How orthodontists and dentists can work together to treat sleep apnea
Years ago, tooth movement was the sole responsibility of orthodontists, but times have changed as dentists have dived into aligner therapy. Still, diagnosis is the most important aspect of treating malocclusions—deciding when it’s best to refer to a specialist and when general or restorative dentists can treat cases themselves.
The same is true for sleep apnea.
In the January 2019 issue of Dentaltown, Dr. Brock Rondeau penned an excellent article on sleep apnea that described stages of sleep, medical risks, screening and treatment by a dental professional. Let’s take a step beyond and discuss treatment by an orthodontist and how dentists and orthodontists can work together for the health of the patient.
The American Association of Orthodontists published a white paper on obstructive sleep apnea and orthodontics, amended March 2019. It describes how the specialty of orthodontics involves much more than just moving teeth, and the management of sleep apnea bears witness to this. There is increasing interest in the role of an orthodontist both in screening for obstructive sleep apnea (OSA) and as a practitioner who may be valuable in the multidisciplinary management of OSA in both children and adults. (The previous sentences are very important because they set the tone for a symbiotic relationship between dental health professionals treating OSA.)
Certainly, as Rondeau mentioned, all dental professionals must begin asking the right questions during their initial exams. Whether it is an Epworth Sleep Scale, or the STOP-Bang test, or just a few questions, we should all be screening for sleep apnea.
In a typical orthodontic office, we have access to view a lateral head film (cephalometric X-ray). A lateral view can be seen to observe the airway from a sagittal view. When a dentist examines a patient and finds positive answers to sleep questions along with a mandibular deficiency, they can begin a differential diagnosis to go along with neck size, weight, blood pressure, sleep pattern and excessive tooth wear that means maybe—just maybe—there is a skeletal component to the patient’s issues.
As examples, here are pretreatment and post-treatment cephs of two patients.
The first is a 7-year-old male who presented to my office with a Class II, Division 2 skeletal and dental malocclusion (Fig. 1). He was a typical, active boy, but discussed how he often felt tired in the morning and his mother noted heavy breathing and snoring. Nothing was mentioned about evaluating the tiredness, so we went ahead and began Phase I interceptive orthodontic therapy with a Class II functional appliance.
Interestingly enough, a Class II functional appliance looks very similar to a sleep appliance used for oral appliance therapy (OAT). After a few weeks of wear, the patient told his mother that he was feeling more rested and slept better. The progress ceph (Fig. 2) clearly demonstrates the now-larger airway after his Twin Block therapy.
An informal study in my office resulted in about 60% of the preadolescent skeletal Class II patients noted feeling better and more rested. After Class II correction, one parent in particular went into great detail to describe how it changed her daughter’s life in personality, school and even digestion. She said her daughter was less agitated and was more tolerable to be around.
Fig. 3 shows a 39-year-old male whose chief complaint was his upper teeth stuck out. He was a significant skeletal and dental Class II, Division 1 malocclusion with a hypodivergent skeletal deep-bite pattern.
We removed the lower first bicuspids and set him up for a bilateral sagittal split-radial osteotomy, a mandibular advancement. At the time I did not ask the right questions, but his neck size was certainly more than 17 inches. He was obese, and little did I know, he was sleeping in a separate room from his wife because of his snoring.
The progress cephalometric radiograph (Fig. 4) displays the significant changes in his airway. After the surgery, the patient began to lose weight because his hunger hormones became more balanced, he felt less tired at work, and his snoring was significantly reduced. As a matter of fact, the patient was able to move back into the same bedroom with his wife. Now they have two more children, which the patient jokingly says are due to my intervention. The patient considers his orthodontics to be life changing.
Previous articles have discussed utilizing OAT appliances, and there are many such appliances to choose from. Whether a dentist or orthodontist places these appliances, a few steps will help ensure minimal movement as well as titrating the appliances.
OAT appliances work, basically, to reposition the mandible into an anterior position so the tongue is positioned forward anteriorly to open the airway. There are many appliances that do this. In orthodontics, we typically see this after a surgical mandibular advancement. With OAT, we temporarily do this during the night so more passive air can pass through the airway. There are also OAT appliances that work in conjunction with CPAP (connected), so less pressure is applied by CPAP pushing air into the airway with the mandible repositioned.
One of the reasons I like the Moses appliance is that it positions the mandible and the tongue inferiorly to open the airway, as well as anteriorly repositions the mandible. With the Moses, I’m not having to advance the appliance anteriorly as much or contributing to muscular strain of the TMJ.
The problem with sleep appliances is that they can move teeth. In orthodontics, we utilize the same mechanics to create a permanent change using something such as a Class II corrector functional appliance. To minimize unwanted changes from an OAT appliance, in my office we utilize a morning positioner to set the occlusion in its normal position. We also have patients wear clear retainers for at least 20 minutes in the morning to make sure any movement is reversed. Some patients require more retainer wear during the day.
The MediByte (Braebon) and the Z Machine (General Sleep) are devices worn at night to measure factors, including oxygen desaturation, RDI respiratory index, apnea and hypopnea, and snoring. These devices can be used to titrate OAT appliances before a final sleep test (either home test or sleep center) can be analyzed by a sleep physician. Without home devices such as these, you’re really determining how successful you’re treating the patient through their comments and feelings; progress home tests can help quantify your treatment.
• Having the dentist and orthodontist work together on potential sleep issues can benefit patients greatly.
• Identifying malocclusions that can contribute to sleep apnea will greatly enhance patient care.
• Conducting the initial screening for Class II correction by age 7, as recommended by the American Association of Orthodontists, makes diagnosis and treatment at this mixed dentition age much easier.