NMDA Journal Summer 2019

20 New Mexico Dental Journal, Summer 2019 compliant and wears it all night, every night. It doesn’t take a ton of research to show that a PAP device is 0% effective if the patient does not wear it. Some other drawbacks of PAP therapy are discomfort from the mask, noise, difficulty to clean, air getting blown into the esophagus/stomach, air leaks from the mask (sometimes into the patient’s eyes), and claustrophobia. Orthodontic treatment for patients can be grouped into children and adult orthodontic therapies. Concerning children and adults, the primary role of an orthodontist is to refer to appropriate medical practitioner based on recognition of signs and symptoms seen clini- cally, in radiographs, and based on reported patient behavioral histo- ry. Particular to a growing child, the hands-on role of an orthodontist is to intercept and correct the growth and development issues that have arisen as a consequence of the airway issues (get growth and development back on track). These are some therapy goals to treat the growing child: • Palatal expansion to correct maxillary width discrepancy • Maxillary protraction to correct recessed maxilla • Development of maxillary and mandibular arch width (to get back to where they should be) • Mandibular anterior repositioning-(functional) appliances to advance the lower jaw and promote increased lower airway dimension (when this is done during growth, it can be beneficial for mandibular growth direction) As for adults, recognition of airway issues is still the key for overall health. The clinical signs to identify will be the same as for children with the addition of recessed jaw structure (severe class II or class III skeletal malocclusions), severe wear/cracked of teeth (posterior and anterior), generalized anterior spacing of upper or lower teeth, gingi- val recession, and severe soft palatal drape. Radiographic signs again are the same as for children with the addition of a volumetric mea- surement of posterior airway (CBCT) as this is beneficial for describ- ing upright airway dimensions and “at risk” airways. This is not for diagnosing sleep apnea though and does not describe the patient’s airway dimension in the supine position. Other behavioral signs to look for are reported history of clenching/grinding and documented or patient reported sleep issues. Orthodontic treatment options for adult (non-growing) patients are as follows: • Orthodontic expansion of the maxilla • Surgical or non-surgical • Development of maxillary and mandibular arches • Orthodontic treatment in conjunction with orthognathic advancement surgery • Maxillary advancement • Mandibular advancement • Bi-maxillary advancement Orthodontic treatment alone will not“cure”obstructive sleep apnea. As orthodontists and dentists, we see malocclusion with patients in our chairs. It is important that we recognize and diagnose the underlying is- sues (airway, jaw joints, etc.) that have led to the malocclusion and to re- fer to the proper medical practitioners to address them in tandemwith our orthodontic correction of the malocclusion. Orthodontics should be seen as a vital part of a team to recognize signs and symptoms of airway issues, to help correct the issues that have arisen as a consequence of them. Orthodontic treatment can correct growth and development ab- normalities that have arisen as a consequence of airway issues as well as promote healthy development of airway dimension in children (grow- ing patients). In adults, orthodontics can be part of a team to and help correct the long-term sequela of airway issues and promote increased airway dimension, either non-surgically or in conjunction with orthog- nathic surgery. The last type of treatment is a mandibular advancement device. This is an appliance that must be made by a licensed dentist that the patient wears during sleep. This device pulls the mandible both for- ward and sometimes opens vertically in order to maintain an open airway. There are several different design types of appliances, but the purpose of all of them is the same. These have been shown to work effectively in mild to moderate cases of OSA, and they do provide some benefit to patients with severe OSA especially if they are not compliant with PAP therapy. These also can be used in conjunction with a PAP to gain a better combined treatment effect, and in severe cases where PAP still does not improve the patient’s AHI enough, this should be considered. These do not come without their own draw- backs though. Beware of tooth movement as a result of oral sleep appliances that reposition the mandible forward. Long-term use can see retraction of the maxillary dentoalveolar complex and proclina- tion of the mandibular dentoalveolar tissues. “AM aligners” can help reposition teeth after removal of oral appliance and greatly help pre- vent or limit unwanted movement. Oral appliance use can also cause malocclusion, often traumatic anterior contact of incisors and a Class III bite tendency if not monitored carefully by a dental professional. If tooth or jaw mispositioning is noted then the treating dentist should address it immediately and intervene with different therapy, a differ- ent device, and/or orthodontic correction. Considerations if Treating Dentists and dental specialists are able to treat OSA only in conjunc- tion with a sleep physician’s diagnosis and therapy order. Dentists are able to make many types of MAD, in fact they are the only healthcare professionals who are recognized as being able to do so. The 2015 Clinical Practice Guidelines from the Journal of Clinical Sleep Medicine recommend a qualified dentist as the provider of choice to provide oral appliance therapy. The American Academy of Dental Sleep Medicine offers a qualified dentist designation. The re- quirements can be found at www.AADSM.org . If a dentist is making these appliances, they will need full arch impressions or scans, bite registrations (with a George gauge or other device to capture the desired protrusion), and prescription from the dentist as to the type of device. Many types of devices and cost of each device needs to be factored in each patients’ discussions as these can be significant expenses. Medicare and some insurances require that dentists use devices that have cross arch stabilization such as the EMA, Herbst, Somnodent Suad, TAP, etc. Typically, dentists should make appliances that last three years mini- mum. There are many appliances that have this matching three-year warrantee. With medical insurance, dentists are treated as durable medical equipment (DME) providers, and durable Medical Equip- ment (DME) is made to last three years. That is when the insurance will generally pay for a new CPAP or a new oral appliance. Some  continued from page 19