The National Institutes of Health estimates that between 50 and 70 million Americans suffer from chronic sleep disorders, and that 80% to 90% of them remain undiagnosed. An article published in SLEEP (1997; 20(9); 705-706) stated, “We estimate that 93% of women and 82% of men with moderate to severe SAS (sleep apnea syndrome) have not been clinically diagnosed.” Overall, a 2006 study of 1,500 respondents stated “26% met the Berlin questionnaire criteria indicating a high risk of OSA (obstructive sleep apnea)”, (Chest; 2006; 130; 780-786) meaning that 1 out of 4 of dental practice patients are at high risk.
When normal breathing is disrupted during sleep, there are certain conditions you would expect, such as poor sleep quality or daytime fatigue, as well as more serious conditions such as cardiovascular problems, kidney disease, type 2 diabetes or other issues affecting overall health. With the patient base so large and the risks so high, dentists should recognize the expanded role they stand to play in offering patients a better quality of life or even saving their life.
The most common treatment for these conditions has been continuous positive airway pressure (CPAP), but compliance levels are low due to patients not being able to tolerate the device. Since 2006, when the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine established guidelines for the use of oral appliance therapy (OAT) in treating OSA, the market has continued to grow. On Oct. 23, 2017, the American Dental Association adopted a policy in which they stated, “dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy (OAT).” The dentist is uniquely positioned to respond to sleep disorders with OAT thanks to their interaction with the patient on a regular basis.
Once a diagnosis of OSA has been made and OAT has been determined as the appropriate treatment modality, it’s time to fabricate the appliance. The most important part of the fabrication process is the bite registration. In effect, the patient is being placed in a temporary biting position in order to provide management of their OSA condition. Treatment will not be successful if the patient is uncomfortable. The bite registration must take into account all of the patient's normal function between their maxillary and mandibular teeth.
Prior to taking the bite registration, the dentist must conduct a complete oral examination to determine whether the patient will be able to tolerate OAT. This examination should determine their maximum protrusion, range of motion, level of bruxism (if any), and TMJ condition. Once the examination is completed, the dentist can begin the process of taking the bite.
For the purpose of this discussion, we will be using the Airway Metrics Bite Registration System. The primary component consists of a Snore Screener (SS) and 15 Mandibular Positioning Simulators (MPS).
How Does Airway Metrics Work?
The Snore Screener locates a general airway for closer scrutiny with the Mandibular Positioning Simulators to identify a target treatment position and a comfortable starting position for the bite registration. It uses a patient’s subjective feedback. Arbitrarily assign #5 to the patient’s best snore sound. The patient then snores in selected anterior positions at 4 mm, 8 mm, and 12 mm vertical to locate the lowest/absent sound. The dentist rates the sound at #5, 4, 3, 2, 1, 0 (no snoring). In the case of mouth breathers, you may not achieve the lowest level (no snoring). This is due, primarily, to the patient’s inability to breathe through their nose. In these cases, you may want to subsidize the airway through the use of a nasal dilator such as Mute.
The best (most quiet) position identified with the Snore Screener becomes the area for subsequent MPS tuning for the optimum airway and comfortable treatment position with the oral appliance. The 15 Mandibular Positioning Simulators allow for over 50 positions in the anterior plane from habitual occlusion to 7 mm edge-to-edge combined with a vertical plane of 4 mm to 12 mm in 2 mm increments.
Use the Airway Metrics Bite Fork & Handle to complete the bite registration technique. Then fit the opposite end-slots of the selected Mandibular Positioning Simulator to obtain a bite registration at the desired anterior/vertical starting position. Use Panasil putty and Futar D (Kettenbach) to complete the bite registration.
Want to see how it works? John Tucker, DMD, has prepared an in-depth video, seen below, illustrating the entire Airway Metrics Bite Registration System technique.