been reported with the use of intraorally and directly molded thermoplastic mandibular advancement appliances in the short- term when compared to a custom-made, laboratory processed mandibular advancement appliance (Pepin, et al., 2019). The use of thermoplastic oral appliances can be a means to identify those patients who are most likely to benefit from the use of custom-made, laboratory appliances (Dieltjens and Vanderveken, 2019). The OSA literature clearly supports the use of custom-made, laboratory-processed OAs that are capable of effecting mandibular protrusion in a controlled manner (Pavwoski and Shelgikar, 2017). Adjustable (titratable) OAs have been shown to provide more successful therapy than nonadjustable or fixed appliances, especially in moderate to severe cases of OSA as systematic reviews have demonstrated their superiority against nonadjustable OAs (Semelka, 2016). Oral appliance therapy used to treat OSA is covered by medical insurance rather than dental insurance with preauthorization the process by which an insurer considers the medical necessity of this service and predetermination the process in which an insurer confirms the amount of reimbursement for a device such as an oral appliance (American Academy of Dental Sleep Medicine, 2019). Patients with OSA must check with their medical insurance provider before they initiate the fabrication of any type of OA to treat his condition. Patients who are prescribed an OA must have a comprehensive dental examination (including both intra- and extraoral examinations). Caries and active periodontal disease must be treated prior to the fabrication of an OA. Fabrication of an OA begins with accurate maxillary and mandibular impressions. The key elements of a clinically successful OA are those which
are custom made by a dentist with extensive experience or additional training in sleep medicine and those which have the ability to effect mandibular protrusions (Laratta, et al., 2017). The effectiveness of differing amounts of mandibular protrusion provided by OAs in the treatment of OSA was the subject of a systematic review by Bartolucci and colleagues (2016). Thirteen randomized controlled trials with mandibular advancements from 50% to 89% of maximum protrusion were included. Meta-regression analysis showed that advancement amounts greater than 50% did not significantly influence the success rate. Therefore, the improvement seen in AHI was not proportional to the degree of mandibular advancement provided by the OA. Other variables possibly influence the success of therapy, and Bartolucci and colleagues remark that these need further study. The George Gauge, a device invented by orthodontist Peter T. George, can be used to set a predetermined degree of mandibular protrusion before the taking of a bite registration. Methods to assess the optimal degree of mandibular protrusion with an OA have been introduced. A remotely controlled mandibular positioner (RCMP) allows titration of mandibular protrusion during a polysomnographic sleep study to predict an effective target protrusive position (Hogg, 2016). A unique technique for titrating the degree of mandibular protrusion for an oral appliance using endoscopy was published by Okuno, Ikai, Matsumura-Ai, & Araie (2018).Widening of the velopharynx during mandibular protrusion (a desirable change) can be monitored during endoscopy. This procedure, according to the authors, can both effectively predict a positive response to OA treatment (in patients with a greater velopharyngeal expansion) and minimize the amount of required protrusion, thereby minimizing occlusal and temporomandibular side effects.
MANAGEMENT OF THE EDENTULOUS OBSTRUCTIVE SLEEP APNEA PATIENT
There is a high prevalence of OSA in edentulous individuals. However, as mentioned previously, there is currently no consensus in the literature on the effects of nocturnal denture wearing on OSA (Heidsieck et al., 2016). A lack of dentition to support and retain a MAD makes these devices problematic for use in edentulous OSA patients. Banu and colleagues (2021) described the employment of a modified OA for a 45-year-old edentulous patient that was non-compliant with his CPAP therapy. The fabrication and use of a modified monoblock (one piece) mandibular advancement device (MAD) for a completely edentulous patient is an oral appliance which can be fabricated for these patients who experience OSA (Banu, et al, 2021). The ability to obtain adequate retention at the appropriate vertical dimension of occlusion remains a challenge in these situations. However, this patient reported in his sleep patterns and a reduction in day-time drowsiness (Banu, et al., 2021). Dental implants have been utilized to improve the retention of OA used in the treatment OSA as poor retention of these devices among edentulous patients decreases patient Compliance Compliance with using oral appliances during sleeping is essential for successful OSA treatment. Nishigawa, Hayama, and Matsuka (2017) investigated the reasons some patients discontinue using OAs. Thirty-eight patients provided with a two-piece Herbst-type oral appliance answered a questionnaire mailed to them. After an average period of 9.6 months, 22 patients stopped using the OA. Eleven of these patients selected “bothersome to use” as the reason for discontinuing appliance use. The other main cause for stopping OA therapy was the patients’ belief that the OA had “little or no effect” in preventing their sleep apnea. Some of the other reasons given for noncompliance were “difficulty sleeping,” a “stifling feeling,” and “mouthpiece coming off.” It should be noted that the
compliance and negates their therapeutic benefit (Heidsieck, et al., 2016). More recently, Piskin and colleagues (2017) published a clinical report on mandibular implant overdenture treatment on a patient with OSA. Overnight pulse oximetry (rather than a PSG test) was used at the patient’s home to evaluate cardiorespiratory stability during sleep. Since the patient could not tolerate CPAP or a MAD, only conventional maxillary and mandibular complete dentures were initially worn while sleeping, to prevent the probable effects of edentulism on upper airway volume and pharyngeal muscle tonus. Consequently, after 6 months, improvements in both pulse oximetry (PO) and the ESS were seen. However, the mandibular complete denture, which became displaced during sleep, was converted to a two-implant overdenture. After an additional 6 months, a significant further improvement in cardiorespiratory stability (oxygen desaturation index and heart rate variability index) was demonstrated. According to the authors, edentulous patients who wear complete dentures while sleeping might preserve and improve respiratory stability. Further improvement in cardiorespiratory condition could be realized with an implant overdenture that promotes motor and sensory capabilities. average AHI of these patients was 45.3, which indicates severe OSA. For such patients, CPAP is generally the treatment of choice, if possible. There have been recent developments in monitoring patient compliance with OA treatment. A micro-sensor thermometer embedded in the OA has been introduced (for research purposes) to objectively measure patient compliance in using the OA. When the temperature measured is higher than 35 °C, patient use is assumed (Gjerde, et al., 2017). These thermosensor devices are not included in all OA so compliance with the use of these devices cannot be verified for all patients who utilize them (Pavwoski and Shelgikar, 2017). The device measures various parameters of use, such as temperature
Page 112
Book Code: DHFL2624
EliteLearning.com/ Dental
Powered by FlippingBook