MAD Responder or Non Responder? That is the question
The big question that dentists deal with when treating Sleep Disordered Breathing (SDB) is… will the MAD appliance work? This seems like a pretty simple question. Positioning the airway to activate and stabilize the ligaments and tissues of the upper airway is a physical therapy. Patients are either responders or non-responders.
The challenge is, the answer is not so simple. In order to determine a patient’s likelihood of responding to Mandibular Advancement Device (MAD) therapy many different strategies and tactics have been tried.
Let’s go back, general consensus is that snoring is the sound that a partially collapsed airway makes and obstructive sleep apnea is the complete collapse of the airway. It seems pretty straightforward that airway cross section should be the key determiner of success with an MAD.
All we need to do is measure airway cross section and we will be able to separate patients who will respond to the therapy and those that will not respond. Measurement tools such as cone beam CT scanning and pharyngometry are currently in use in dental practices and provide clinicians and patient’s confidence that their therapy is on the right track.
Literature reviews simply do not find a direct connection between reduced airway cross section and response to MAD therapy. I have been thinking about this for over 20 years so you can allow me to dwell on this a bit.
Is it possible that the tonality of the tissue, the site and the degree of airway collapse and the combination of how long the patient has been experiencing symptoms may all work together to create a set of conditions that add up to a primary complaint of snoring and a diagnosis of sleep disordered breathing.
These measurements are important. They may only be a part of the story. Since the in-office measurements are all taken in a dental office, awake, seated with excellent posture and with a technician coaching. Perhaps the data is skewed by the fact that the patient is not asleep flat on their back with their mouth wide open and snoring like a banshee.
What if the best way to predict success with a patient like this is to measure the patient’s response while they are asleep?
Why not just make a simple provisional mandibular advancement device (PMAD) like Silent Nite and have the patient go home and try it. Provisional treatment of the patient’s primary complaint is well understood, low risk and is the path most dentists take when they first add SDB treatment to the practice. Other sleep appliances include the EMA, Oasys,and the DreamTAP.
Silent Nite is low cost, with a simple bite technique and has a 25 year track record of success. If the patient stops snoring they are a responder. If they do not, and connector adjustments don’t help, then they are not a responder. Provisional therapy is billed out of pocket and is delivered in the hygiene dept.
Once the patient is identified as a responder and has an OSA diagnosis from a sleep physician a more objective bite registration may be indicated to register jaw position while the patient is actually asleep.
In that case there is really only one other solution. MATRx Plus is a device that measures sleep parameters as any home sleep test with one difference. MatRx Plus also has the ability to simulate MAD therapy, measure its affect on sleep disordered breathing and record the optimal bite in the treated position.
So the best way to see if a patient will respond to MAD is to try it provisionally. The best way to record a bite registration is to take it while the patient is asleep.
MATRx is a simple process, the patient takes the device home, wears it for 3 nights and brings it back to the dental office. The report has been automatically uploaded, scored and returned before the patient gets to the office. All that is left is to fabricate an MAD to the optimal position as determined by MATRx.
Sleep physicians will recognize the titration strategy. As it is very similar to the gold standard of sleep therapy, a CPAP titration study more commonly known as a split night study. This is a study where a patient sleeps for 4 hours without treatment and for the next 4 hours cpap is adjusted to its most effective setting, establishing a therapeutic pressure for home use.
As a practicing dentist you make these decisions all day long. What level of certainty do I need to meet the patents expectation of success? While at the same time run an effective dental practice. For many provisional treatment with Silent Nite, is the easiest most practical method. For others, in more competitive markets with more affluent or better insured patients MATRx plus is the only choice.
It is just one of those questions with many answers.