Davis, and I am the Practice General of Dentistry near Provo, Utah. Before I get into the meat and potatoes of this presentation, I want to tell you a story about a patient that I had a couple of years ago. I received a phone call from the sleep doctor, and he told me, he said, Doc, I need you to get this patient in really, really soon. I said, okay, great. And so I rearranged my schedule, got the patient in, and while we were doing the patient interview, I realized he was leaving for deployment the next week. There obviously wasn't time to get a custom oral appliance device made, and I was really glad that I had this tool in my tool belt to be able to help this patient. This presentation is going to talk about this tool that can be really, really useful. So without further ado, I want to share some thoughts to you about the use of temporal oral appliances in a dental sleep medicine practice. There are a few things I hope you get out of this presentation. First, I think it's important to be familiar with the different temporary device materials and propulsion mechanisms, so you can better meet your patient's needs. But then we'll also be looking at patient characteristics and histories, terms that could be a good candidate for temporary appliance therapy, because ultimately you want to match device features with patient needs. We'll talk a bit about the ADSM definitions and recommendations. We'll discuss some appropriate uses for temporary devices and some indications, and then in the end we'll do a presentation that will show you how to adapt a temporary oral appliance chair side. When looking at different device material options currently available chair side or chair side fitting, we see several types. One option is made entirely from a single-phase thermoplastic material. This is often referred to as a boil-and-bite appliance or over-the-counter device. Patients routinely purchase these on their own and fit them at home by immersing them in water, heated water, and then forming it in the mouth. While many in this category are monoblock in nature, others like the one shown here are slightly more sophisticated and allow for some calibration. Generally, upper and lower trays are warmed and fit at the same time. When heated adequately, the buccal and lingual flanges can be molded against the teeth to create retention. Although a dentist is better equipped to fit the appliance chair side than a patient attendants on their own, the single-phase material presents some retention challenges. This is concerning because long-term use of a poorly fitting material could presumably increase the likelihood of tooth movement. Another option involves a moldable material in some sort of preformed tray. These pictures demonstrate two different devices that would fall into this category. The one on the left uses a hard plastic tray with a BPS putty in the intaglio surface for retention. This particular device is unique in that it offers three vertical choices and can be calibrated to estimate and can be calibrated to estimate therapeutic position. When appropriate, it can then be scanned as a construction bite positioned for fabrication of a custom appliance. We see in the image how a Barb Parker blade is being used to remove some of the buccal excess material so that the scan can have access to the buccal surface of the teeth. The device on the right uses a more flexible tray along with an elastomeric denture relying material. The result is a monoblock style of appliance, so calibration requires a removal and replacing the lining material in order to change medial jaw position. The inventor of this device calls it the sushi appliance. As you can see, it kind of looks like a roll of sushi. And he mentions that he very rarely uses this, but it's really good for patients who are in clear liner therapy. A final option is designed with a solid plastic tray in combination with a highly adaptable thermoplastic material. This style most closely resembles a custom device. Manufacturers provide a specific instructions and many times videos on the best fitting techniques. Some suggest warming and inserting both arches simultaneously, while others recommend fitting one arch at a time. Unlike the monophase materials, which can be re-warmed for several fitting attempts, the thermoplastic material in these devices are less amenable to re-warming. A clinician might want to order a spare device to be able to practice the fitting before trying on a patient. And that's something I definitely recommend doing. These devices are very technique sensitive and you should practice. Most of them I practice on myself before I try them on a patient. Most of them I practice on myself before I try them on a patient. Also, since the trays are rigid, it is important to be sure the patient's arch form and size will fit within the body of the tray. No matter which style of temporary oral appliance you choose, the fit is very important for retention and avoiding side effects like tooth movement. In instances where the inner appliance are fabricated for use while waiting for a custom appliance manufacturing, tooth movement could affect the fit of the final device. When I was active duty army, a lot of times we would use a device like this after making the scan and while waiting for the custom oral appliance. One of the reasons that we stopped doing that is because we were finding a lot of tooth movement in between the time that the custom appliance arrived and the fitting and the registration. So we stopped doing it because there was a lot of adjustments that had to be made. And we found that it just wasn't worth our time, especially with the rigid tray with the dastardly plastic line material. These tend to have more density to move teeth. So at this point, I think it's important to mention another type of device that is often overlooked. Tongue retained devices can be used for both short and long term management of OSA in some situations. As an example, this can be an affordable solution for patients who are dentalists or for those who do not have sufficient dentition to support a custom oral appliance. Tongue retained devices can be purchased in various sizes and are sterilizable when manufactured from silicone. This gives the clinician the ability to try in several sizes in order to select the appropriate device for the patient in the office before sending home with the device. They can also be incorporated into a custom device as seen here at the right. If you are thinking of making a custom appliance with a tongue retained device feature, I recommend that you have the patient try a prefabricated version first to make sure that they are going to be able to handle a tongue retained device. Many patients find a tongue retained device to be uncomfortable and compliance becomes a real issue. Now, let's talk about options for calibrating the temporary device. When making a temporary device selection, propulsion considerations are just as important as material choices. Just as a reference, I want to remind you of the conventional way to distinguish different styles of custom device propulsion. These categories were originally introduced by ESIC and its group and later modified by the AEDSM for use in their comprehensive training program. Some temporary oral appliances are designed to mimic propulsion mechanisms found in custom devices. You can see with these images of currently available temporary devices that almost all the propulsion mechanisms are represented with the exception of the attached bilateral compression style, or at least if there is one out there, I haven't found it yet. In any case, it can be useful to consider the advantages and disadvantages of temporary device propulsion in the same way you would consider a custom device. For example, if I have a lateral bruxer, I'm less likely to use the unattached bilateral unlocking device and I'm more likely to use the attached bilateral traction device. Now that we've discussed options for temporary device materials and propulsion, we need to take a closer look at our patient. A comprehensive examination and patient interview will help guide your choices. To avoid locking flow materials into deep undercuts during the fitting process, be sure to identify those areas in advance so you can take steps to avoid that problem. This can include tip teeth, edentulous spaces, gingival recession, or even bulky dental restorations. Be especially cautious if there is a fixed bridge where materials can flow under a pontic. Just like when using a VPS analog impression, a little bit of rope wax or other malleable material is effective at preventing this locking in these types of situations. On the other hand, if there is very little in the way of undercuts, retention could be compromised. These images show examples of potentially over-retentive areas on the left and possibly inadequate retention on the right. In that first image, you can see that there are very large abrasions and black triangles. These can be problematic if you don't block them out with wax when molding the device. On the lower picture, you can see the patient has attachments for clear liner therapy. These can create too much retention with the device, which makes it tough to remove after it is formed. One rule of thumb is when looking at oral appliances is, if you would block it out for a VPS impression, you need to block it out for the temporary device as well. On the right-hand side, we can see that the teeth are possibly short and that the embrasure spaces are small, which means that there's less likely to have the retention that we need to maintain the device in the patient's mouth. Keep this in mind as you choose the device materials and planning your blockout materials. It would be helpful to try a tray into the patient's mouth before you make your final selection, but that's problematic since temporary devices cannot be sterilized, with the exception of silicone tongue retaining devices. However, you can often find a sterilizable impression tray in the office supplies that closely matches the temporary device in the general whip. Watch for exostosis as you try it into place. Also, make note of any heightened gag reflex. Observe the tongue's ability to accommodate the tray size. This is also a great time to make note of evidence of that bruxing habit that exists. Your patient evaluation should also consider the desired protrusive and vertical positions of the temporary appliance. It is important to think about the position just as you would a custom appliance. I recommend that whatever method you use for determining the protrusive position of device for a custom appliance, use that for your temporary appliance as well. You can use a George gauge to determine the position just as you would a custom appliance, or a lot of times they actually have a George gauge on the appliance, or if they have a current efficacious appliance, you could also use that to guide the position of the temporary device. Temporary devices have fewer options for vertical changes, so that becomes a little more difficult, but it is still an important consideration during your selection process. So, how can we determine which temporary device restyles most adventation to our patient? To begin, let's talk about some very common patient scenarios. First, when we examine our patients, we should consider both the hard and soft tissues. For example, since temporary devices are generally manufactured as a one-size-fits-all or most, we have to be sure the device can be fitted to the arch shape and size, as mentioned earlier. Some of the trays can be softened with heat and stretched a bit, or compressed into a more narrow shape, but there are limitations to their malleability. When we identify the extent of the patient's occlusal curvatures and their tongue size, we are thinking more vertically. At that point, we want to make sure the temporary appliance we choose can be fitted in such a way to allow for the most ideal vertical dimension for that particular patient. Say, for example, we are highly motivated to give our patient primary lip closure, the minimal bulk and device vertical dimension would be more ideal. On the other hand, you see a large tongue positioned above the occlusal plane. In that case, a greater vertical dimension might prove to be more comfortable and efficacious. And just like with permanent devices, we have to be sure the device is retentive. In a patient with poorly retentive or missing lower molars, a device with bilateral traction might tend to displace the mouth opening or with mouth opening. And a device that is only partially moldable might prove to be the least retentive choice and advice in any circumstance. Then we also have to consider the patient's functional needs. Will they be going through stages of dental restorative work where multiple remolding is warranted? This could guide you to use a boil and bite style of material. Do they have a known nocturnal bruxing habit where an elastomeric advancement system would allow for more freedom of lateral movement? And this could prevent dislodgement. This may lead you to avoid a monoblock or bilateral interlocking device. Do they need to breathe through their mouth at night? If so, consider device design that has space for an oral air passage or allows them to open their mouth. A patient who is known to be claustrophobic will often be more comfortable with the same ability to breathe through their mouth and move their jaws just as we described. In any case, your clinical judgment is critical for choosing the materials and design. So being familiar with multiple devices is very beneficial. Your patient examination interview should consider all of these factors. There will inevitably come a day when you have a patient come with a broken appliance like the one pictured here. The patient may not want to wait until a new custom appliance can be made or they may want to delay for financial or insurance reasons. I've had patients come in with situations like this who say they can't sleep without their appliance and need something right away. A temporary appliance can be a good thing for this. For this reason, I think it is important to keep at least one or two options in stock for immediate chair side delivery. Just like in making a custom oral appliance, it is also important to discuss informed consent for temporary appliances acquired with a patient signature. The ADSM has an informed consent template that can be modified for use in your own office. It can be found on the website under Members Only Tools and Templates. A recent article published in the Journal of Dental Sleep Medicine is a great resource for using temporary oral appliances as well. Next, I'll be showing you a demonstration on a patient, but before we get to that, I hope to leave you with some clinical pearls. Number one, always read the manufacturer's instructions. Each manufacturer is going to have specific directions for best fitting techniques of their product. Number two, when using a thermoplastic material, make sure that your water bath is set to the correct temperature for that type of material. This will typically be between 160 and 180 degrees Fahrenheit. Number three, if you don't have a hot water bath, which many of our practices don't, you may consider boiling water and timing how long it takes for the water to reach the desired temperature or using a thermometer to make sure that it's at the correct temperature. Number four, educate the patient before you begin. Let them know what it will feel like in their mouth and how long you'll have to have it inserted. It's also beneficial to coach them as you go on where and how to position their tongue. So going back to the patient I talked about at the beginning, we were able to make a temporary oral device for him. He deployed and then when he returned, he was able to get a custom device fabricated. So that worked out really well for him. He was able to get the treatment that he needed in that deployed environment. Without a temporary appliance, I wouldn't have had the opportunity to do that. Please consider learning as much as you can about these devices and having some on hand. So with that, let's take a look at the video demonstration of the dorsal style temporary appliance. This particular device allows for individual fitting of upper and lower trace. Please enjoy. Today I'd like to demonstrate a temporary oral appliance for the treatment of sleep apnea or snoring. Before I demonstrate the appliance, I'd like to talk about the definition and some reasons why you would use a temporary oral appliance. So a temporary oral appliance is prescribed by a qualified dentist to treat sleep apnea or snoring. It's generally prefabricated or has a prefabricated shell that can be customized to fit an individual patient and can be calibrated. These appliances are indicated for short-term use, typically three to six months of continued use or 12 months of interim use. This means that over-the-counter appliances do not qualify as a temporary oral appliance. Looking at a life expectancy of these appliances, as I mentioned before, they're typically used for three to six months of continued use or 12 months of interim use. Check the FDA guidance as well as warranty information from the manufacturer before you use the appliance. Regardless of the life expectancy of the appliance, remember these appliances are not indicated as a substitute for custom-fabricated oral appliance therapy. Now, when would you use these appliances? One, if the patient has a lot of restorative dental work or orthodontics. Two, if there's uncertainty that the treatment will work or that there will be compliance. Three, if the patient has a short timeline. For example, if they're going on a very long business trip and would like treatment during that time. Or four, if there's some sort of financial restraint. For example, if they're waiting to meet their deductible for insurance. Some advantages for temporary oral appliance therapy. One, it's quick, immediate treatment. Typically has a lower cost than custom oral appliance therapy and typically you can remold it as dental work is completed. However, there are a lot of disadvantages to the temporary oral appliance. It isn't as effective as a custom oral appliance. It won't last as long, typically three to six months as compared to three to five years. You can't bill medical insurance and doesn't qualify for this E0468 code. It also doesn't meet the definition of a custom-fabricated oral appliance as defined by the American Academy of Dental Sleep Medicine. The patient will also notice a few disadvantages. One, they typically have little to no lateral movement and they're typically bulky, less comfortable, and they typically have less compliance. Okay, let's demonstrate the Armentarium that we'll be using for our demonstration today. This device comes in two separate pieces, an upper and lower tray. Some of the devices will come hooked together in one tray, upper and lower, that you'll be doing at the same time. In this case, we'll be doing it separately. Underneath, we have a patient case and then two different timers, a one-minute timer that is used for timing the device in the hot water bath and a three-minute timer for timing the device inside the patient's mouth. It also comes with a handle that will give us ease of use while in the hot water bath as well as in the patient's, putting in the patient's mouth. Okay, let's talk a little bit about the device that we're using today. The device we're using has a dorsal-style propulsional mechanism and we'll actually take this off when we go to put it in the patient's mouth and we can reattach it afterwards. On the front side of each of these has a little hole we can attach the handle to. This will give us a little more control when we're putting it in a hot water bath as well as when we're putting it in the patient's mouth. On the inside of our device, we have a thermal resin that when heated to a pre-heated temperature that when heated to approximately 160 degrees will become clear and moldable. We'll then be able to put this in the patient's mouth and mold it to their teeth. We have a hot water bath which we've used a tea kettle to heat up the water to boiling temperatures and then we've let it cool down to approximately 160 degrees. It doesn't need to be exactly that temperature, just around there to be able to make it clear and moldable. We'll use a one-minute timer when our device goes in to make sure we get to the right timing and this is a cool water bath. After we take it out of the hot water bath, we'll dip it in here for a couple of seconds. That way there's no hot water when we put on the patient's mouth and then we'll also use this to set the material afterwards. We'll use a three-minute timer while the device is in the patient's mouth to make sure it sets the right timing. We're going to start with the upper tray. I've already attached the handle which will allow ease of use when placing the hot water bath as well as when I place in the patient's mouth. I've also removed the propulsion mechanism, the dorsal fin propulsion, which allow me to insert it a little more easy in the mouth. So I'm going to get this warm. It'll be warm but won't burn you. When I place in the mouth, I want you to push against this inside area with your tongue and mold it to your teeth. Then I want you to create suction which will then mold the rest of it around your teeth. It'll be in there about three minutes while it solidifies and then we'll remove it and put in the cold water bath. Okay, I've warmed this up and I'm going to put this in your mouth. Okay, go ahead and bite down in firm pressure. I'm going to remove this handle and wrap your lips around. I want you to press your tongue up against the inside and push that material against your teeth and go ahead and create suction. Okay, now I'm just going to press on here and mold this against your teeth and open for me and do the same thing on the inside. Okay, now go ahead and put firm pressure and wrap your lips around there and we'll just wait three minutes. So now we've molded and cooled both trays. We have replaced the dorsal propulsion mechanism and we have reinserted them back in the mouth. We also measured the maximum protrusion and we selected a comfortable start position. So as you can see, our dorsal propulsion mechanism is engaged, our midlines are coincident, and we've selected a 50% range of motion as our start position which is a comfortable position for her. Now that you've seen the demonstration of a temporary oral appliance, I'd like to talk about a few important points. First, many of the rules for bite determination of a custom fabricated oral appliance apply to temporary oral appliances. You want to ensure your midline is consistent in MIP as well as in protrusive and ensure the alignment is the same with the oral appliance in the mouth. You can use a George gauge to help you with this and some temporary oral appliances even have a George gauge built in. One thing I like to do is have the patient snore before and after placing the oral appliance to make sure that snoring is decreased. Lastly, ask the patient if they're comfortable with the device in. If they aren't comfortable with the device in now, it's going to be way worse at two o'clock in the morning. So in summary, there are different types of oral appliances, temporary oral appliances. There are advantages, disadvantages, life expectancies, different materials, and propulsion styles. But in general, the principles for fitting are the same. What's most important is patient comfort, midline position, and retention. Thank you for your attention. I truly believe that having a temporary oral appliance in your treatment arsenal will be a benefit in unexpected situations. Thank you.

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