Discover How Oral Appliance Therapy Benefits Your OSA

David Federici, DMD

Thank you for having me.

Audrey Wells, MD

The Oral Appliance is the primary nonsurgical CPAP alternative for obstructive sleep apnea. I know that people are interested in this. I want to start by defining what it is. I have brought a little show-and-tell here. This is just one type of oral appliance. The idea is that there are two pieces. There are custom-made fits for a person who is using them on the upper teeth and the lower teeth. Then the two pieces engage in some way. There are different ways of doing this, such as when the lower jaw is brought and held in a forward position. Anything to add to that, or anything else you would like the viewers to know?

David Federici, DMD

Well, there are about 100+ different types of appliances. While the one you showed has a mechanical hinge on the side. There are kinds, as you said, that are made of different materials. It is our job to evaluate the patient’s dentition, teeth, tongue size, amount of teeth, jaw, shape, and size of cheek tissue, anteriorly to be able to pick the appliance for them. But you are right, every appliance works by advancing the mandible and thereby bringing the tongue with it so that at some point of protrusion of their jaw, this varies from patient to patient. We maintain airway patency. While some people have a very large amount of protrusion, it might be 40, 50, or 60% of that protrusion that is their sweet spot to open up the airway. It varies from patient to patient. The advancement is where we work weekly to test and verify that the airway eventually opens. As you said, the different appliances have different ways of doing that.

Audrey Wells, MD

They are also called mandibular advancement devices or MAD devices for that acronym. These are interchangeable terms. For anyone watching, oral appliance therapy, or OAT, and the mandibular advancement device are interchangeable. Now, I am wondering, how do you know if you are a candidate for an oral appliance device?

David Federici, DMD

When we do evaluations, a lot of our referrals are from sleep physicians, pulmonologists, cardiologists, and patients who are unable to, unfortunately, tolerate the CPAP. We do a thorough dental examination as well as a muscular examination. Historically, having a TMJ was thought to be a contraindication, but we are finding out now that many people do nocturnal grinder brux or have TMJ issues because they are not treating a sleep-related breathing disorder. Once we treat them, the body’s ability to want to grind or to send the signal to grind is eliminated because that is the body’s natural way of trying to move your jaw and tongue forward without an appliance. After we do that evaluation, the main contraindication would be somebody who has very loose teeth via the appliance you showed is custom fit. It fits snugly on the teeth. We do not want this to happen while they sleep in the middle of the night. But if you have mobile teeth or periodontal disease where your teeth are very loose, then that would promote a greater tension between upper and lower teeth and can advance tooth mobilities. That is the only contraindication. The other contraindication would be somebody who has very little jaw muscular protrusion. Most patients have 6 to 8 millimeters of protrusion. Some people have very small jaws, and their muscles are very short and only allow for three or four millimeters of advancement. Then it becomes, can we move that patient’s jaw forward enough to maintain a paden or open airway? 

For those particular cases, we implement the use of temporary appliances before they make the big investment into a more expensive one. Not knowing if they are going to be able to use them to their full extent. We will try a cheaper version that, while it is not a custom fit, does give us some feedback if they are going to be a candidate and a responder. We have very different approaches based on the patient’s needs. For patients who have dentures, a lot of patients, as they get over 65 and become more apt to have sleep apnea, start losing teeth. I have made appliances that snap on or fit over their dentures. There is a way to have the appliance fit onto their jaws when they take their denture out, and the appliance can be made to fit in a denture and hold their jaw forward.

We have had people who only have a certain amount of teeth get some implants placed in their jaws, and besides retaining their teeth, the dentures of the partials can also be fabricated on the inside of an appliance to snap onto the implants. There are a lot of different ways, and I do not feel as though, Hey, I only have six or eight teeth. We have worked with patients with four teeth. We have worked with patients with dentures. There are very small, few little areas where we cannot make an appliance. The number one reason, probably 95–98% of the time, is that the teeth they do have are loose and mobile, and they cause discomfort. If we would attach them for six, seven, or eight hours when they sleep,

Audrey Wells, MD

That makes sense. What you are describing, and in my experience too, there is a certain level of expertise that is necessary from the dentist who is making these appliances and evaluating whether a person is a good candidate. I would love for you to elaborate on what that expertise should be.

David Federici, DMD

Being a faculty member of the American Academy of Dental Medicine, we have a website at AADSM.org, which is where patients can go, as well as dentalsleep.org, where there is information for patients to find out about oral appliances. You can find out more about the actual pathway to making an appliance but also find in your area where you can find a qualified dentist in your area. We have two pathways. The American Academy of Sleep Medicine. One is called a Qualified Dentist, and a dentist will choose to go through one level of education. We recommend that that is the minimum standard for treating their patients, family, friends, and things of that nature. When you start to want to work with bidirectional collaboration that works with doctors like yourself, we usually recommend our students go on to mastery too then they can become eligible to sit for a board exam and become board-certified diplomates, which is the highest level of education. That also includes a clinical, hands-on competency scenario. They get the most education from severe patients. You do not want people who just take a weekend course on this and think they can go back to their office on Monday morning and treat a condition that, in some cases, can kill them. We have a stroke; we have A-fib. We have so many conditions related to untreated sleep apnea. I always recommend when I teach this, you do not know your surroundings. 

If you have other diplomates in your area and you think you are going to take a weekend course. Most referral networks are not going to include you in that loop because you have not proven yourself educationally. But we have them strive for the highest levels because some people end up thinking they only want to work with their patients and end up with their patients telling their doctor. Before, the doctors were talking to each other, and you got a call from a sleep position. Now you are, Well, I am not a board-certified diplomate yet. We try to have them aspire to have the highest levels, and most people do go through with that because they realize how much they are changing and saving, in some cases, patients’ lives, and it propels them to want to seek out the highest level to collaborate with.

Audrey Wells, MD

I think that is important to underscore because when I talk to patients about the oral appliance treatment, a lot of times they will say, My dentist told me he can make something, and occasionally I will have someone come in for a sleep apnea evaluation. Even planned to get oral appliance therapy from their dentist, who was looking at the airway and noticing that when they were back in the dental chair, they were obstructing. What I am hearing is that on the website dentalsleep.org or aadsm.org, a person who has a dentist offering to make an appliance can input that name to see if they are qualified. Is that true?

David Federici, DMD

Correct. Just because somebody can, and we all, as dentists, can order something from a lab, But it is how you use that, how you track its efficacy, that it is working, the pulse oximetry, and the data that you want to see from us. Someone who is not qualified will not be able to follow through with that for you. We are working for you. You write us a script through medical insurance or Medicare, and you need to be able to evaluate the dentist. What is your level of education? Are you in the insurance network? Are you part of Medicare? Do you use lab-grade, medical-grade, precision-milled oral appliances? Are you doing these cheap things? The last thing a sleep physician like yourself is, once you have a patient, come back to them and say, Hey, I do not know who you sent me to, but the dentist screwed up my jaw or my brace, or he charged me X amount of dollars, and the thing cracked after nine months because the dentist just was not experienced. Some small percentages think they are helping the patients out. Unfortunately, without the training, they could be doing damage they are not even aware of, even though their best interest was to try to help their patient. I have been your dentist for 30 years. I will order something for you, but you have got to know your limits in every area of health care. It is important, that you have an awareness campaign of you, the sleep positions, and the doctors referring to us are just as comfortable as the patient would know that the dentist is experienced enough.

Audrey Wells, MD

Agree. I think there is also the benefit of having consistent messaging about what obstructive sleep apnea is and the damage that it can cause, not only if it is untreated but if it is undertreated as well.

David Federici, DMD

Correct. We have so many people who buy products on Amazon or at the pharmacy, and they think that because it helps them stop their snoring, their sleep-related breathing disorders are fixed. Half of those people are doing it for snoring and do not even know they have possible obstructive sleep apnea. It can only be determined from a PSG or a home sleep test, officially a medically interpreted sleep study. That is what we always tell our patients we have to have before we can treat them. You cannot say, I think you are suffering from high blood pressure, Let us put you on some medication without having a baseline of what block blood pressure you are treating. If we think we have stopped snoring and there had been a severe case of obstructive sleep apnea, they may have reduced their obstructive sleep apnea in half. To the patient, Hey, I am stopping snoring, at this point, my bed partner is back in the same room are all, Kumbaya. But unfortunately, we tell the patients that is just one piece of the puzzle. We cannot just go buy over-the-counter snoring cessation products and think we have treated it.

Audrey Wells, MD

This is a big problem because the oral appliances that are custom-made for sleep apnea can be a bit expensive. I want to put a pin in that so we can talk about insurance coverage. But I have also pulled one of my examples of what is called a boil-and-bite device. These are over-the-counter appliances that you put into boiling water or a cup that’s just been boiled, and then you can bite down to customize it. But talk to me about why this is not a long-term solution.

David Federici, DMD

As you said, It is not custom; it is a one-size-fits-all, and as we know, we have tons of different sizes of mouths, tongues, tons of different sizes of arch shapes, and also airway tongue size is very important in picking an appliance because the bulkier something is in your mouth, the more it keeps your tongue backward. As we said earlier, our job is to move things forward. But if we have a thick piece of equipment in the front, the tongue is pinned. It cannot be effective. Those types of scenarios would be if you wanted to try them, a test to see if it stopped your snoring before you invested. By all means, you can do that, but unfortunately, you do cause a lot of jaw issues because they are not custom. You can change the vertical and horizontal components, although some of them are starting to have a little flexibility and extend horizontally. 

But the patients do not bite the right way sometimes. You could lead yourself in self-diagnosing or self-treating. If you bite wrong and start advancing, you could push your jaw to one side or the other and think that it is not going to be good for you based on the soreness, but in actuality, you just did it wrong. We try to downplay those over-the-counter type products because you could be giving yourself the false sense that you might not be a candidate. That is before we even talk about the medical grade, the materials, the cleanliness, and the precision with which we make these at this point; that is the next level, quality.

Audrey Wells, MD

Yes. I think your point is well taken: people can get the wrong impression. There is a pun there, I think. From using these boil-and-bite appliances, they can come to the false conclusion that a custom-made oral appliance may not work, but in actuality, they are not even the same thing. It is worthwhile to have a consultation with a dentist who is not only informed but also has adequate training and experience.

David Federici, DMD

Correct.

Audrey Wells, MD

I want to go back to the insurance coverage and the cost of these oral appliances because this is highly skilled work and the insurance coverage is not through dental routes. Tell me more about that.

David Federici, DMD

Correct. The Diagnosis Code G47.33 is a medical code. These appliances are durable medical equipment that is reimbursed by medical insurance even though they are made by dentists. Dentists can, in some cases, join medical networks to become end-network providers, but most of them are out of network, just like you, on the medical side cannot jump into a dental network. Sometimes it is tricky for us to jump into a medical network. But it is a covered procedure. Of course, it is going to follow the same guidelines with expected deductibles. Unfortunately, we are seeing more and more insurance plans with a greater three, four, or $5,000 deductible. The patients usually have to pay that first before the insurance even kicks in.

A lot of times we will see this time of the year as patients start meeting their deductibles; they are looking into now that they have met them. Let us go ahead and make it. Of course, I tried to talk them out of that. If I see somebody in January, I am not going to say, Hey, go on treated with severe sleep apnea till September so you met your deductible; you are just prepaying your deductible now with the appliance, and guess what? The rest of the year now, all the rest of your medical visits are covered because you just happened to meet your medical deductible for the year on the dental appliance. It works in multiple ways. But yes, it is covered under medical insurance and not dental insurance.

Audrey Wells, MD

Is there any difference in Medicare requirements or stipulations?

David Federici, DMD

Yes. Medicare also depends on the doctor or dentist. If we can join Medicare networks and get fingerprinted and background checked, we can join Medicare. There is a basket full of appliances. The one you showed earlier with the metal hinges is one of the PDAC or Medicare-approved appliances that are done these days. While there are some other ones out there that do not have the metal hinges that are Medicare-approved they are out there and very popular. They do force us for coverage to pick from those specific appliances. Now, if they want to upgrade, Medicare will say, Hey, as long as you do things by the book and get a Medicare-approved appliance, we will reimburse you based on your jurisdiction. 

There are different jurisdictions around the country, and Medicare will kick in an X amount toward our fee of Y. Historically, Medicare has never even reimbursed for appliances. Many years ago, they started having it covered. Anybody who had their CPAP and could not get used to it had to pay for the whole appliance out of pocket. Now, a great amount of that is covered. There are stipulations with Medicare, though it is called a same-and-similar rule, which means they only cover one form of therapy every five years. There is a 60-day window. We tell all of our referring physicians to make sure their patients decide whether they are going to keep the CPAP machines or not within those first 60 days because once Medicare pays for them, it is a major hurdle. 

Multiple-level appeals are needed to have them also reimburse and make an oral appliance. You have to get it and turn a CPAP in. You have got to show proof that you stopped all the supplies. You have to have another face-to-face visit with the sleep physician. It is very difficult to get both forms of therapy covered. But we do it. It is a skull and crossbones when we see somebody who has that. But so we try to educate our referring sleep physicians, pulmonologists, and cardiologists to make sure that they can decide within that 60-day window whether you can tolerate it or not. Because once they pay for it, it makes it more difficult.

Audrey Wells, MD

That makes sense. I think that any time you are dealing with insurance, it can start to feel quite overwhelming once you get into it. But what I am hearing and want to confirm is that the dentist who is constructing the appliance should be familiar with these pathways and be able to educate the person who is interested before any deductibles change hands or before the appliance is made. Is that fair?

David Federici, DMD

Definitely. Most dentists who are at the high level of treating obstructive sleep apnea with oral appliance therapy should have the pathways down for billing the medical insurance a patient should not have to pay out of pocket. Yes, some dentists choose to say, I do not want to deal with medical insurance or Medicare. I do this as an ancillary technique. I am a fee-for-service, cash-paying patient, and we see that a lot on the cosmetic side for Botox, injectables, and things of that nature, where I have a practice where I just deal with fee-for-service. 

Again, when you decide off the websites to find a particular provider in your area, you have every right to ask those questions. When you are calling, you are going to have an interview with them, saying, Do you take medical insurance or do you work with the medical biller that can process my medical insurance? Do you work with Medicare, your participating provider with that? Do you use medical-grade appliances? Will you be working with my sleep physician? What is your level of education? I know you have experience with qualified and board-certified diplomates, but those are questions that the patients can ask their dentists if they happen to say; Well, before we even get to the point, I am going to check you out on our website to see if you are qualified enough. Just ask those questions. 

I had a patient the other day come to me and say, Yes, my dentist was perturbed that I once told him I was having this done. He goes, Well, I can make you one of those. I do those. She said, Well, unfortunately, my sleep physician only wants to work with board-certified diplomates who have expertise in it. That, she said, caught him off guard. But again, some of these dentists, unfortunately, do not know the severity of treating this and think that a weekend course, as I said before, is enough education. Usually, when I lecture about this, I say that the weekend course should be an introduction to see if you are willing to take on the challenge to treat it. That is not the education to do it. That is an introduction to see if you are up to the challenge and want to take it on. 

If so, then you are going to seek out the best, highest level of education practice, get the billing down, get the Medicare down, and have that collaboration network so that every sleep physician, including yourself, knows my level of education, my care for the patient, all my workflows that their patients are going to come back to and that they had a positive experience that did not mess up their muscles or their joints or give them an appliance that cracked after nine months. That is the last thing you guys need. Have your patients come back because you are busy enough.

Audrey Wells, MD

I agree so much and want to underline everything you just said. It is important to have that standard. I am going to go into the candidacy for oral appliances again now at this time for obstructive sleep apnea, of which we define the degree or severity based on HHI. There are some limitations to that. It is not the perfect way to define severity, but it can help inform treatment options. Now you have mild obstructive sleep apnea, 5 to 14 airway obstructions per hour; moderate obstructive sleep apnea, 15 to 29 airway obstructions per hour; and then severe, which is 30 and above. Who is a good candidate for oral appliance therapy?

David Federici, DMD

All of the candidates that you mentioned are severities candidates. Of course, is the collaboration between the ASM and the AADSM is mild to moderate? It can be a first-line therapy. Of course, if you have severe CPAP, that is going to be the first standard. If they fail CPAP, then something is better than nothing. While we say that, and that is why I mentioned all severity levels are candidates for oral appliances. If we have somebody who is super severe and we can reduce their hypoxic burden and their severity down to mild, that is what we’re looking for. You are up here. Yes. We would have loved it if you could use CPAP and oral appliances. 

While it may not be first-line therapy for the severe, we have greatly reduced your hypoxic burden. Your severity level. Your risk level has greatly reduced to the greener, safer zones of severity, to the point where we are not worried about you dying in your sleep with the severity amounts. Mild to moderate is first-line therapy and recommended if the patients fail CPAP due to any type of issue, whether they are right mask airflow, multiple sinus infections, claustrophobic, beards, mustaches, noise, air leaks, whatever that may be. 

If you have exhausted all your attempts, we are more than happy to collaborate with you because we want to reduce the burden of sleep apnea for these patients. We are not here to compete. We are here to complement and help you out because, unfortunately, you guys cannot do certain things like scan and make impressions and make these appliances, and we can order CPAP and do that. The collaboration—the bilateral collaboration between these professions—is key to giving patients multiple ways to bring down the severity levels that you mentioned.

Audrey Wells, MD

I think one thing that people do not necessarily consider is the possibility of combination therapy. The oral appliance with the forward jaw protrusion can help open up the airway. But if it turns out that was not sufficient to resolve the obstructive sleep apnea, then CPAP can be applied with the oral appliance in place. In that instance, lower-pressure settings are oftentimes used. Over the years, I have had several patients use this type of approach.

David Federici, DMD

Absolutely. For some people, it is just that pressure, the constant, and this was my issue. I had 31 severe 31 events per hour, and for me, I was 100% compliant. Yet every time I stopped breathing, it sensed it. It ramped up the air pressure, and being a light sleeper, it woke me up. I was treated for apnea but still sleep-deprived, not getting to the deeper stages. Slow wave, stage three in stage four REM sleep, to the point where, at the end of the day, I was still getting tired and hitting the rumble strips on the way home. I told my pulmonologist that, in this case, the treatment could be worse than a disease. What good is 100% compliance if for me, I am still tired, on the dashboard it looks like there is no need to call Dr. Federici because he is using it every night. He must be okay. But I did not know what. I did not know at the start. It was me not being able to tolerate it. then, over time, when you read articles and see that there is a certain percentage that is not able to tolerate it. That is what drove me to make it an appliance about 10 years ago. It changed my life to the point where I said, I have got to do this going forward because I have seen the benefits that it has helped me out with. 

But to get back to your point about the combination therapy, the appliance can work with, as you said, a combination, you can set the pressure much lower. In some people, we have our physicians and DMEs just keep it as a flat five centimeters of water because the appliance does 80 or 90% of the work. Then the additional pressure comes in. In some people, their airway is just, I call it, their plumbing. They just kink a little lower than where the appliance works. Anatomically, they may be kicking down here. We are opening them up here. But somewhere below that level, there is still a constriction to the point where we need that secondary supplemental oxygen flow that you mentioned that can then bring them fully down to normalcy. Oxygen generators are another popular thing I use, which is just a nasal cannula. At two, three, or four liters per minute, I am finding Persevere is enough, whereas it is not the full CPAP mask; sometimes just supplemental oxygen can do it. We have nasal violators that help open up the nasal passages, which increase the intake of oxygen, which, combined with the appliance, sometimes also sends them over the edge and brings down that residual non-treatable type. 

There are many ancillary techniques. But, again, by becoming board-certified in this, you get that education and you deal with those difficult cases. It is one of the questions we get all the time: What do I want to ask the dentist, and how do you treat nonresponders? What if you got him halfway reduced? What are your next steps? If you have a cricket, then they do not have that experience level. That is something you have to take into consideration because you have a lot of non-responders out there or partial responders. How you deal with that is just as important.

Audrey Wells, MD

I agree. The only way you are going to determine if you are a non-responder is to get the follow-up sleep test after you are acclimated to the oral appliance treatment. Once you can wear it throughout the night, you are looking for some symptom resolution. Sometimes a forward titration is needed, so more protrusion can be necessary. But at the point where things seem stable, you need to get that follow-up sleep test to understand whether you have any residual sleep apnea.

David Federici, DMD

Correct. The efficacy test is a way to confirm what we are doing. Some patients say, Hey, I feel great. I have so much energy. You changed my life. Why do I have to go back to see Dr. Wells and have another sleep study? Because for some people, the subject of objective things does not line up. You might be 50% reduced from a 30 to a 15. Do you think we have changed your world? In actuality, we have still got a decent amount of obstructive sleep apnea that is not treated. In some people, a 50% reduction think that they are treated well when I tell them there is good news and bad news. Instead, the good news is that there is more to go. You are going to reap even more benefits if you think it is good now, you have only helped half. 

We have to continue, as you said, to advance the job a little bit more and use some additional techniques if we need to, such as nasal dilators, positional therapy, or supplemental oxygen. But we are working for you because we need a script from you in a letter. Medical necessity to bill insurance and Medicare. We are working for you. It is important for us all, as dentists, to send the patients back to check our work per se. Yes, we know it is a one-night snapshot; this is just the first test to diagnose them as a one-night snapshot. But we see them so often as we are advancing them; we get multiple studies and pulse oximetry reports. 

What I usually do is ask each doctor, How do you want me to report to you? Do you want it as we go? Do you want a letter that was done, or do you want me, the patient, to call you and I will bring their latest pulse oximetry report? Say, Here we are at. Give them a sleep study again. If it does not come up, ideally send them back to me, and I will do a little bit more tweaking. It is again about the lab collaboration network that we have, which is to always keep in communication so that the best interests of the patients are always fulfilled.

Audrey Wells, MD

I love it, and it is tender loving care for your sleep. That translates to long-term health benefits. It is super important to collaborate.

David Federici, DMD

Absolutely.

Audrey Wells, MD

Now, I will tell you, I am quite a frugal person, and I am capturing the beginning of my sleep apnea. I try all of the things that I recommend to my patients, except for some of the surgeries. But if I were thinking about oral appliance therapy and I had a high deductible, which happens to be true at the moment, my question to the dentist would be: What is the likelihood that my sleep apnea would be resolved with this? What is the likelihood that I am going to be able to tolerate this? I want you to look in your crystal ball and tell me that this is money well spent. Can you comment on that? Especially contrasting a mild sleep apnea patient with a severe sleep apnea patient.

David Federici, DMD

I wish we had that crystal ball. When a patient comes to me, I can say that on day 47, we are going to have 92% of our sleep apnea reduced. I wish we could do that, but with experience, you learn to look at the components of the sleep study. If there is a greater percentage of the smaller obstructions called hypoxemia versus apnea, is that at minimum centers, only 30% obstruction of the airway? Then you can assume that the appliance will work on the hypotenuse and that portion of the apnea better than the full-blown apnea. But again, in the anatomy airway, if somebody has a huge tongue that is a large hamburger patty in there and they are obese and their necks are 20 inches wide, there is going to be a component where we are going to have to throw the kitchen sink at them, we call them and try all these different techniques of keeping them off their back.

But at some point, BMI comes into play. With those impacts, there are other ancillary techniques, and we push them back to them. While we would love to have a pill that would treat this, or we would love to have just the appliance, not everybody fits in that basket. Those are going to be 100% responders. We will do everything we can in our power. You have tried everything in your power with the CPAP machines. Now some of that has to fall to the patient. Saying, Hey, you have got to do your job. 

Sometimes I will be honest with you and say that the appliance if we can get them down 50, 60, or 70%, while it is not ideal, gives them more energy to have at the end of the day instead of falling asleep after eating to go out and walk. We call these downstream therapeutic effects where you keep going, you feel better, and you have more energy. All of a sudden, your BMI starts coming down, and the efficacy of the appliance starts getting better because you are reducing that mass burden. We put tongue fat deposition, you only lose weight, your tongue gets smaller, and your neck gets smaller. All these tissues that are clogging your airway are starting to thin out and just perpetuate. 

There are cases where I say, Do not give them that efficacy test yet. Let us give it more time to work. They have been suffering from this for so many years. We cannot help it that maybe in six weeks they are not going to be fixed yet, but they are feeling better. They are starting to exercise now. Let us reevaluate at six months and then again test them. We see numbers. I have taken patients where I have had their endpoint, and nothing has changed on their jaw. Then I take another pulse ox reading overnight recordings. The reduction has occurred 10–20% more in six months with no changes. 

Sometimes it is the autonomic nervous system; it is reprogrammed. We have enough nights of oxygen, therapy, and medication. The more and longer you take it, the lower your cholesterol might go, or it will have more of an effect. Lowering your blood pressure. We do not evaluate a blood pressure medication after a week. It may take 67 days to get my blood pressure down back to normal. The medication might take you only 17 days. We do not try to have a specific, finite endpoint. We just want to see some subjective improvements to the point where the patient’s starting to feel better objectively and is just giving us feedback. Then we will communicate that with the sleep physicians or pulmonologists, and we work forward from there.

Audrey Wells, MD

Great answer. I think it is another reason why the post-oral appliance test is important because you would not want to be using it unless it was beneficial to you. Knowing how much it is benefiting you is important. Now, one thing I have seen is that for people who benefit from the oral appliance, it is great. They use it for years, and sometimes there are some side effects. Sometimes the dental situation changes as well. Talk about the agility that a dentist needs to monitor those things and address them when they come up.

David Federici, DMD

As we talked about early on, tooth mobility coming into treatment is going to be a factor. what happens during and after treatment. The more years you have, the more you are physically holding the jaw forward, and those trays exert pressure. Your job is to move and hold your jaw forward. We keep a close watch on that. You talked about impressions earlier with a lot of us dentists are now doing digital scans. We have a digital record of the actual patient, if they say, I think something is shifting down here. My bytes changed a little bit because we had the original scan. We can make them those Invisalign retainers, and during the day they can wear the retainers to move them back to where the original position was to offset what the appliance may be doing.

While they are wearing the appliance at night for their sleep apnea, during the day, they will wear a clear tray that can reverse some small menu changes you talked about that could be happening. We consider that for the dental work, you said, we have to be able to modify the appliances. That is another thing we tell the patients: we will see them with a missing tooth, and we will say, Hey, do you plan on getting some type of tooth replacement in there? Yes, I am going to get an implant in there. They said it would take about a year before we could design the appliance to be hollow in the area to accommodate a future tooth placed in there so that you do not have to keep getting new appliances and rescan every time there is a major dental treatment in your mouth.

If you fill in a space, that is the biggest thing, but you may have a six-tooth bridge in your front that the appliance is made on, and something happens—it decays. I need a whole new six-toothed appliance, while the old one is not going to fit on your new one. We have some appliances that could be reamed out to accommodate that. A lot of times, they will just scan that arch and make it a new tray if it goes over that. 

We have many techniques to work on not having to make new appliances as dental work changes, but for the bite changes and anything of that nature, we try to keep very close track, which is why we do six months after therapy is completed, and then yearly. We want to track the changes. We tell the patient, If they notice anything, they should not wait for their yearly checkup to come back. Because we have your scans, we can make you something to interceptively reverse those changes you are seeing.

Audrey Wells, MD

Good points. I want to clarify that you mentioned the tray that can help move the teeth back into their original position. Is that the same thing as a morning aligner, or are they two different things?

David Federici, DMD

The morning aligner comes with every appliance. That is a way for a patient’s jaws, which have been held for six, seven, or eight hours, can be brought back to the normal bite—the home-based bite, we call it. The day we see them before therapy starts, there are multiple different ways you can do this. There is a boil and bite; the old mouthguards would be just a flat wafer. You just do a normal index, and that is your home-based bite. When the patient takes the appliance out in the morning, since those muscles have been stretched forward, their teeth are not going to meet normally immediately upon removal of the appliance. We tell them to put this morning or reposition in their mouth, and some of them chew with them gently, which stimulates the muscles to shrink back and recover the normal bite.

We just tell our patients: do not eat breakfast until your bite has normalized. The old way to do it was to sit there, do the thinking man’s pose, and physically push the jaw back. It will happen on its own after about 60 or 90 minutes, but most people want to get going with their day, and they cannot wait an hour before they eat. For me, my philosophy is that I just get up in the morning, and in the first minute of this, 3 to 5 wearing the repositioners is spent cleaning the appliance. Then just a few more minutes, and then it recovers.

Audrey Wells, MD

It seems that could be a sign of a good dentist—one who is experienced. If they have the morning aligner as part of their standard treatment, that is a good sign that they know what they’re doing.

David Federici, DMD

The other retainer we talked about is something they would wear during the day. Only if we felt there were changes, tooth shifting, or the tooth was crooked—things of that nature. We have some Invisalign patients who have to wear these retainers at night. How can they wear the retainer at night if they have the appliance? We say, look, you are going to have to wear it during the day to maintain that Invisalign therapy that has perfected your nice straight teeth. There are ways to piggyback it, but it is a little tricky to do that. Again, having a great comprehensive exam, knowing what the patient has currently, anticipating their future needs, and just designing and picking the right appliance that we feel would be the best one. It could be modified, keeping all the records. It is a full, broad approach that the experienced dentists who do this have to follow.

Audrey Wells, MD

What a comprehensive plan and discussion! I like that. I think that it helps people to understand how much goes into making the oral appliance, monitoring it, and addressing any issues that arise. It takes a lot of expertise, and I thank you for helping people understand that and helping dentists get trained.

David Federici, DMD

My pleasure.

Audrey Wells, MD

For everyone interested, I want to reiterate that dentalsleep.org is a website where you can go to check the name of your dentist to find out if they are qualified. There are also lots of good patient education materials there, and then aadsm.org is the other website where you can find lots of good information. Dr. Federici, it has been a pleasure to speak to you today.

David Federici, DMD

It is my pleasure. Thank you so much.