The 3 Most Common Mistakes with Oral Appliance Selection

Clinical Spotlight , Current Issue

Editor’s intro
Dr. Jamison Spencer explains the three most common mistakes dental sleep professionals make when choosing an appliance. Read his advice to help choose an appliance that is appropriate for individualized patient’s needs.

by Jamison Spencer,  DMD, MS

Almost every week I get an email from someone asking “Jamison, what’s your favorite appliance?”

I get this question almost EVERY time I lecture.

Sometimes, if I’m feeling particularly rude, I’ll answer their question with a question.

“What is your favorite dental bur?”

“Or your favorite endo file?”

If this exchange occurs in person they will then look at me confused, and then answer back, “well, I guess that depends on the situation.”

Right!

There is no one best appliance. There is the best appliance for the specific patient, based on what’s going on with them currently. In other words, the “best appliance” might even change over time!

Here are the 3 most common mistakes I see good dentists making when it comes to appliance selection.

Note that I said “good dentists.”

Only good dentists care. Bad dentists will just use whatever they learned at some manufacturer’s course, or whatever is cheapest, or whatever they saw an ad for.

And they’ll use it on EVERY PATIENT.

I’ll assume that’s not you (or not you anymore), and give you a few simple things to look for when deciding which appliance design is likely to perform the best.

Mistake #1: Choosing an appliance that does NOT allow adequate lateral movement for a patient with evidence of historical lateral bruxism.

This is by far the most common mistake I see. A dentist chooses an appliance that does not allow for lateral motion, or very little lateral motion, and the patient clearly has evidence of historical lateral bruxism as witnessed by their worn dentition.

While it’s true that some patients may have reduced bruxism activity once their airway is protected, this is unfortunately not universal. I always “plan for the worst, and hope for the best.” So, I choose an appliance in such cases that will allow the patient to continue the mandibular movements that they have done in the past (again, based on their historical wear patterns).

In general, in such a case you’ll want to avoid what I refer to as “interlocking” appliances or “mono-block” appliances. While this isn’t always intuitively obvious, the question to ask is “will this appliance design allow this specific patient the lateral movement that they may need?”

Mistake #2: Choosing the appliance that you think will be the hardest for the patient to break.

This one I can totally forgive. We’ve been trained to look for materials that are super strong and unlikely to fracture or even wear. We see ads for materials that are said to be indestructible, and have lab guys challenge us to break the material using pliers… and we can’t.

We think to ourselves, “Wow! That dude with the huge masseters will never be able to break this stuff!” And that’s probably true.

But sometimes I wonder if we shouldn’t be asking a different question.

Rather than asking “what can I make this out of that the patient can’t break?” perhaps we should ask “why is the patient trying to break this in the first place?”

With a single crown, having an indestructible material probably isn’t that big of a deal, and I think we understand that using the diamond hard material is not stopping the patient from “trying to break it.”

But when we are fitting something to all the teeth, and connecting the upper and lower jaws, using an unbreakable appliance for sure does not stop the patient from moving their jaw in a way that may have historically resulted in damage.

So the question is, which would you rather have break? The patient, or the appliance?

Since there is no such thing as an appliance that can stop the patient from trying to “parafunction,” where do the forces go? If the appliance is so strong as to not break, where do those forces get transferred?

Answer: to the teeth, restorations and periodontium.

Personally… if I’m in a car crash, I’d rather have the car be destroyed and me walk away from the accident.

If I’m wearing an oral appliance and I am putting excessive pressures on the appliance for some reason, I’d rather have the appliance be the weak link.

Mistake #3: “n of 1 syndrome.”

I hear about this all the time.

Someone comes up to me and says “I tried X appliance and it was garbage.” I ask some follow up questions, and usually find out that the dentist… usually a good dentist… tried a specific appliance from a specific lab one time with a specific patient, and that one experience wasn’t very good.

Maybe the appliance was too tight. Or too loose. Or too bulky. Or the patient didn’t like it. Or it didn’t seem to work that well (which is a whole other article as to what that even means). Or it didn’t last as long as they thought it should.

I had a prosthodontic professor that used to say, “you have to earn the respect of the material.”

It took me a long time to figure out what that meant.

My interpretation of that statement, applied crassly to dental sleep, is “just because you suck doesn’t mean the appliance sucks.”

I opened this article by saying that it’s inappropriate to think there is one best appliance that you can use all the time for every patient.

However, I know that there are many really, really, really good dentists who ALWAYS use the same appliance for virtually all of their patients. Often this dentist is using an appliance that they either invented, is named after them, or both.

And they get great results!

Why? Because they are masters with that appliance, and they’ve figured out what to do when various things happen, through lots and lots of experience.

So whatever appliance you don’t like, I’ll bet you anything there is someone out there who has fantastic results with it. They’re just better at using it than you are.

You see, it’s not about the plastic (or nylon). It’s about our skill and expertise in using the plastic.

I can buy my paint brushes at the same store that Rembrandt buys his, but that doesn’t mean I can do the same thing with them.

So be careful with the “n of 1” syndrome. Remember back in dental school where it took time to “gain the respect of the material.” It takes time to gain the respect of the appliance, and to learn what to do when and why… and perhaps more importantly, when not to do anything… which we’ll discuss some other time.

 

Editor’s call to action
Dr. Spencer’s experience is paramount in avoiding common mistakes when making decisions about appliances. Read this interview and find out more about this dental sleep professional.
https://dentalsleeppractice.com/clinician-spotlight/dsp-interview-with-dr-jamison-spencer/