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By Dr. Jerry HuIt is without a doubt, the most researched, most documented, and most accepted type of appliance used in dental sleep medicine is the customized mandibular repositioning device (MRD, MAD, MAS, etc.). From using evidence based meta analysis to randomized controlled studies, the customized oral appliance, especially the Herbst style from all the government studies, we can firmly conclude without dispute that it is the first line of treatment choice in dental sleep medicine.
The remarkable ability that the oral appliance has to make dramatic improvements in sleep study parameters, (such as NADIR O2, AHI/RDI/REI when the proper bite and appliance type is selected) is widely known in the medical and dental community. In essence, the properly made device is truly a rescue device. Patients who already show CPAP intolerance and failure should immediately be given customized oral appliance therapy alternatives by sleep physicians and the entire medical- healthcare community.
Sleep dentists using the trusted and reliable airway bite techniques and selecting the proper type of appliance are equally important. Combining sleep hygiene instructions and evaluating nutrition, mental health, and exercise plans are also essential. With all the right ingredients at play, the customized oral appliance can be a life saving treatment choice for sleep apnea patients. They truly can rescue the patient, even at severe levels of obstructive sleep apnea (OSA).
There are several articles and evidence based science that prove the success of Herbst style appliances. Using qualified and skill technicians who know how to engage undercuts, design anatomy and proper retention into the fabrication process is absolutely crucial. The type of Herbst arm used and how it is connected all matter as well. With properly made Herbst appliances, it can be proven that severe AHI levels even above 60-70 can be taken down well under 5 (some even to 1 or 0) with proper calibration and follow through by sleep dentists.
It sure is a very reliable method to look at every patient’s own unique mandibular movement parameters and limits. Paying close attention to patients’ mandibular excursions as they are counting numbers is key. Incorporating the methods recommended by Dr. Ricketts and Dr. Speigel, such as shouting the word, “Shun,” and correlating letters such as “N” for vertical are a part of taking a proper bite. Discerning nasal airway issues while reclined also is a paramount part of the data collection.
When the proper bite and appliance such as the Herbst is used, the sleep physicians and the entire medical community will have confidence reinforced in dental sleep medicine. This also means the sleep dentist needs to identify the whole picture of the patient. If the patient needs to see an otolaryngologist for turbinate reduction, RhinAer or VivAer, the dentist should refer and work interdisciplinary. The same with cardiologists on heart issues, neurologists with Alzheimer’s, memory, etc, pulmonologists on lung and breathing, oncologists with cancer, which all have connection to sleep apnea treatment success. Working with nutritionist, exercise trainers, myofunctional therapists, physical therapists and specialized chiropractors (SOT) are also necessary at times. Every patient who walks in the door has their own unique phenotype, their own medical history, medications and past treatments, etc. It is therefore important the time and attention is given when taking on dental sleep medicine cases for OSA.
In the literature, it is found that there are definite non-responders to customized oral appliance therapy. Albeit a small percentage, those patients have the option of epigenetic appliances. But it is extremely important for severe apnea patients, who so many are CPAP intolerant and non compliant, that the tried and true customized oral appliance, such as the Herbst is used - rescuing immediately. Epigenetic appliances such as open loop cricket, occlusal correctors, sagittals, crozats, DNA, etc., are great considerations for non responder OAT patients. Appliances such as the open loop cricket is also fantastic for cranial strains and distortion correction.
With the proven evidence based science, the customized oral appliance truly is a life saving rescue appliance. It should always be considered as the first line treatment choice in dental sleep medicine. For those learning and diving into dental sleep, it is important to know that this treatment choice is also the most recognized and accepted one by board certified sleep physicians.
Remember, no treatment can proceed without the diagnosis, referral and letter of medical necessity from a sleep physician.
Let’s continue to save lives together as thorough and caring sleep dentists!
Dr. Jerry Hu