Implementing a Successful Sleep Workflow
Imaging and theragnostics improve treatment acceptance and predictability
Richard “Sully” Sullivan, DDS
Implementing new procedures can be challenging for dentists. Oftentimes, practitioners return from continuing education courses excited to try something new at their practices only to fail in implementing what they learned. It is not that they do not want to be successful or that their patients would not benefit from a new treatment but rather that some procedural workflows can be challenging to integrate into a practice.
Fortunately, technology is changing dentistry, enabling dentists to perform tasks and procedures more efficiently and predictably. Technology is also helping to reduce the educational gap in patients' understanding of potential treatment. In many cases, patients begin to actively take ownership of their oral health because of technology's ability to help them understand what is happening.
Some of the biggest hurdles for a dentist who is interested in implementing a protocol for obstructive sleep apnea (OSA) are creating the awareness, having the conversation, and getting patients to take a test. It is important to note that the dentist's initial role in sleep apnea treatment is not to diagnose but rather to create awareness through screening and then refer patients to a proper sleep physician for diagnosis.1 However, this can prove to be difficult because these conversations can be extensive. Fortunately, technology can help dentists reduce chairtime, communicate more effectively with patients, and ultimately, motivate more people who require sleep apnea treatment to accept it.
For example, a new patient who presents to a dental practice checks "yes" to snoring, has a history of stroke and a family history of cardiac arrest, and is on a number of medications, including those for blood pressure, anxiety, and diabetes. This medical history alone strongly suggests that the patient could benefit from ruling out OSA.2 Discussing the correlation between some of these medical conditions and oral symptoms can sometimes create confusion or be difficult for patients to understand; however, cone-beam computed tomography (CBCT) scans are able to help patients visualize areas of constriction in the airway based on the color of the images (Figure 1), which can open up a conversation about treatment.
Patient education with 3D images often produces not only the awareness but also the proper sense of urgency that patients need in order to seek testing for OSA. Because dentists cannot diagnose OSA, before any oral appliance treatment is initiated, it is important that these patients get properly tested and receive a diagnosis from a sleep physician to determine if oral appliance therapy is an appropriate treatment option. It is best practice that dentists take a collaborative approach to care because visually assessing a scan of a patient's airway alone is not diagnostic of sleep disorders.
A patient of record presented for her 6-month visit with signs and symptoms of OSA.
A CBCT scan (Orthophos SL 3D-Ai, Dentsply Sirona) was taken to evaluate her airway. After a discussion with the hygienist and doctor, during which the patient was shown her airway in 3D utilizing airway segmentation software (SICAT Air, Dentsply Sirona), she agreed to take a sleep test in order to rule out OSA. Upon completion of her sleep test, the patient had an AHI score of 27.9 and received a diagnosis of moderate OSA from the sleep physician. The patient's options were discussed, and because her diagnosis was moderate, she wanted to try oral appliance therapy prior to trying continuous positive airway pressure (CPAP) therapy.3 The physician agreed and prescribed a mandibular advancement device.
In a traditional model, after physician approval and prescription, this patient would have an oral appliance made, and the appliance would be titrated over the following weeks or months to subjectively improve her symptoms, and follow-up testing would be performed to objectively verify that the appliance was appropriately lowering her AHI score. The challenge that a clinician has in this model is predictability because some patients will not respond to a mandibular advancement device or might require several follow-up visits to achieve the proper position.
For this case, the patient was provided with an at-home theragnostic sleep testing system (MATRx plus™, Zephyr Sleep Technologies) that has the ability to determine whether a patient will respond to oral appliance therapy and, for those will, can also provide information regarding the optimal therapeutic position to produce positive results.4 For the therapeutic component of the study, the system utilizes a motorized impression tray that adjusts in small increments throughout the night. The patient underwent a 2-night theragnostic study, which determined that she would respond to therapy and that the position needed to produce this response was 65% of her maximum protrusion (ie, 3.2 mm).
This information is valuable to the dentist regarding increasing the predictability of treatment, but it is also valuable to the patient, especially one whose OSA is near the severe level, to know whether or not oral appliance therapy could work prior to investing in an appliance.
At this point, the fabrication process began by getting the patient into the exact position that would allow her to respond. Using a bite-registration gauge (George Gauge®, Great Lakes Dental Technology), the desired bite was captured with bite registration material. With the gauge in the patient's mouth, a bite scan was taken using a digital scanner (Primescan, Dentsply Sirona) (Figure 2). The patient's bite was also taken using CBCT (Orthophos SL 3D-Ai, Dentsply Sirona). After the digitally scanned teeth were meshed with the CBCT of the bite in the software (Figure 3), the treatment position was sent to the laboratory to fabricate a milled appliance completely digitally.
Less than 10 days later, the appliance was delivered and ready for use (Figure 4). After undergoing a period of oral appliance therapy to improve her OSA, a follow-up test revealed that the patient's AHI score had dropped to 7.
The reality is that many dentists still struggle to convince at-risk patients to get tested for OSA, and getting them to accept treatment when the protocol involves seemingly endless titration with no prediction of success is another thing entirely. The use of 3D imaging with airway segmentation and an at-home theragnostic sleep test can help improve treatment acceptance as well as the predictability of treatment with mandibular advancement devices. Although technology may not be required, it provides workflows that can motivate more patients to accept treatment, delivers more predictable results, and ultimately, allows dentists to help more patients improve their overall health.
About the Author
Richard "Sully" Sullivan, DDS
Sullivan Dental Partners
1. Quan SF, Schmidt-Nowara W. The role of dentists in the diagnosis and treatment of obstructive sleep apnea: consensus and controversy. J Clin Sleep Med. 2017;13(10):1117-1119.
2. Tietjens JR, Claman D, Kezirian EJ, et al. Obstructive sleep apnea in cardiovascular disease: a review of the literature and proposed multidisciplinary clinical management strategy. J Am Heart Assoc. 2019;8(1):e010440.
3. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827.
4. Remmers JE, Topor Z, Grosse J, et al. A feedback-controlled mandibular positioner identifies individuals with sleep apnea who will respond to oral appliance therapy. J Clin Sleep Med. 2017;13(7):871-880.