed as close to that junction as possible. The implants are placed 2mm apart and parallel (see illustration). Typically, 5 implants are placed per patient.
Fifteen minutes later, the patient is driving back to work. Post operatively, most patients experience very little discomfort, typically managed with ibuprofen and cold liquids. It takes several weeks for the scar tissue in the soft palate to form, and to integrate with the implant material. Therefore, patients are advised not to expect clinical improvement for at least two weeks, and that maximal improvement can take up to three months. Decreasing palatal flutter in this way can directly decrease snoring and apnea, and (anecdotally) it can also synergistically augment the effect of OAT, thereby providing the assist that some dental devices need to get to the end zone. Over 50,000 patients have been treated with the Pillar Procedure, and not a single significant complication has been reported. The most commonly reported complication is “partial extrusion” of one or more of the implants. This occurs in between 1 and 2% of patients, and is managed by removing the exposed implant.

It is a simple, essentially  painless chair-side procedure…

Pillar Procedure courses are offered throughout the year and sometimes in conjunction with Dental Sleep Solutions. You can get more information by calling Pillar’s manufacturer at 214-369-2347 or by visiting www.PillarProcedure.com.

Dr. Craig Schwimmer is a practicing ENT from Dallas, TX, who has per-formed thousands of Pillar Procedures, and serves as Chief Medical Officer of Pillar Palatal, LLC. He can be reached at CSchwimmer@PillarPalatal.com.
Dr. Richard Drake is a practicing dentist in San Antonio, TX, and co-founder of Dental Sleep Solutions and DS3 software. He routinely utilizes the Pillar Procedure in his dental office.

  1. Long-term Results of Palatal Implants for Primary Snoring. Maurer JT, Verse T, Stuck BA, Hormann K, Hein G. Otolaryngol Head Neck Surg. 2005; 132: 125-132.
  2. Patient Outcomes After Soft Palate Implant Placement for Treatment of Snoring. Rosenberg B, Alsaffar H, Kandessamy T. Journal of Otolaryngol Head Neck Surg. 2010; 39:323-328.
  3. Extended Follow-up of Palatal Implants for OSA Treatment. Walker RP, Levine HL, Hopp ML, Greene D. Otolaryngol Head Neck Surg. 2007; 137:822-827.
  4. One-year Results: Palatal Implants for the Treatment of Obstructive Sleep Apnea. Norgard S, Hein G, Stene BK, Skjostad KW, Maurer JT. Otolaryngol Head Neck Surg. 2007; 136: 818-822.

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