Welcome. I'm Dr. Claire McGorry. I'm moderator for this evening's webinar on dental site medicine and less than perfect teeth. I am joined with our speaker, Dr. Kevin Postol. If you're able to see and hear me right now, that means you've successfully logged in. All participants audio has been muted to ensure everyone can hear us clearly. Zoom webinar allows you all to submit questions anonymously using the question answer button on the bottom of the screen. You can also upvote a question by clicking the thumbs up below each question entered. So we're going to respond to the questions either verbally or with written responses at the conclusion of the presentation in the order of upvotes. So if you want something asked, feel free to thumbs it up. And finally, the AADSM does not endorse any services, products, devices, or appliances. The use, mention, or depiction of any service, product, device, or appliance during this webinar should not be interpreted as an endorsement, a recommendation, or preference by the AADSM. Any opinions expressed or communicated regarding any product, device, or appliance during the webinar is solely the opinion of the individual expressing or communicating that opinion and not of the AADSM. Whenever possible, presentations should be supported by evidence. In instances where evidence is lacking, speakers have been asked to verbally disclose that their presentation is case-based or based on clinical experience so that you can use independent clinical judgment to make decisions for your practice and patients. And now I'll turn it over to Dr. Postol. Thank you, Claire. Good evening, everybody. I hope everybody had a great day today. And thank you for taking the time out on this busy Thursday evening. I'm sure everybody has many things they could be doing. And hopefully in the next hour, I will share with you some of my clinical cases and those of some other people I've gotten clinical cases from of doing dental sleep medicine on not-so-perfect teeth. To give you guys a little background, yes, I am the current president-elect of the AADSM. I have been a general dentist now for the past 32 years. I started doing dental sleep medicine 17 years ago. I've been a diplomat of the academy for the past 12 years. I recently, this past May, I sold my general dental practice. And as of beginning of May, I am now just doing dental sleep medicine on a full-time basis. So if anybody ever has any questions about transitioning from a dental sleep practice into one is just a sleep practice, I am more than willing to give you my two cents of how that's gone. Now, needless to say, before I did this, my practice this last year, I was doing about 50% sleep and 50% dental. So it did make the transition a little bit easier. So needless to say, I am always willing to share any thoughts I have on doing dental sleep medicine as a solo entity. I do not have any conflicts. What I'm about to say is my opinion and my opinion alone. I do apologize to anybody if I use the wrong terms at times. I am not a mastery graduate or somebody who's taken all the courses some of you and hopefully most of you have taken. A lot of my training came, as I said, over 12, 13 years ago. I would like to first thank these people for helping contribute some slides. Some of them are my mentors, some of them are my colleagues. And I have found through the years of dental sleep medicine, probably more so than general dentistry, it really does help to have people you can turn to when you've got questions about cases, about what to use, what appliance to use as we're going to go through tonight. And hopefully I can be a source for you in the future as you need it. At the conclusion of this presentations, we're going to go over the different categories of appliances, being four of them for the most part, a fifth one if we consider the tongue retaining device. We're going to look at how each of these appliances can be beneficial to each patient and how each one of these appliances will fit into different situations. Because a lot of times every patient, no matter what they're come and present with, there's always more than one appliance you can use. And one of the biggest questions I always get when people are new to dental sleep medicine is what appliance should I use? And the answer is there's never a correct answer. There's always multiple answers you can use for that question. But when we look at contraindications of mandibular advancement devices, there are four main ones that we always look at. Can the patient bring their jaw out enough to actually make a difference? And if you do this enough, you're going to have patients come in there, especially some of your older patients who cannot move their jaw on their own. They just simply cannot protrude their jaw by themselves. Unless there's something wrong with your jaw, you will find that a lot of these times you can actually move these patients by actually just titrating the appliance. So don't always look at that as a reason not to do an appliance. When I get patients that come in with TMJ symptoms, I actually revel in that and think I'm going to be able to help them with their TMJ problems with an appliance. Sometimes it might only help them during the night and you've got to do something at the same time during the day. But don't ever think that because somebody comes in with a painful jaw that you can't help them with a device. I have found it just so much differently. You'll see some people who think that patients that don't have at least six teeth or they have teeth that are paradigmatically unstable or they have decayed teeth, that's a judgment call that each of you have to make. I will show you a case here very shortly on a patient that I did a device on three teeth. I've done them on a couple implants before. I've done on patients that have had broken teeth, teeth that they're going to replace. I've done it on periodontally involved teeth that they're not going to treat at the time. You've got to decide what's more important, their health, especially if they're not going to wear CPAP or their teeth that they still might not even restore even if you didn't do anything for their sleep apnea. So that's a judgment call where you feel comfortable. Some people aren't comfortable even moving a patient's bite at all. So the comfort levels lie in each of us dentists and we've got to make that decision on our own. But when we go through the patient selection criteria, I've actually had an interesting week thinking about this, and the regard is that there's about 18 different things we each look at when we try to pick out an appliance for each patient. You know, we look at are they grinding their teeth, patient preference. So many times that people think a patient won't wear a certain appliance and I have found out it really comes down to the dentist and how they go about explaining each patient's, the different appliances. Tongue size, does tongue size make a difference? There are certain appliances I won't use with a larger tongue and there's certain appliances with a larger tongue I want to do, manipulate them more to give patients more tongue space, especially with some of my male patients. If the patient is indentulous on the maxilla or mandible, I have found in my own realm, the indentulous maxilla is easier to work with than the mandible. I have tried working with indentulous mandible and without implants, I have failed every time I've done it. Severity, I don't find severity is a big problem nowadays in picking out the appliance and the realm of how can that appliance be best used by itself or in combination with some other therapy. The size of the patient's mouth can play a huge factor, especially if somebody's got a small mouth, you don't want to put a big appliance in their mouth. Male or female, how does that play a role? Nasal or oral breathing, you don't want to put an appliance in their mouth that the patient feels like they become very claustrophobic at times. I look at some of these appliances nowadays with maximum vertical opening. Can I open an appliance more vertically? Am I limited by the types of materials that are available nowadays? Some of them are, some of them aren't. Some of them you have to remade if you want to use them on a regular basis. Can all the appliances be brought out far enough? Most appliances nowadays have a protrusive range of at least six to seven millimeters. You can a lot of times have them reset to even bring them out further. It's all about where you have these patients start with that makes an ability of how far they can actually protrude and if it's necessary at times. There are a lot of times that I feel like we might actually be over protruding some of our patients and sometimes it's maybe just opening them up vertically and protruding them a little bit. That goes to trying to figure out what's best for each patient. When we look at gag reflex, you'll have patients come in that will tell you they gag on different things all the time, have a very strong gag reflex. I like you've probably worked on some of these patients dentally that it can be very difficult. In sleep I found them not to be as difficult. Most patients can tolerate our oral appliances especially if they don't touch their soft palate or any of their portion of the heart palate at all. Clostrophobia is a huge issue for a lot of our patients in the realm of they've had issues wearing their CPAP. They come into talking about how the CPAP made them claustrophobia and they're very aware of it now and you've got to make them feel comfortable with each appliance selection that you do that they're not going to have the same problem. Our older patients you've got to see what they can do when it comes to adapting these appliances to them. Are they going to be able to move the appliance? Are you going to have to have them come in? Are these patients live long far away? Do they have something that can help them with their appliance? All these things come into the factor and then the number one thing you've got to look at is the cost of the appliance and then that really comes down to not only your cost but are you in network with insurance? Are they requiring you to use their insurance benefits? Are they a medicare patient? All these things come into factor so these 18 areas all play a role that you've got a very short amount of time to decide what appliance is going to be best for that patient and even if you've selected what you think is the most perfect appliance I'm going to tell you up front you're going to make a mistake. I've had it happen. I had a girl come in this past week that we made her a nylon appliance because she wanted something small that didn't take up a lot of room. The problem is she had very short teeth and I could not get the nylon appliance to adapt to her teeth because it just kept coming off so I had to make another appliance and the question is who pays for that? In my office I pay for it. I never charge a patient for a second appliance if I feel like I didn't get the first one to fit properly but that's again each person and each dentist's role of determining where they feel comfortable with that in their own office. Appliance selection. We all know we have lots of different appliances, lots of different offers that we can offer our patients. I think it's important that we have different appliances in our office to show patients what we can do. Appliances that can be connected in the front, connected to the side, have less room in the front, have more opening for you. There's lots of different appliances that you can get. It's very important we as dentists try a lot of these appliances out so we understand how they work, how they fit, and what's comfortable, what's not comfortable. You might find some of these appliances not very comfortable or very friendly for you to use whereas other dentists might find them all comfortable to you. There are certain ones I like, certain ones I don't like in my own mouth and does it sway me in how I talk to patient about selection? It probably does but there are times that my selection does come down to what I think is best for the patient even though it might not be something I'd want to wear in my own mouth just based on what they've got going on. Which appliance is right for each patient? As I said there's many different choices. What choice is right for each patient depends on what's going on in their own circumstances, their own dentition, what's going to happen down the road, what their atomy is right now, their dexterity. I had a patient recently who came in who's actually just talked to him today. He's a quadriplegic. We made him a nylon type of an appliance. He's having issues keeping it in his mouth and the question is he does have caregivers there but you've got to have something that's easy for him to take in and out and not feel claustrophobic or have other issues. So you're going to have different patients that are going to have different needs at all times. So does appliance design make a difference in efficacy? What we have found out you will note your manufacturers are going to tell you there is. What we have seen from studies the two studies I've got mentioned down here is that there is no different. You can make all these different appliances and I tell that to all my patients there's all these different appliances out there and every one of them if we treat them at the same position as long as they can wear it there should be no difference in what their outcome of their sleep is. Does appliance design make a difference in the compliance with treatment? Absolutely. I will tell you recently I had a dentist I made appliance for because he had tried to make an appliance for himself. It was an appliance that was an attached midline traction device and what it was is after he made it he could not stand it because he was he felt like he was too trapped. When I looked at his mouth and tried to give him some advice what we found is he had some premolars taken out he was very claustrophobic he liked to grind his teeth that type of an appliance just didn't work. So we made him a different type of appliance and he's doing wonderful with it now. He's sleeping much better and he's feeling much better about appliances now for his patients that he does refer to me. But yes it is possible that compliance does make a difference with our patient. So remember when you have these patients in their your office there's both a science and an art what we do. The science we know these appliances work. We know from all the research that's been done previously and will be done in the future that these appliances have overall about a 50 percent efficacy of working correctly for all our patients overall. Our more mild patients we have an 80 to 85 percent efficacy and for our moderate patients a little bit less. But where we have to put these patients in the end is different for every single patient and that's where the art comes in. The art of knowing where to put these patients getting them to a place that they're comfortable that they're sleeping better they're feeling better and then either doing a pulse oximeter in your office doing a home sleep study or sending them back to your local sleep physician or however you do it in your own office to find out where that patient needs to be in the end to make them have the best night's sleep they can possibly have and have their apnea as controlled as possible. But when we look at the categories of appliances and I'll be the first one to tell you it's very hard for me with these categories. You know you have the unattached bilateral locking. You have the attached bilateral traction which you can have either rigid or a non-rigid one. Now they make nylon in each of these appliances. You have the midline traction which is the one appliance that's connected in the front whereas all the other ones are connected to the side. You have the bilateral compression. When do I use each of these appliances? You know we're going to go over that here in a little bit but each of them do have their place and so it's always good to have a good selection of appliances. I've even had a couple patients so we've used a tongue retaining device. I actually had a chiropractor coming to my office at one point who had a bilateral compression appliance was doing well but he felt like his tongue was falling backwards. So he comes in to me and we have his apnea under control but he feels like his tongue is still falling back. So he shows me what he'd done. He put in his bilateral compression. He had gotten himself a tongue retaining device and then used the tongue retaining device on top of that to pull his tongue forward. Never seen anything like it. Have never seen anybody try this again but it worked for him. So the point is is that every patient is going to be a little bit different of how you treat them. Some are easy. Some are a little bit more complicated. Some you have to use combination therapies. Some you just like I said are very straightforward. When we look at each of these appliances you have the first one the bilateral interlocking which is an appliance that I use at times. It's a good appliance. It allows patients to open and close their mouth. It allows them to us to move the wings forward. I do on all my appliances make sure we put the elastic bands on them so that that way the patients can keep their teeth closed. It doesn't keep their lips sealed but it keeps their teeth together so it doesn't fall open. I find it's important to do on our appliances. You'll find some of your patients might need to double up on the elastics. Some patients won't use the elastics. Everybody's different how I feel but I feel like it's an important thing to offer your patients to have that ability. Some of them will have bruising to the appliance. Some of them will have just acrylic on it. Every lab you use will be a little bit different and you'll find a dorsal the type of bilateral interlocking appliances. Lots of different manufacturers make them. Some of them will have the wings that have more of an angulation to them. Some will be more straight up. They all do the same thing. It's just trying to find a different mechanism that the patient finds comfortable to use on a daily basis. I try to tell patients all the time appliances do not work if they're on your bathroom sink. When we look at the bilateral compression appliances, these are the appliances that are going to be a more of a push appliance. It's going to push off that lower mandible so you've got to have something that makes sure you've got good retention with upper posterior teeth. If they don't have upper posterior teeth, I tend to not use this appliance. Again, it's an appliance I find it's important to have elastics for patients to keep things closed, keep their teeth closed. You have both the bilateral traction flexible appliances that are made by different manufacturers with the elastic straps. It's an appliance you're going to find that is a little bit more forgiving for patients to wear. It's a little bit smaller. It also is a lot less durable than some of the other appliances on the market, but it's a good appliance that some patients want. It's a cheaper version that sometimes help our patients out if they're not sure about an appliance working for them. You've also got the rigid bilateral traction. Again, many manufacturers make them. Some of them have the rigid straps. Some of them have the non-rigid straps on the nylon type of appliances. Again, good appliances. The downside to them is that retention can be a little tricky at times. You also find that if you ever have to open vertical, it's not an appliance that you can add to at all. And then lastly, you have the one appliance that is connected in the front. It's important to keep in your arsenal. I think it's a good appliance when we have some patients that might be missing multiple posterior teeth. You've got to have something to retain to. I find this one works well in certain indications. How you connect it together in the front, there's multiple different ways that they can be connected in the front. It's also an appliance that a lot of doctors will use for a lot of our combination therapy patients. It's less bulky on the sides. You can have a lot more tongue space in the posterior region, but it does take up more tongue space in the front. So if that patient wants more tongue space in the anterior region or if they're claustrophobic, I tend to stay away from this appliance. And lastly, the tongue retaining device. If you've never tried one, I would totally recommend trying one. It's a device that works well for some people. It's a device that can be very irritating to the tongue. I have a tendency to use it more for my denture patients when there's nothing else that I can do for them if they don't want to get implants or they're out of resources of where else they can go. So it does have its place. It's a very limited place. It also is a place sometimes people use it for patients that got periodontally involved teeth. I tend to not go this route for periodontally involved teeth but it is a place you can go. Oh, as we know, dental sleep medicine is not an exact science. There are lots of different appliances. I just found out recently that there are now over 240 FDA approved appliances. It's a lot of appliances for us to decide. And all those appliances also can have many different materials placed inside of them for patient comfort and fit. Do you want more of a rigid fit? Do you want something softer for the patient? Do you want something that you can realign? Lots of different ways of going through these appliances. You could probably go thousands of different choices. And then on top of that, these appliances nowadays, we know that there's 96 of them that are FDA approved for the E0486. And then we have another 15 appliances that have got the K code approval. So again, lots of different appliances for patients, lots of different manufacturers are getting approval for different things all the time and every day and things change dramatically on a daily basis. So what we're gonna do now is we're gonna go over a couple of cases. I've got actually five cases we're gonna go through. I'll be the first one to say, you might find a different way that you would treat each of these patients. And the whole point is, is that every patient can be treated differently. This is just the way I decided I wanted to treat these patients. So when we look at Sean, Sean was a patient who came to me, he was snoring, he had witness apneas, excessive daytime drowsiness, he had moderate sleep apnea, he had desets, he had times where he was stopping breathing of over 30 seconds. And because he was younger, he didn't wanna try CPAP. He was not married at the time, but he had a girlfriend and it was just something he was not willing to do. He wanted to get a better night's sleep, but he was not ready to therefore convert to CPAP. And I will tell you, this case I did about 12 years ago and Sean's in his mid 40s and he's still born in oral appliance. Actually he's on his third one now with us. Sean has upper denture and a lower partial, which I'll show you in a second. He does wake with headaches and he has no TMJ issues at all. But when you look at Sean, Sean basically had five teeth for me. His upper teeth were impacted and his lower teeth were not in the greatest shape. Actually this tooth here had a cavity in it. Sean, as you can see, has a very low dental IQ. Huge tongue. Sean had a very narrow and short dental arch and a very high palate. Makes this case very challenging. There's lots of ways we could actually look at this case to treat it. Do you treat it with him wearing his denture and partial or do you treat it without? My own rule of thumb is now, we'll go here. So, you know, Sean had lots of considerations. You know, he wake us up with a dry mouth every day. It was because of the fact that he was on medications for high blood pressure and anxiety. Cost was a big concern with Sean. This was a case that he did not have medical insurance. So he was paying all this out of his own pocket. And he also, because he felt like he grinds his teeth, he wanted to be able to move his jaw around a little bit when he slept at night. So what did we decide? Key considerations is Sean was missing some upper teeth. He still had some of his lower teeth, even though they weren't in good shape. I did explain to Sean, if he didn't keep those teeth, it was going to be very hard for him to wear an appliance. And Sean has become better about his home care. And then he had, like I said before, he had mildly narrow dental arches and he had a big tongue. So the question is, what did I do? We made Sean a unattached bilateral interlocking. And I apologize for not having better pictures. I was actually, I thought I had better picture, but basically what I did was I did this case just like a denture in a partial case. You know, we took an impression of his upper ridge. We made wax rims. We made a wax rim on his lower arch. I used a gauge then to get a protrusive bite, just like you would have with somebody with teeth. And then we made him unattached bilateral interlocking. I've had very good results with these because they don't pull off. I can make the upper just like a denture, so I get good adherence to the palate. And I know that for the most part, it's not going to flip out of his mouth. What other options could I have done? I could have given Sean a tongue retaining device and been done with him. I don't know if he would have worn it very long. The bilateral compression device, I have tried with these patients before. I don't get a good retention. Maybe somebody else does. What I found is because he doesn't have back molars, I find that these pull off a lot. So that's part of the reasons why I used the bilateral interlocking. Let's look at case two. Ed, the big concern was is he had these huge toroi on his upper and lower arches. Ed, who was 52, very loud snore, which a lot of our older men are. Witnessed apneas and excessive daytime drowsiness. He has high blood pressure and AFib. He also has moderate sleep apnea. And he did stay out a little bit longer than our last case Sean did, meaning that he probably is holding his breath a little bit longer than Sean does. He tried CPAP for about a year. And unfortunately, like a lot of our patients, after about a year or two of using CPAP, he got to the point where he just couldn't use it anymore. And I think part of his problem was, is that he was a grinder. And CPAP really makes it hard for people who grind their teeth. And some patients, even with CPAP, will still grind. And he just became very claustrophobic. Ed also had no TMJ issues to speak of. Ed had an overbite of four and three. He was a class two patient. Not a very large tongue, as you can see. He was mildly carotid. He's got a very narrow arch, higher arch palate. His big issue is these tori. These tori became an issue. Ed had all his teeth. Teeth were in fairly good shape. So that was the issue. So the question will be is, what do we do for these type of people who want to grind their teeth? Ed did have dental insurance. So as much as cost is a concern, I am in network. Some of you who are not, that's gotta be a question you've gotta ask. Ed, 80% of his events were on his back. As we all know, patients do much better on their side. That's for another discussion. I have given up the thought of trying to get patients to always be side sleeper. I've tried it for many years. I think it's hard as people get older to change their methods of where they're sleeping. Certain people do better at it. I have struggled with doing that. If trying to get people to switch from side back or on their stomach. Oh, we're at key considerations. He's moderate apnea. He's a back sleeper. He breathes with his mouth. He grinds his teeth. He's claustrophobic and he has a mildly neural dental arch. Well, I first made Ed in a pitch bilateral compression. Worked great for about the first eight months. And then as you can see, this is Ed's appliance after eight months, he had bent the bars. And we did this three times on him. He kept bending the bars. So the question is, what do you do then? And then who should have to pay for it? Like I try to tell my patients to do that. It's better to bend the bars than to break a tooth. So you've got to have a reason why the patients are doing this and try to figure out what you can do to help them stop that. There's many different things you can try to do. I will tell you that I now, if you look at this case here, I use different bars on my Herpes appliances. These are new bars that I got from a lab that are actually a little bit more durable and do not bend as much. I could have made Ed an appliance that was a attached bilateral traction device. I've had patients where I've actually had them in the mouth with these large tori. And what I wanted to point out here is there's times where you'll put these appliances in and they feel something hitting there. And I've actually had to cut straps in order to get them to fit above their tori. So you've got to watch the tori. You've got to make sure you keep these appliances on tooth-borne only and away from their tori. Ed ground his teeth, so I wanted something very rigid. I didn't want to use something that he would have a tendency to break or push off the bands. I could have used the bilateral interlocking with him. I think it would have been fine. I could have used more of a bilateral rigid traction here. I think there's lots of different options that I could have done with him that would have all worked. It was just my choice to go with this appliance here. And for the most part, it worked until he started bending bars. And since I've changed the bars out to more rigid bars, he seems to be doing much better. Phase three, Mike came to me. Mike is one of those patients that is a difficult case. He was not one of my dental patients. You'll see them, especially if you do more sleep. Mike really doesn't care about his teeth much. Mike had active gum disease. So the question you've got to ask yourself is, do I want to treat him or not? Or do I want him to get his gum disease taken care of before I ever treat him at all? Again, that's something you've got to ask yourself. As you can see here, Mike, like the other two cases, was a loud snore, difficulty staying asleep, significant daytime drowsiness. He was more of a severe patient. ZSATs weren't as bad as our last patient, but he still had some significant ZSATs. And he had tried CPAP and couldn't sleep with it, did not do well with it. I did ask Mike the issue with why he could not use a CPAP. And what we found out is in Mike's case, it just made him very claustrophobic. He didn't like something on his face. I think it's very important, especially our more severe patients, find out the reasons why. What is their reasoning? What is their why? Is it because they don't like how it feels on their face? Is it the tubes? Is it the noises? Do they get mass leaks? All those play a factor, especially later on when you're trying to figure out how best to treat these patients. So Mike came in, and as you can see, Mike had an overbite of over jet of five and six millimeters. He was a class one patient. He likewise had a large tongue. He had a little bit of degeneration in his right joint, no pain. And he had moderate to severe periodontal disease, especially in the back area, which he was at the time not going underneath active treatment. Mike, in his mind, dentistry was not very high on his priority list. I do tell these patients, if you want to wear an appliance, you need to keep your teeth, otherwise it's very hard. So a lot of times that can be a motivating factor also. I did look at Mike and go, we have a guy here who has periodontal disease with tooth mobility. He has severe sleep apnea, and he can't tolerate CPAP. So what appliance is right for Mike? So in Mike's case, we use an unattached bilateral interlocking. The big one with this one is, what did Mike do underneath it? So Mike, during the day, wore Essex retainers to try to keep his teeth from moving too far and to keep his teeth in the place. He felt comfortable with them. There are times where I've made the appliance over the top of him. Sometimes I'll have the patients take them out and make them right over there, tell them that we will try to keep everything in place. I tend to, on these patients, use a more rigid appliance that's going to keep their teeth in place so they don't move. I don't want something that is a little bit more forgiving on either. Like the AccuFit, I want something that's more of a milled appliance in these patients so that things can't move at all. My only concern sometimes with these patients is that if they lose a tooth down the road and they have to have something replaced, am I going to be able to get this appliance to fit with them at all? So those are all questions that you have to talk to your patient about what's going to be best for them to use in the long run. Oh, in Mike's case, the other options Mike had that he could have done was that he could have used at some point some combination therapy if he felt that that was best for him. We could have used lots of different appliances on him. I think any of these appliances would have worked fine. I would have been a little leery of trying to use the midline traction device just because he was a little bit claustrophobic. So I would have tended to stay away from that one. But I think for the most part, all the other appliances, I think more importantly for Mike in his case, I think it would have been more importantly about what you use underneath your appliance and to make sure that those teeth stay stable and they're not moving if Mike's grinding his teeth. I think that's very important, not only to look at the outside of the appliance, but also look on the inside of the appliance of what you're putting against those teeth. Every patient's got a little bit different dentition when they come in. Do they have large fillings? Do they have mobile teeth? All that comes into effect. So not only when we pick out appliances, we need to look at the outside of the appliance, we also need to look at what we're putting on the inside of the appliance. Well, Frank is a 70-year-old male. He is a patient who likewise has moderate to loud snoring and witness apneas. He can't wear his CPAP because the mask leaks. So he's also got some medical conditions. He's got moderate to severe sleep apnea and he descends worse than the other three cases. So he's got some issues going on. And as you can see, when he's in the supine position, he's a whole lot worse. And the issue is he sleeps more in the supine position, even though he'll tell you that he sleeps in the lateral position as you'll find most of your patients do. Frank has an overbite, overjet of five and six millimeters. He's a class two patient, he's got a large tongue. As you can see, he's got a bridge in the anterior region of his mouth. He's missing his lower posterior right teeth down here and he grinds his teeth. So there's lots of different things that are coming to play. He's also got a lot of worn teeth here. He's got a large flame here. He's got some older dental work. He's had lots of things going on in the past. And I'm not gonna sit there and say that he won't need more dental work down the road. All that comes into play and to make sure you get an appliance that fits, it doesn't pull off on this lower right. So lots of things to think about when you're thinking about Frank of what we need to do best. Luckily, the one thing he didn't have going on is he had no TMJ issues. So like I said, he's missing multiple teeth. He's got the anterior bridge, lots of dental work, mildly severe OSA. And his other thing is he was a Medicare patient. So he wanted to make sure he could use his Medicare. Cost was a huge concern with Frank. So I use on Frank a midline traction device. We were able to make him a device that he wore well. He seemed to do well with it. I got good retention from his front teeth. I did put a material underneath the device that if he has to have more dental work, I can adjust for new dental work being done. In this case, I also did that just in case we went to combination therapy, which I will tell you at this time, Frank is in combination therapy. The combination therapy are done separately. There are people who will combine the CPAP and the oral appliance together. I have done a few of those cases, but for the most part, I would say 95% of my combination therapy cases are with CPAP and oral appliances can be done separately, very easily. It's trying to find out what it is that that patient didn't like. In Frank's case, it was the mask leaks. Once we were able to get the oral appliance in his mouth, we were able to bring his pressures down, the mask no longer leaks. Frank did much better with the two combined. Likewise, there was other appliances we could have used to help out with Frank. We just found that this one's gonna be best, but there is nothing wrong if I were to try something else. My big thing, like I've said about the bilateral compression is I don't mind using an appliance as long as they have their upper teeth. I do not use the bilateral compression if they're missing the upper posterior teeth. Likewise, I will not use a bilateral traction if they're missing lower posterior teeth. So then we're gonna go to our last case. Our last case is an interesting case. We find one female, Betty. Betty came to us with no teeth. She had lower implants. Betty, as we see, has mild sleep apnea. She was, they tried CPAP for her first, but she had lots of issues with CPAP. As we all know, you'll get many, many reasons why patients can't use CPAP. It could be sinus infections. Our number one reason is the air into the eyes. I think that's the number one reason why my staff hears all the time. We also, I had a lady in the other day who gets nosebleeds every time she uses her CPAP. You'll have some people who get aphasia. Lots of different reasons patients can't be using CPAP. Try never to downplay CPAP because you don't know down the road if you're not gonna be using CPAP or Inspire with these appliances. There's lots of different combinations. If it's trying to do lateral sleep, it's weight loss. We have to keep our arsenal always ready of how we can treat these patients. Our goal is to get these patients as healthy as possible. Oh, this is Betty when she first came in, she had upper and lower dentures. As you can see, she was in a little bit of crossbite. These dentures were made by a different provider. They fit well, she was happy with them. I also didn't wanna put anything over the top of her dentures. I'm just not wanting to open them up that far, even though they do have their teeth like that. I'd rather do it with what I'm gonna make her. Betty had two implants on the lower. She has some mild degenerative joint disease in both her right and left joint, but there was no TMJ symptoms. So, there was nothing that really made me think we shouldn't try to do an oral appliance with her. My only thing is always when I talk to my denture wearers or places with implants, I do have an upcharge for doing the wax rims and making them just like dentures again. And for the most part, I've never had a problem with that. You just do it just like you do a denture. You make your wax rims, you make final impressions and bite rims made from study models, just like you do a denture. And then you have, you take a bite registration, just like you would any other case you do. You act just like their teeth. Sometimes I've done it where, like I've said before on these patients where I'm missing upper teeth, I like bilateral interlocking appliances because I can get very good retention on the upper arch. The housings in this case were picked up to delay of her oral appliance. When we got good retention, there's times where I've done it where I've had the labs, put them in there. You can do it multiple different ways. If you feel comfortable putting your locators in, if you feel comfortable letting your lab do it, however you want to do the best. I've had very good luck though, using bilateral interlocking with these patients for these denture patients. Again, I could have used a tongue retaining device. There's lots of different options. I could have used an appliance that was a bilateral compression. Again, because she's missing teeth, not a big fan. I know some people do it and that's why I bring it up because it just shows you. There's multiple different methods of treating each and every patient. Oh, we're going to look at a couple of cases real quick before we open this up to some question and answers if anybody has any. The question always is, is what do you do about those cases when you get an acrylic type of an appliance that doesn't fit because you've got lower retention issues? Meaning the patient comes in and the appliance wants to pull off because of either the elastics or it just doesn't have good retention from the lab coming in. Is it something you have to send back or is it something you can add to? In our office, we've come to the conclusion that we will heat these appliances up as much as we can and try to soften them and then try to mold them on the model or mold them in the mouth to get better retention. And we have very good luck with it. The same thing, if they're too tight, we'll heat them up and put them on their models and we have good luck of getting them to be more comfortable with teeth. There's times we'll add Bowacryl, there's times we send them back to the lab. So retention is just a matter of trying different things in your arsenal to help that patient so they can start being treated as soon as possible. So when you look at retention, I had an example, I had a girl come in about a month ago, 21 year old girl, very short teeth, very small teeth in the back and she really wanted something very small and easy to wear. When she looked at all the appliances, we decided we would try a nylon appliance. Unfortunately, after heating it up multiple times, the retention on it just wasn't where it needed to be. Every time she put it in, it failed. So we ended up going with a, the attached bio-attraction with the flexible straps. And after adding some Bowacryl to the appliance, I got very good retention and we were actually able to make it very well for the patient and she's doing great in her office now wearing that appliance. Again, I could have done a little bigger appliance, there's other appliances, but I was trying to keep them as small and as simple for her as possible. Retention issues, again, how many teeth the patient has? Do they have back teeth or not? Or do they have anterior teeth? Do they have bridge work? All that comes into play. Do they have crowns? Do they have decay underneath those crowns? All that comes into play when you're gonna decide what appliance to use. And as I've said before, as important it is to look at what the outside of the appliance is, it's also just as important to look on the inside of the appliance for that patient long-term, because these patients are gonna have these appliances, hopefully for at least a five-year minimum, but a lot of these appliances, these patients are gonna get five to 10 years out of it before you hopefully can replace the appliance. Again, these patients, they have dentures cases. There's only certain appliances that seem to work for these patients. I tend to stay away for bilateral traction devices. I tend to stay away from the bilateral compression devices. So I tend to stay more on the midline traction or the bilateral interlocking for these patients, just because I get better retention for these patients and they do better. Some of you might have better luck with some of the other appliances. That's just in my own realm of me treating all the patients I have done over the last 17 years. When you have patients that come with large tongues, what I wanted to point out with these appliances, there's nothing wrong with making, especially if you can get good retention with your appliances on their anterior portion of teeth, is to either, let me go back, sorry about that, to go back and making these appliances lingualist on the, for the patients so they get more room for their tongue, taking off as much or scalping these appliances as much as possible so that the patients can have as much room for that large tongue as possible. However you can do that, if it's using an appliance that's made out of acrylic or nylon that's thinner, or if it's making some of these other appliances more, less, have it lingualist on the backside, there's different arsenals you can do to help your patients along. This last screen has got lots of cases, and what I wanted to bring up about this last screen was this. As you can see, you're gonna have patients come into your office that are missing teeth, have decay, that tell you they wanna get some teeth done later on. How you go about that are if they're in Invisalign and they've worn an appliance before, but they wanna be treated while they're in Invisalign, you gotta have an arsenal of ways of treating these patients. I've had patients come in and tell me they wanna restore some teeth and they're missing a bunch of teeth. I'll send it to my lab, have teeth waxed into a final case, and then have an appliance made like that. It depends on which appliance. I will tell you certain appliances that are harder to adjust, I try to stay away from them. I am not a big nylon fan. I am more of the bilateral interlocking or the bilateral compressions or even the midline traction on those cases, just because I can subtract and add and you've gotta think about what I'm putting in the inside of that appliance to make things better for that patient. I've had patients get bridge work that we've been able to adjust. It's about taking impressions of the underside of the appliance for the labs so they can do it right. If you start doing dental sleep medicine on your own, you're gonna have patients that then have different dentists, making sure that that dentist knows what to do to make sure that your appliance works best. I never realized how hard that was until I sold my practice and I'm now working with that dentist in my office on the current basis. And he has no realm of what an oral appliance even was. And the first few times that he did dental work on some of these patients, he made it where it was very hard to get our appliances to fit again. And I even explained to him on a daily basis what he should do. And it is amazing. The dentists out there who have no realm of dental sleep medicine, when it comes to our patients who have oral appliances of what to do to make sure things fit correctly and positively again. You'll see in this middle screen, I have a type of a temporary device that I actually made for a couple of patients over in Invisalign. They would come in with, they were actually patients that I had done oral appliances and then now decided down the road that they wanted a T-Straighter. I made their, they had their Invisalign done. And then while they were doing the Invisalign, we made them a temporary of appliance that we could adjust as needed. There's lots of different varieties of appliances that can be temporary. And you wanna make sure that it's some type of soft liner that can be adjusted so it doesn't get caught and it can adhere to the Invisalign traits. Usually these patients, you've got a starting position and an ending position of where they need to be. And so you can set them pretty close to where you need to be. Lastly, when you look at this case here, you've got a patient who's got a very deep bite. So you've got to worry about some of these patients with their Curvus B and Curvus Wilson about how you do their appliances, making sure you've got an appliance that when they close down will actually fit properly. You're gonna have appliances come back that fit great and then they go to bite into them and you can't get them together. And it's because of that arch in the back of the ramus that it's not long and close. So there's lots of different things you've got to look at with the dentition, not only the teeth, but also the soft tissue. We have to remember, the lab gets the teeth, they don't get any of the soft tissues. They don't get to see where the ramus is. They don't get to see how far back that pellet goes when they're making these appliances. So we got to remember that when we're doing those appliances. With that, I actually gave you a little handout that was done by Jonathan Parker for the last few pages. I felt Dr. Parker did this a few years ago and it gives you a good mechanism of what to look for when you're looking at each patient, especially when you're starting out of what appliances to use on different patients. So I hope these last few pages you'll find useful and you're helping select patients the proper appliance for their sleep apnea. And with that, I am open to any questions. All right, let me start my video here. If any audience member has a question for our speaker, please submit your questions using the question and answer button on the bottom of the screen. I'll be asking questions from the top down, so please make sure to use the upload feature. Also, in some instances, your question may be answered by a moderator. You can click tap to see moderator's answers. So let's go to the Q&A here. The top one is, can the doctor repeat what appliances to avoid with MACs and mandibular missing posterior teeth? So on, if patients are missing the mandibular teeth, I really try to stay away from bilateral traction devices. And it's just because of the fact is that you have any, the attachments are on the posterior teeth, it tends to rise up. Whereas on patients that are missing posterior maxillary teeth, I tend to stay away from bilateral compression devices. Thanks, all right. So what material did you use on the antagonist surface with the anterior midline traction case to allow for relining in an area if needed? I have a tendency to use a lot of Thermacrol in my office, especially on those patients that are gonna possibly need dental work or have ongoing treatment while we're doing these appliances because I can heat it up, I can add, I can subtract. That just seems to be my go-to material for patients that I have found that might be needing some dental work or have dental work that might be successful to damage down the road. And then it looks like there's a couple of questions that just looking to get those last couple of slides from Dr. Parker and wondering if they're available. I think they are available. Yeah, they are available. So we can make sure that those are. Dr. Parker wanted everybody to know, please share those slides with everybody. Great. And then one of the patients has a spacing with upper teeth as well as within lower teeth. The person was, Miguel, was considering an Evo from Prasomnus. What would you consider using patient on this excellent oral hygiene, no cavities, but heavy spacing, it seems? I would have no problem with an Evo appliance. It's a very rigid appliance. It holds things still. I'd have no issues with that at all. I have a tendency when I have a patient that comes in that has good oral hygiene, has spacing that we wanna keep where they are to use a more rigid type of an appliance. Totally agree. And then it says, what appliances should be avoided with patients with a deep bite? I have not yet found, what I found a lot of times with these patients with the deep bite is I end up having to cut off the upper second molar portion of the appliance to get it to seat all the way. That's my bigger thing. So I have a tendency to use more of a bilateral traction device because they're a little bit thinner. So I can use, wrap the distal of the molars around. But with a lot of those cases, I end up, by the time they bite down, I end up having to cut those areas off anyway. And then what would you recommend for class three patients? Hopefully they don't come to see you. Hopefully they're not sleep apnea. Cause I'll tell you, I've seen very few sleep apnea patients who've got class three. I always worry that I can actually help them. But I have had a few of them. I don't think there's any change you have to make for class three patients. I've never done anything different with them. I've used probably every appliance out there for class three patients with no reservations about the appliance. Do you typically set your bite at six millimeter interclusal or do you adjust change for different patients in different appliances? You're gonna hear different realms and different things. Trish, you probably wanna close your ears now. I have a tendency to find out where their maximum protrusion is. I usually back them off six to seven millimeters from there. I also will look at that even there, if maybe they're only protruding out six to seven millimeters total, then I'll probably start them out a couple millimeters. So it depends on each patient. If you got somebody who can protrude out 10 millimeters, then I'm probably gonna start them out at four millimeters to begin with. Because I don't wanna get to a point where if I had to get to a hundred percent maximum protrusion and I couldn't get the appliance there because I didn't make it my starting point well enough. There's lots of different ways of doing it. You've gotta find what is comfortable to you. I think there was the question though was the interclusal, so vertical. Oh, the vertical, how do I determine vertical? I know there's lots of different devices on the market to look at vertical. I tend not to do that as much. I tend to look at each patient differently. I look at their size of their tongue. If patients come in with large tongues, I will start with them a little bit higher vertical. I also look at lip seal. I think lip seal is very important. And the higher vertical you get, the less lip seal and the more their mouth is gonna be dried out. So especially with my female patients, I usually go a little bit less vertical to begin with, maybe two to three millimeters vertical. And then on my patients that are larger men with the bigger tongues, I'll start out five to six millimeters vertical with them. But I also talk to them about their dry mouth because it could become a very big issue with some of these patients. And then the last question was, do you do mandibular advancement devices sometimes over dentures themselves? And what are you considering when considering it? And I was actually gonna say one more question is I know you had that anterior locator case. Did you engage the locators? I think I missed that, okay. Yep, I did. Yeah, we engaged the locators. Yeah, we put housings on in the denture. And as far as the thickness of those, you don't want it too rigid, obviously, but you want it rigid enough for- Yes, I've had better luck in my own office because the dentures, patients with dentures, they're more rounded and they don't have good retention on them. I've just had better luck making them on the ridge themselves. That way, if they ever have to give a new denture, it has no bearing on my appliance. If they crack the denture, they do something to the denture, they're two separate entities. That's just my own personal preference. I don't want their denture to have a bearing on my appliance. Or vice versa, if they say, my dentist told me that your appliance is making my denture have issues. One of my famous cases, I had a gentleman come to me who had upper and lower dentures, severe sleep apnea. The man would fall asleep driving and he had a wife who was blind who would ride with him to keep him awake. And I'm thinking, they almost drove through my door one time because of the fact that he almost fell asleep with the wheel. Comes in, we make it, he has no teeth, didn't want implants, nothing about it. Made a perfect bilateral interlocking appliance. Fit great, I had really good retention. Comes in a month later, I asked him how it's going. He goes, well, I should have probably told you beforehand, I never wear my dentures either. And I asked him, why did you do this? And he goes, well, it was. So I've done it now three times that I've actually done an appliance in this movie has no teeth and I've had success once. So I tell patients that, I will tell them my success rate on it is very low. So I've had some patients, I've had lots of other patients to just walk away and say, it's not worth it. So I think it's so important to be honest with your patients about your success with these different cases. And it's so important with these patients that come in with missing teeth or broken teeth to ask them, are you planning on doing anything? I mean, I had a gentleman the other day who came in, he had no idea they had two broken teeth. And he's like, well, I might go get those repaired. So we added some block out to those areas so that the appliance could be made so that if he gets the teeth fixed, the appliance will still fit. So you've got to try to help your patients. And then also with that, there are certain materials and I don't want to use inside of the appliance because the Fed says, I want the appliance to fit afterwards just in case the dentist doesn't do what I want him to do because that will happen also.

dental sleep medicine

appliance options

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TMJ symptoms

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compliance with treatment

individual patient

gum disease

sleep apnea

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