Continuous positive airway pressure (CPAP) was introduced in 1981 and is still the standard of care today for obstructive sleep apnea (OSA). While CPAP technology has improved, it still remains unpopular with patients, rarely worn throughout an entire night, and has less than optimal long-term compliance.
Introduced in the 1980s, oral appliances were in an attempt to provide an alternative to the unpopular CPAP. Oral appliances act by protruding the mandible and attempting to position the tongue out of the oropharyngeal region, thus promoting nasal breathing. Oral appliances can be segregated by their manner of therapy. Tongue retaining devices utilize negative pressure from a bulb attached to the tip of the tongue to reposition the tongue. It is maintained in place by the lips or teeth. This is a popular option for the fully edentulous patient. Mandibular advancing appliances (MAA) are attached to the dental arch. The mandible is held in a protruded position. The protrusion is either fixed or titratable.
Unfortunately, sleep dentistry appears to have become single-minded in its treatment of adult apnea with an appliance. Dental sleep academy credentials are based on appliance usage on apnea, ignoring the more important diagnostic role that dentists can play. If dentistry compartmentalizes itself on oral appliance fabrication for OSA, females with hyper-responsive airway issues like insomnia and TMD and the majority of children with neurocognitive, systemic, and craniofacial abnormalities are completely eliminated from the purview of the dental sleep medicine practitioner.
The future calls for interdisciplinary (medical and dental) algorithms based on the patients’ requirements rather than the practitioner’s procedure of choice. Dentists should strive to not be seen by other health care providers as simply a durable medical equipment supplier of oral appliances but rather as a professional member of the interdisciplinary team.
Sleep prosthodontics, airway prosthodontics
Sleep dentistry may be thought of as the study of an oral appliance and its impact on the airway. Airway prosthodontics is the study of the airway and its impact on the stomatognathic system. The stomatognathic system encompasses the mouth, jaws and the closely related structures of the oro-pharynx and fauces. Dentists deal with this system during its development and maintain it throughout a lifetime.
Sleep dentistry addresses the how: how does an appliance assist nocturnal breathing? Airway prosthodontics addresses the why: why are patients developing malocclusions, creating myofacial pain symptoms and wearing their dentition? The original term “sleep prosthodontics”1 did not capture the full extent of the problem given that the airway must be maintained throughout the day. Sleep is simply the time when breathing is most highly compromised. Airway prosthodontics highlights that people requiring assistance during the night may require more sympathetic activity all day long to maintain a patent airway. This hyperventilation continues the inflammation and chronic stress throughout the day and could establish the conditioning found in central sleep apnea.
While a physician must make the diagnosis of sleep-disturbed breathing, the dentist can play an important role. Many times the lack of witnessed apneic episodes or the lack of particularly egregious daytime symptoms may lead to a delay in care by the medical community. The impact of a poor airway can many times be detected in the patients’ craniofacial development, oral impairment and occlusal dysfunction well before the clinical presentation of systemic disease. A poor airway might trigger sleep bruxism, erosive reflux, myofacial pain and malocclusion.
Finally, airway prosthodontics is not restricted to an appliance but instead has a single-minded focus on the patients’ health. It also encourages a patient-centered solution that includes a wide range of options, including altering occlusal vertical and sagital dimensions, orthodontics, oral mycology, nutrition/diet counseling, orthognathics, and otolaryngological surgeries.
It should be obvious that many of these "resolutions" will impact the facially generated treatment planning choices made in complex dental cases, hence the exquisite blend that is beginning to take shape at Spear Education.
1. Rouse JS, " Sleep Prosthodontics: A new vision for dentistry" Inside Dent. 2013;7:60-80.
Jeff Rouse, D.D.S., Spear Faculty and Contributing Author