Discover How Oral Appliances Transform OSA Treatment

Lee Surkin, MD

Thank you, Dr. Wells. When you were introducing me, I was like, Is that me? That’s that person’s way too busy. But, yes, that’s me. Thank you.

Audrey Wells, MD

I think you’ve got a lot on your plate, for sure.

Lee Surkin, MD

But it’s all good stuff. It’s, I’ve tried to be a trailblazer as a cardiologist by incorporating sleep because they’re so closely related, and then, throughout all of the years of being in practice now, over 25 and 26 years, you realize that there’s not a one-size-fits-all treatment solution for, sleep disorders in general. especially obstructive sleep apnea. Just by my nature, I guess I’ve gotten involved in so many different areas to try to improve things for our patients.

Audrey Wells, MD

I couldn’t agree more. There is still a lot of personalization that’s needed when customizing treatments for different sleep disorders, especially sleep apnea, as you mentioned.  although CPAP is still the gold standard for sleep apnea care, oral appliance therapy is now making us surgeons, especially since the pandemic and the CPAP machine shortage. I wonder if you can inform the audience about how oral appliance therapy fits into sleep apnea treatment.

Lee Surkin, MD

It’s a treatment option that is growing in popularity and has a very important niche in treating obstructive sleep apnea. Standard practice guidelines would suggest that a dental appliance or oral appliance therapy device can and should be used as a first-line treatment option for individuals with mild or moderate obstructive sleep apnea and as an alternative option to CPAP for those individuals with severe obstructive sleep apnea. They just can’t tolerate CPAP, or, they can’t imagine wearing a mask on their face and pressurizing their airway. I just don’t want to have anything to do with it. Then, the dental option for severe sleep apnea takes a front-line position as well.

Audrey Wells, MD

I agree. I want to say that for those who are looking for an alternative to CPAP treatment, one of the big questions is, are oral appliances covered by insurance? Because, when it comes right down to it, cost is a factor.

Lee Surkin, MD

What’s interesting and not well known at all is that these dental appliances, or oral appliances, treat a medical disorder and are therefore covered by most medical insurance carriers. Yes, it is medical insurance billing that benefits the patient because, a minority of people have dental insurance anyway, but it can be very challenging for the dentist because dentists deal with dental insurance or you or no insurance for that matter. They don’t have a lot of experience navigating medical insurance. I can speak for you, Dr. Wells, that even for physicians and medical doctors, medical insurance can be expensive, and it’s not uncommon that it’s a nightmare for us to deal with.

Audrey Wells, MD

I love your pun there in the context of a sleep discussion. But it is true. I remove myself to save my stress when the topic of insurance comes up because it is extraordinarily frustrating to me, and I want to just get the nuances down here because, with a diagnosis of obstructive sleep apnea that comes from a test, medical insurance would be used. But there’s also something further left on the spectrum of severe upper airway resistance syndrome or just primary snoring. Is there any coverage for oral appliance therapy, either from medical or dental insurance, for those conditions?

Lee Surkin, MD

Is it those sleep-disordered breathing conditions that are not officially diagnosed as obstructive sleep apnea, snoring, or upper airway resistance syndrome? Your podcast attendees know what snoring is, but upper airway resistance syndrome is, as it sounds, a resistance to airflow in the upper airway that can be disruptive to sleep but does not meet the criteria of obstructive sleep apnea. It’s like a middle-of-the-road thing. It is much, much more challenging to get insurance coverage for snoring or upper airway resistance syndrome, even though, according to standard practice guidelines, an oral appliance can and is quite suitable to treat those sleep breathing disorders that are not officially obstructive sleep apnea.

Audrey Wells, MD

It’s my clinical experience. Those often occur in women, sometimes in women of normal weight. Unfortunately, they can be quite disruptive to sleep quality and have an impact on day-to-day functioning. I just want to validate anybody who’s going through that experience. It is real. Even though you’re not meeting these criteria for obstructive sleep apnea, the detriments to your sleep quality are problematic, and it may be worthwhile to pay out of pocket to get treated. I’m wondering, can you ballpark a cost? If someone is paying out of pocket or has a very large deductible, what could they expect to pay?

Lee Surkin, MD

For a custom-made oral appliance that is typically provided to an individual by a well-trained dentist, I would like to maybe spend a little more time on that. Well-trained, qualified dental sleep medicine provider. If there’s an out-of-pocket cost, the pricing is very variable depending on where you live, but it can range from a couple of thousand dollars to many thousands of dollars for this type of device. I strongly recommend that individuals seek out dentists, either through their primary care provider or, if they have an established relationship with a sleep medicine physician, a properly trained, thoroughly trained dental sleep medicine provider. There are courses out there in the United States that are appealing to dentists, like a weekend course where you go into the course on Friday as a dentist and you come out on Sunday afternoon now as a sleep dentist, and yes, go ahead and practice dental sleep medicine because you did the course. Well, that’s just not adequate when you’re dealing with treating a disorder as complex as obstructive sleep apnea. It requires collaboration with a sleep medicine physician as well as, I’ll say, the village, if you will, of health care providers involved in that patient’s care, from primary care to ear, nose, and throat to pulmonary to cardiology. It needs to be a collaborative, interdisciplinary approach to care, but it can be very costly. Health care in general is very costly. If you have a high deductible or have to pay out of pocket.

Audrey Wells, MD

I agree with the idea that a seasoned and capable dentist needs to be in charge of making the oral appliance therapy just so you’re getting the most value out of the appliance. If something is going wrong or you’re experiencing side effects, that person is equipped to handle that and communicate with your sleep medicine doctor or even your primary care doctor about what the next steps are. It’s like you’re in good hands. Someone had extra training, and, the cost is tough. Sometimes I relate this to buying a new bed, though. If you go out and buy a new bed, you certainly want to have something that’s quality. You want to make it customized for you and how you sleep, and you’re going to spend money to pay for that. It’s an investment in something that you do for a third of your day, every day for years. The same is true for the oral appliance. I hope that helps to contextualize a little bit, why this type of investment would be worth it. I’m wondering if you can explain a little bit about how long these oral appliances last and what some circumstances would be where someone would either grow out of them or not be able to use them anymore.

Lee Surkin, MD

They typically last several years before they need to be replaced, like CPAP. If an individual gains or loses a lot of weight, there needs to be ongoing adjustment and follow-up. If individuals are grinders, which we call boxers or bruxists in medical terms, that can wear down a dental appliance to the point where it needs to be replaced sooner than one would expect. There is a life expectancy for CPAP machines as new technology comes out for CPAP, or typically they’re renewed every five years. A dental appliance is typically renewed every three to five years as well.

Audrey Wells, MD

Got it. I would guess that if there’s dental work that necessitates filling, a crown, or something like that, that might affect the fit of the oral appliance as well.

Lee Surkin, MD

The patient journey if I can take liberty and share that with our podcasters. The individual would have ongoing sleep problems, snoring, awakening, feeling refreshed, awakening with a dry mouth headache, that thing. Sleepy, tired, low energy during the day—God forbid, an accident because they drove when they were sleepy, or, we’re operating some equipment and just weren’t completely alert, and they got into an accident. That would typically prompt a referral to a sleep medicine physician or potentially even to a dental sleep medicine provider from a primary care provider. Let’s go with the sleep medicine physician who would evaluate the patient and determine the type of testing that would be required to make the diagnosis after obtaining the clinical history of an encounter with this individual. Then, depending on the results of the test, the sleep medicine physician would engage with the patient on treatment options. then, if the dental option was felt to be most appropriate, refer that patient to the sleep dentist, who would then do a thorough dental evaluation. 

Back to your question, Dr. Wells. If that individual had significant dental problems and needed implants, cavities, or dental work, all that stuff has to be done first before a dental appliance would be appropriate to treat obstructive sleep apnea. That’s a very important aspect that the dentist evaluates in addition to others. The dentist evaluates the airway and the temporal mandibular joint because there can be an impact from the dental appliance on the temporomandibular joint. Does that individual have temporomandibular joint disease, which can sometimes negate that individual’s candidacy for dental appliances? It can sometimes benefit from an oral appliance to treat obstructive sleep apnea. That’s, again, coming back to my point about the importance of getting well-trained, qualified sleep. Dentists cannot be underestimated.

Audrey Wells, MD

It’s yes. The American Academy of Dental Sleep Medicine, or aadsm.com, has a very convenient way to find a trained dentist with your zip code. I like that feature of their website. One thing that I’ve talked to people about who use CPAP is that they’re unhappy with some components of it, especially with higher pressure settings, is the idea that you can layer these two treatments to get a better effect, or, in other words, using an oral appliance in combination with CPAP, especially if the CPAP pressures are quite high. Can you talk about that?

Lee Surkin, MD

Taking a step back, we know that CPAP is a very sophisticated air compressor that draws in room air, presses it, sends it, and sends it into a tube, into a mask. The individual breathes in this continuous, hopefully, gentle flow of pressurized air, which pressurizes the airway. It will reach a point when it’s properly adjusted for the individual’s needs by not allowing the jaw and tongue to collapse back against the airway, which pressurizes the airway. Sometimes people have very resistant, stiff airways that require higher levels of pressure. when you get to higher levels of pressure, it is subjectively that individual can become more difficult to exhale, to breathe out. They say, My patients tell me, “Doc, it feels like I’m breathing out against a brick wall. I can’t get the air out because the pressure is too high.”

There are options that we, as sleep medicine physicians, can recommend to our patients, like positional therapy. If you position the individual on their side, that is a favorable position for the airway and can result in a reduced amount of pressure being required. If you place the dental appliance that we’ve been talking about into the mouth, what that does is provide a stabilizer, if you will, to the jaw. As the individual gets to sleep, goes into deeper stages of sleep in all the muscles of the body, relax. Those muscles also include the airway muscles. the airway muscles, when they contract, they enlarge, and when they relax, they narrow. Everyone experiences a degree of narrowing of their airway when they go to sleep and enter deeper stages. That narrowing of the airway, deeper sleep, and relaxation of the muscles can allow the jaw and tongue to move backward. Imagine if we had a device that simply could be custom-made and placed in the mouth at bedtime. When you rest your teeth in it, it stabilizes the position of the jaw and therefore stabilizes the tongue position.

The sleep dentist will evaluate the patient, send off a scan or a mold of the teeth to a lab, have an appropriate appliance made, place the appliance when it comes in at another visit to help stabilize the jaw and position it a little bit forward from the position that, is where your teeth, upper teeth, and lower teeth would be in alignment. A millimeter to millimeters forward, we’re stretching the airway a bit. We’re positioning the jaw and the tongue a little bit forward to help keep the airway open. If you have a patient who requires very high CPAP pressures and is not tolerating it, you can place one of these custom-made dental appliances in bedtime with the CPAP mask, and that will help to keep the airway open larger and should hopefully require less pressure on that from the CPAP machine to maintain consistent airway patency or that open airway and breathing all night long, better quality sleep, better health, better life, the whole nine yards.

Audrey Wells, MD

That’s what we’re shooting for a way to deliver healthy sleep to a person affected by sleep apnea. One thing that I talk about with people, especially if they wear a nasal mask, is usually one that fits over the nose, which I prefer because it’s usually more comfortable. People can tolerate that better because they need to have lip closure around the oral appliance so that air isn’t coming out. The nasal masks leave your mouth out in the open. around the oral appliance, you have to have lip closure to keep the air in.

Lee Surkin, MD

Yes. For the most part, dental appliances require you to have a closed mouth and be able to breathe in and out of your nose, so we would probably want to spend a little bit of time talking about the importance of nasal breathing as well. There is one specific type of dental appliance that has an open airway built into it for individuals who have chronically difficult breathing in and out of their nose, so that could potentially be used. But for the most part, you’re right. The dental appliance is a closed-mouth type of treatment.

Audrey Wells, MD

What sorts of things might a person try to keep that lip closure around something that’s taking up some space in their mouth?

Lee Surkin, MD

Again, working closely with the sleep dentist, getting that guidance with regards to positioning the dental appliance, which can be adjusted and should be custom fit for those individuals. If an individual has a smaller mouth, if you will, you wouldn’t necessarily want to put a large, bulky device in. You would choose something more streamlined and small. That it would be comfortable for the user.

Audrey Wells, MD

For sure. Going back to your point on nasal breathing, this is something I beat my drummer about all the time because the nose is specialized for breathing. What do you tell patients who say,  I don’t breathe through my nose?

Lee Surkin, MD

I tell them that it’s in general; we know that it’s bad for your health in general. Being required to breathe through your mouth is indicative of a problem with your nose and can increase the long-term risk of many different health problems. If your nose is congested and you are not able to breathe at least through one nostril at a time, not everyone agrees to breathe out of both nostrils all the time. But as long as you can breathe out of one nostril all the time, then you’re good. But if you can’t, then that leads to the development of obstructive sleep apnea, and that obstructive sleep apnea in that individual could potentially be cured by going to an ear, nose, and throat physician and having the nasal passages opened up, which can be done medically or with a minor surgical procedure.

Audrey Wells, MD

Just the simple act of having that hinge joint can crimp the airway a bit. Such that you’re more likely to collapse at that level.

Lee Surkin, MD

Ear, nose,  and throat surgeons are the folks who need to be part of the team that I mentioned before as caregivers for patients with sleep-disordered breathing.

Audrey Wells, MD

There’s a lot you can do with relatively minor procedures to stabilize the nasal passages or debunk the inside. For some people, that’s going to be a permanent fix. That uplevels their health. I want to tap into your cardiologist’s brain a little bit here because many people would be surprised to know that mouth breathing can have effects on your heart and other systems. Can you talk about that?

Lee Surkin, MD

The studies have shown, and there’s been a pretty popular book written about this, that, the more consistently you need to breathe out of your mouth can result in, long-term cardiovascular problems and, other health consequences. It’s even recommended that you try to breathe in and out of your nose when you exercise. That is very important to keep in mind and have a low threshold for bringing it to the attention of your primary care provider and getting a referral, or having the primary care provider initiate treatment, or getting a referral to your ear, nose, and throat physician.

Audrey Wells, MD

So important. But when it comes to mouth breathing, anybody who’s doing that for a significant amount of time should take a step back and think about options where they can promote nasal breathing and start to turn things around by getting to nasal breathing all the time.

 As we close here. Dr. Surkin, I wonder if you can let people know where they can go to find out more about oral appliances such as Nexus and where they can go to learn more about you.

Lee Surkin, MD

Thank you. In my role as chief medical officer of Nexus Dental Systems, first of all, the website is nexusdentalsystems.com, and there’s a referral resource even through that website to locate a well-trained, qualified dental sleep medicine provider. I’m building a national network of board-certified sleep physicians in every state who will collaborate with sleep dentists in their state in the care of their patients. One of the things that Nexus Dental Systems does for dentists is very efficiently to help them navigate medical billing on behalf of their patients. Through the efforts that Nexus Dental Systems provides to the dentists, assistance with reviewing their insurance, the patient’s insurance, and assistance with medical billing, we are effectively saving patients a lot of money because we can get the dentists in-network with many different insurance companies across the country. If you’re in-network, you’re going to save, and as a patient, you’re going to save a lot of money compared to having to go out of network or out of pocket. We at Nexus Dental Systems also educate. We have a comprehensive educational program through an academy called the Academy of Clinical Sleep Disorders Disciplines. It’s nonprofit. the doctor was on, as I had told you earlier, but I was one of the organizers of the curriculum that was accepted as the first of its kind as an elective course in sleep medicine at the Medical University of South Carolina. 

We launched it last year, and we were invited back this year. It’s ongoing as we speak this fall semester for medical and dental students. We are very involved in education, educating the dentists comprehensively, thoroughly certifying them, and giving them practical training on which appliances to choose based on their patient’s anatomy. We hold their hands until they’re ready to fly on their own, and we are involved in that aspect of comprehensive trends, not a weekend course. It’s a very rigorous course. But if you’re going to do it, you’ve got to do it the right way. There are many other aspects of what Nexus Dental Systems offers to patients and, of course, dentists. It’s on that website.

Audrey Wells, MD

Well, that’s fantastic. I just want to underscore what you said earlier. It’s an involved procedure. The process of constructing these customized oral appliances can be expensive. You want to carefully select the dentist who is constructing that and following up with you. Give us the website again, please.

Lee Surkin, MD

Nexus Dental Systems so NEXUSDENTALSYSTEMS dot com, nexusdentalsystems.com. You can find my bio on that website as well. There is a search engine where you can enter your zip code and locate what I’ll call Nexus Dentistry, which is defined as a very well-trained, experienced, and qualified sleep dentist.

Audrey Wells, MD

That’s fantastic. A lot of people would be interested in getting value out of that and certainly avoiding wasting money on things that don’t work. great. Well, thank you so much for our discussion today. It encapsulates the idea that oral appliance therapy is a viable alternative to CPAP treatment. for anybody interested, we’ve given some actionable steps to start looking into that if it interests you.

Lee Surkin, MD

Thank you, Dr. Wells. It’s been a pleasure.

Audrey Wells, MD

Same here.