Provisional Mandibular Advancement Device-PMAD, Provisional Mandibular Advancement Therapy - PMAD, Silent Nite sl, EMA,

Dental Hack’s Sleepy Journey Delivers

Dr Alan Mead from Dental Hacks Podcast did an excellent interview with Dr. Lance Timmerman called “Dr Lance Timmerman’s Sleepy Journey”. It may have been an older episode, but it popped up on my drive home. Dr. Timmerman made a few comments that really inspired me. The points that got my attention were actually smaller points in the interview but they leapt out at me, I want to share them with you here..

First the statement that “the treatment of airway, snoring and sleep apnea does not require any specialty equipment that is not found in the average general dentistry practice” was spot on. There are plenty of headwinds to developing a practice that addresses daytime sleepiness as a result of snoring and sleep apnea, dental materials and techniques are not difficult they are just different (my nod to John Tucker DDS).

Many clinicians do very well with a simple STOP-bang questionnaire or an Epworth sleepiness scale for screening.  Dr. Timmerman did mention that he owns a home sleep testing device, however he didn’t mention which one.

Provisional Mandibular Advancement Device -PMADHome sleep testing for sleep apnea with Nox T3
In home testing can confirm that Provisional Mandibular Advancement Device – PMAD is titrated optimally

The HST device is used for appliance titration/calibration. I feel that this is a great tool and since the symptoms of snoring and sleep apnea take place at home, while sleeping, a home sleep test is the best way to monitor the success of an oral appliance. I would suggest that this is a specialized piece of equipment that can be added later as the practice develops.

Dr Timmerman shared a personal story about treating his father who has sleep apnea and is successfully treated with CPAP. As the story goes, the Dr. and his father were planning a European vacation so an oral appliance was made to avoid possible treatment gaps due to equipment issues, power and the like. The style of appliance was not mentioned.

Travel, inconsistent power and convenience are all great reasons patients successfully treated with CPAP may want to consider an oral appliance. Successful sleep therapy is a habit and all habits can be broken. Dr. Bradley Eli once told me “One night untreated can be the first night of the rest of the patients life”.

“One night untreated can be the first night of the rest of the patients life”

Dr Bradley Eli DMD

Frost and Sullivan report that over 5 million CPAP machines were sold in the United States in 2017. It is widely reported that only 50% of patients are able to make CPAP a part of their life after 45 days of effort. I have often wondered if using an oral appliance in conjunction with CPAP could give a patient the variety necessary to stay in care.

I am reading (listening) between the lines, here but I suspect that as a trained sleep dentist Dr. Timmerman must be aware that with a primary relative who suffers from sleep apnea he is 8 times more likely to have sleep apnea himself. He decided to screen himself for the disease.

After a diagnostic test Dr Timmerman was found to have a case of loud snoring but with an AHI of 3 was well within normal limits for sleep apnea. Dr Timmerman treated his snoring with an oral appliance. He reported a successful result, but the part of the story that got my attention is, that when he missed one night of treatment he could feel the difference he felt sleepy and not as sharp.

This in spite of only having an AHI of 3, meaning he does not qualify for medical treatment or medical insurance reimbursement. Patients in the same position will go untreated or worse, use an over the counter appliance with no professional supervision.

Dr Timerman noticed that simple snoring was in fact affecting his sleep quality enough that he wears an appliance every night.

In practice, the dental treatment of sleep disordered breathing has been in existence for at least 35 years. The practice of dental sleep medicine has been shaped by medical insurance reimbursement, which does not fit easily into the average dental workflow.

The medical model and the pursuit of the non-compliant CPAP patient that goes along with it, may have blinded the dental practitioner to the true size of the opportunity for dentistry. The metrics are clear 50+ percent of the people you see today will snore, 30+ percent snore every night.

Snoring is the sound a partially collapsed airway makes. Due to the hereditary nature of the condition the opportunity for a family dentist in anywhere USA is limitless. The condition is pervasive and linked to obesity, hypertension, heart disease and stroke.

The most important question a hygienist can ask a patient is…

“Do you snore?…would you like to stop?”

If the patient answers yes in the current model a series of things need to happen in order to help the patient. In many cases, the patient is referred to their physician and that is the end of it. In some cased the patient actually goes through the entire process and finds that CPAP isn’t the answer for them.

At this point time has passed and the patient may not continue to pursue treatment or treat themselves using an OTC appliance.

There may be a much better way to move a snoring patient through the process and in many states it is an auxiliary procedure.

Ken Berley DDS, J.D. suggests that it is a much better to screen every patient in the practice for sleep apnea according to the 2017 ADA guidelines using a questionnaire STOP-Bang, ESS Epworth sleepiness scale.

Then initiate treatment with a provisional mandibular advancement device PMAD for snoring symptoms with a clear informed consent and a referral to a medical professional.

It is the physician’s role to diagnose the patient and substitute a provisional treatment with a definite therapy. In some States the access to sleep specialists is limited and results in delays of 3-6mos or longer. Provisional therapies have been shown to reduce symptoms until medical consultation can be achieved.

Provisional mandibular advancement therapy is a much clearer path for the practitioner and the patient. In many states this is an auxiliary practice.

Low cost devices like Silent Nite sl (the one I wear) or the EMA appliance (I own one and have worn it) can be fabricated for the patient based on information from a questionnaire like a Stop Bang or an Epworth Sleepiness Scale. It is very important that treatment be initiated as quickly as possible due to the health risks associated with going untreated. Other sleep appliances include the EMA, Oasys,and the DreamTAP.

Provisional Sleep Apnea Treatment, Silent Nite sl, EMA
Provisional Sleep Apnea Treatment, Silent Nite sl, EMA

The caveat here is that the patient must be aware of the risks and all of the possible side effects and risks associated with being treated for the symptoms of snoring without a full diagnosis. Any practitioner following this path should document the patient’s knowledge and understanding of this with a signed informed consent document. Dr Ken Berley DDS,J.D. has shared a document like this for you to download for free. CLICK HERE TO DOWNLOAD


Dental Hacks

Dr Lance Timmermans Sleepy Journey

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Randy Clare

Randy Clare

Randy Clare brings to The Sleep and Respiratory Scholar more than 25 years of extensive knowledge and experience in the sleep and pulmonary function field. He has held numerous management positions throughout his career and has demonstrated a unique view of the alternate care diagnostic and therapy model. He is considered by many an expert in the use of oral appliances like Silent Nite, EMA and TAP to treat snoring and sleep apnea in the dental office. Mr. Clare's extensive sleep industry experience assists Sleepandrespiratoryscholar in providing current, relevant, data-proven information on sleep diagnostics and sleep therapies that are effective for the treatment of sleep disorders. Mr Clare is director of business development for Glidewell a dental solutions company his focus is on dental treatment for sleep disordered breathing.

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