As mentioned in a previous article on treatment for patients with sleep disorders, sleep appliance designs are many and varied. With the numerous amounts of options out there, how can we be sure that we are selecting the most appropriate appliance for a specific individual?
From home-fitted and adjusted appliances available on the Internet, to appliances requiring meticulous professional adjustment, it's imperative to be comfortable with a wide variety of treatment options.
There are some things you need to know before making any treatment recommendations:
- Arch form: One of the most important things to know to determine which appliance to use is to be aware of how the patient's mouth is built. There may be a case when a patient has issues that affect the amount of tongue space. For instance if they have a very narrow arch form, it's likely they have quite a bit of crowding. If your appliance has significant bulk in the tongue space, it will add to the problem.
- Buccal Corridor: There are a number of common conditions that can affect the choice of where the adjustment mechanism for the oral appliance should be located. For instance there are people who have too little room lateral to their upper teeth. There are patients with large exostoses that diminish room in the mouth due to the outgrowth of bone. There are also patients whose head of their coronary process comes too close to their second molars when they advance their mandible forward or open wide. Choosing an acrylic device that takes these limitations into account will enhance success.
- Dexterity: Understanding the dexterity requirements of each appliance you may choose from and how that matches up with the individual patient is something you need to keep in mind. Most appliances today require an insertion of a key to make necessary adjustments. For patients who are older or have poor vision, the requirement of inserting a key into a tiny hole may either frustrate them or not even be possible for them to do as often as needed.
- Patient concerns: Patients may have a whole host of concerns when it comes to appliance selection. Patient may be concerned about maintenance issues, comfort and whether they can feel comfortable about their usual mouth movements with the device in. Getting to know the patient and their story will reveal what they have tried before to treat the symptoms of their sleep disorder. This may suggest a recommendation. Odds are, some of your patients will have already tried a sleep appliance that they found at the drugstore or online.
- Lip competency: The ability of the patient's lips to close together in front of their teeth is a huge factor to pay attention to. The appliance will cover the teeth in a layer of plastic and can affect how far the patient can close their lips. So if you have a patient that already struggles with lip competency, and you are now providing them with an even larger vertical opening, it is only going to cause more problem for them. Which can result is poor periodontal health around their front teeth or cause dry mouth from too much air intake. It's also important to realize that some appliances look bulkier under the front lip than others do which can also be a factor in lip competency.
- Adjustability: It's been suggested in many studies that adjustable appliance have much more patient acceptance due to comfort. Unfortunately, the ability to predict just how far the jaw needs to be brought forward to effectively treat these patients isn't concrete yet. The most important influence on adherence to OA therapy is initial comfort. If your patient begins with significant problems, it may be difficult for them to give the OA a good chance. Having a device that can begin with minimal challenge and advance to a more effective position is a key to success. How patients adjust it differs between devices and it's up to you to match the mechanism with the patient.
There are many more considerations to keep in mind when applying what you know to the needs of the patient in your office. This isn't unique to dental sleep medicine. Dentists do this every day with restoration choices and oral health counseling, whether to refer a procedure, when to use the rubber dam, and thousands of other decisions. Adding dental sleep medicine requires more knowledge, but you already have the skills.
Steve Carstensen, DDS www.stevecarstensendds.com