I am leaving in a few minutes to go to China and Japan to teach dental sleep medicine. I won't be making a blog entry next week, but will be back the week after.
Often times I am asked by dentists involved in dental sleep medicine if they should get their diplomate status with the American Board of Dental Sleep Medicine or not. This is my opinion on the subject.
Appliances come in many different materials or material combinations. With all the different types out there it is hard for a dentist or patient to choose what to use.
Here are my thoughts about each material and what I prefer.
There are a few sleep appliances made 100% out of metal. These appliances are very good for someone that grinds so severe they wear everything down. The downside is these appliances can’t be adjusted much at all. If any change happens to the teeth such as restorations or crowns or lost teeth you can’t change the appliance. Also, if there is a metal allergy it can be an issue. The more metal contact with the teeth in an appliance the less likely I would use it.
All acrylic appliances (no linings). These are great appliances and I have used them for years. It can be a Herbst, dorsal or a few other styles. The impressions need to be perfect and little to no cosmetic work done to the teeth. Veneers are a problem with a tight fitting acrylic appliance because they can be pulled off or broken upon insertion and removal of the appliance. If no cosmetic or major work was done to the teeth the all acrylic appliance can outlast most others and can be relined and repaired if there are tooth changes such as loss of a tooth or crowns.
Polymer material like the Narval appliance is very strong and works well with people that grind. They are great for people with allergies to acrylic or monomers. They are expensive appliances and you can’t make much adjustment to them like adding material or relinings.
Acrylic appliances with a soft lining have a lining like a sports mouth guard and are easy to insert and remove. They feel the most comfortable to the patient and easy for an assistant to deliver the appliance. The soft lining is gentle on veneers and restorations. This is my favorite type of appliance to use because less potential for damage to the teeth. The downside is you can’t reline the material or add to it. The lining does not last as long as the acrylic. In most cases the lining lasts about 3 years. The only way to change the appliance if major work has been done to the teeth would be to remove the lining and put thermoplastic lining instead (only Dynaflex lab is doing that right now).
Acrylic appliance with thermoplastic lining is made by Dynaflex. It has to be warmed in hot water and placed in the mouth for a very short time and removed. If it is in too long after heating it is hard to remove and may cause damage. This is technique sensitive to deliver to the patient. It can be re-heated and refitted over and over making the appliance very good for times where major dental work has been done. If you live in a hot climate like the deserts of the southwest where temperatures get over 100 degrees this may not be the best choice because the lining can be destroyed by the heat. Also it must be explained to the patient to not try and heat the appliance and refit it at home.
So what appliance material do I prefer? I prefer an acrylic appliance with a soft lining. I know the soft lining won’t last as long as an all acrylic or all metal appliance, but I also know they won’t damage restorative work and are easier to deliver. Since I changed over to the soft linings my delivery time was reduced significantly and the patients have been happier. I have not had any dental restorations damaged as a result of an appliance with a soft liner. I have however had to glue the soft liner back in on several patients and had to drill out some parts of damaged liners.
The key is to try the different types of materials and see what work best for your office and your patients knowing the limits and potential problems.
How do we approach nutrition for sleep apnea? Are there foods to avoid? When should people eat? What should they eat? Can we advise on diets?
First, let’s discuss what foods should be avoided. These are my opinions based off of discussions with ENT MDs, fellow sleep dentists, and nutritionists. There is no hard scientific research yet so I won’t be referencing anything.
Dairy products produce phlegm in the mouth and throat. This phlegm or mucus can cause the throat to close up or not breathe clearly. I typically explain to all my sleep patients to stop all dairy products at least 3 hours prior to sleep.
Peanut butter may have protein and help some people with their diet or post workout drinks, but late at night it does cause some stickiness in the throat and some minor allergy issues. We try to avoid all peanut butter 3 hours prior to sleep.
One of my favorite fruits is bananas, but it can cause mucus and airway issues. Bananas should be avoided an hour prior to sleep.
Alcohol is a central nervous system CNS depressant and should be avoided 2 hours prior to sleep. The heavy use of alcohol may cause central sleep apnea or elevate the snoring and obstructive sleep apnea.
Marijuana edibles inhibit the CNS and can contribute too many issues affecting sleep. None 3 hours prior to sleep.
Narcotics (not a food, but I bunch it in) these will affect the CNS and may cause central sleep apnea, and in particular opioid addiction.
Second, when should people be eating for sleep apnea? It is best to not eat two hours prior to sleep. A full stomach at sleep can lead to weight gain because the body does not digest as well when sleeping, and we also see more acid reflux problems with full stomachs in sleep.
I prefer my patients to have their last meal about 3-4 hours prior to sleep, but stress at least 2. I also try to get patients to a 3 meal a day program and snacks limited to 2 times a day.
Can we advise on diets? Yes, and we should. I like to point out that most diets work for the first 2-4 weeks and weight loss under most plans works well in the beginning. After a month it is no longer a diet, but more of a behavior change.
There are good diets I point my patients towards like the Mayo Clinic Diet online, Nutrisystem, South Beach diet, or Weight watchers and the list goes on.
Whatever diet we point them towards our follow-up is important to get them to start and follow through. People need encouragement and support. At each of my follow up visits for sleep apnea treatment I ask about their diet. Even though as dentists we can no longer get paid for this by Medicare or medical insurances, we can still help by offering the guidance and support.
If you want to make money from a diet program you could do an MLM program like Beach Body, or affiliate marketing with things like the Mayo Clinic diet, or even selling nutritional supplements.
Did you know medical doctors are required to provide nutritional guidance or refer to a nutritionist all their diabetic patients that they have on a diabetic care program?
The use of type III HST in dental sleep medicine has caused quite a bit of controversy. Some people in the medical community have voiced concerns about dentists being ill trained to use the HST equipment for diagnostic or even titration purposes.
There are companies selling type III HST equipment teaching dentists to screen their patients for sleep with the use of the HST. The dentist would then send the test data to a third party Board certified sleep physician to read, score, diagnose, and refer back to the dentist for treatment with oral appliances.
This practice of a dentist being involved in the diagnosis and using his/her equipment is the heart of major debates in dental sleep medicine. For the sleep physicians it is something they feel dentists should not be allowed. In several states the medical boards have worked with the dental boards to disallow it. Many of the medical insurances will not approve a dentist ordering a sleep test or using their equipment for diagnostic purposes. Medicare will not allow a dentist to be involved with the diagnostics or even to loan out the HST as this violates the Stark laws and can result in jail or large fines.
Using the HST for the purpose of checking the titration with the auto score features is an accepted practice. This is not a diagnosis and it is not an official scoring and interpretation. This is a guide to see objectively if the oral appliance is working and if not how best to treat. The use of the HST will allow the dentist to see body positions and snoring and apneic events. The dentist can then recommend adjunct therapies to help with treatment such as body positioning.
It is acceptable for a dentist to order a reading and interpretation from a board certified sleep physician with the titration HST for the purpose of board certification requirements documentation. It is however best to send the patient back to the diagnosing sleep physician to re-evaluate the treatment at 6 months post treatment.
For HST equipment used in titration studies I personally recommend equipment that can detect central and mixed sleep apnea. For most testers this requires the use of a RIP belt. I also want the tester to be under $10 per use in disposable supplies. We need to keep costs to a minimum because we may have to test several times. The equipment needs to be durable, and easy for the patient to use, and the cost to purchase or lease should be reasonable.
My favorite tester is the Alice Night One by Philips. It is about $1800 to purchase and cost about $6 per use. The Apnea Link Air by Resmed is another good one at a price about $2400, and the Medibyte Jr at about $3000 as well.
A question that is always asked of me when I lecture is, “can I put or loan out my HST equipment to medical doctors to use and in turn they send me the mild to moderate sleep apnea patients?” The answer is “probably not”. If the medical doctor accepts Medicare and you do this it is a violation of the Stark law for the medical doctor. If you are treating a Medicare patient even though you are not a Medicare provider then that is still a Stark law violation. If you are a Medicare provider and do this you have made a serious stark law violation. You cannot have any gifting or incentive to receive a patient. It is a non-influence policy with Medicare. For cash patients there are no specific laws I am aware of, but it is in bad taste and will offend other medical doctors and bring you unwanted negative attention.
Another question is, “Can I do dental sleep medicine without the HST for titration?” Yes you can, but not as well. You will never know the objective results unless the patient is tested and you would rely on the sleep physician to verify your treatment. Also you would not have all the tools to know if positional therapy is needed.