It’s Not About the Plastic
Common mistakes that dentists make when selecting sleep apnea appliances
Jamison R. Spencer, DMD, MS
At virtually every sleep dentistry course at which I'm invited to lecture, an attendee will ask, "Jamison, what's your favorite appliance?" Sometimes, if I'm feeling particularly bold, I'll answer his or her question with a question, such as, "What is your favorite dental bur?" After looking at me confused, the individual's answer is usually something along the lines of, "Well, I guess that depends on the situation." That's right! There is no one best appliance for snoring and sleep apnea. There is only the best appliance for a specific patient based on his or her diagnosis and specific needs. Furthermore, the "best appliance" for a specific patient may even change over time. The bottom line is that the best appliance is the one that the patient will actually use. When it comes to appliance selection for snoring and sleep apnea, there are three common mistakes that I see good dentists making. Note that I said, "good dentists." In my opinion, "bad dentists" will just use whatever they learned at a manufacturer's course, whatever is cheapest, or whatever they saw an ad for—and they'll use it on every patient. I'll assume that's not you and give you a few things to consider when deciding which appliance design will perform the best.
The first common mistake that dentists make is choosing an appliance that does not allow adequate lateral movement for patients with historical evidence of lateral bruxism (ie, worn dentition). This is by far the most common mistake that I see. Although it's true that some patients may exhibit a reduction in bruxism activity once their airway is protected, unfortunately, this is not universal. Clinicians should "plan for the worst and hope for the best" by choosing appliances that will allow patients to continue the mandibular movements that they demonstrated in the past. In these cases, you'll want to avoid what I refer to as "interlocking" appliances or "mono-block" appliances.
The second common mistake that dentists make is simply choosing the appliance that they think will be the hardest for the patient to break. This one I can easily forgive. As dentists, we've been trained to look for materials that are super strong and unlikely to fracture or even wear. For a single crown, having an indestructible material is a positive, but when we are fitting something to all of the teeth and connecting the upper and lower jaws, using an unbreakable appliance, if one really existed, will not stop patients from moving their jaws in a way that may have historically resulted in damage. Because there is no such thing as an appliance that can stop a patient from engaging in parafunctional behavior, where do those forces get transferred to? The answer is that they get transferred to the teeth, any restorations, and the periodontium. So, which would you rather have break—the patient or the appliance?
The third common mistake made by dentists is prematurely arriving at conclusions regarding the effectiveness of the appliances that they try. I hear about this all the time. Someone will come up to me and say, "I tried X appliance, and I hated it." After I ask some follow-up questions, I often find out that the dentist, who is usually a good dentist, tried a specific appliance from a specific laboratory with a specific patient and that this singular experience wasn't very good. Maybe the appliance was too tight, too loose, or too bulky. Or maybe the patient didn't like it, it didn't seem to work that well (which would require a whole other article to explore what that even means), or it didn't last as long as the patient thought it should. I had a prosthodontics professor who used to say, "You have to earn the respect of the material." It took me a long time to figure out what that meant, but my crass interpretation of that statement applied to dental sleep medicine is, "Just because you can't make an appliance work, doesn't mean the appliance doesn't work." I opened this article by saying that it's inappropriate to think that there's one best appliance that you can use all of the time for every patient; however, I know that there are many really good dentists who use the same appliance for virtually all of their patients, and they get great results. Why? Because they are masters with that appliance, and they've figured out what to do when various things happen through lots of experience. So, a dentist may not like an appliance, but there may be dentists out there who achieve fantastic results with it. They're just better at using it.
You see, it's not about the plastic, acrylic, or nylon; it's about our skill and expertise in using these materials and choosing the correct design in the first place, which involves effectively communicating with the patient to select an appliance that he or she will actually use. It doesn't matter how ideal the appliance is if the patient won't wear it.
About the Author
Jamison R. Spencer, DMD, MS, is the director of dental sleep medicine for the Center for Sleep Apnea and TMJ in Boise, Idaho, and Salt Lake City, Utah. He is also an adjunct faculty member at the University of the Pacific Arthur A. Dugoni School of Dentistry.