“Certainly Enjoying Not Wearing CPAP Anymore!”: An Interim Case Report of Biomimetic Oral Appliance Therapy

 

By Felix Liao, DDS, MAGD, ABGD

 
Key Points: The mouth plays a crucial role in sleep quality, snoring, and sleep apnea. Obstructive sleep apnea remains 74-90% undiagnosed (1). Improving sleep by freeing is a great service for biological dentists to provide. This case report documents how Biomimetic Oral Appliance Therapy (BOAT) can make a positive difference in the oral-systemic health and quality of life in a patient who is already free of amalgams, root canals, and periodontal inflammation. Unlike the typical Mandibular Advancement Devices (MAD), Biomimetic appliances (a/k/a DNA Appliance) can signal stem cells in periodontal ligaments to grow mid-facial bone volume in adults (2) and enhance airway (3).

The Case of HR

hr1HR is a 58 year old white male who had been on Continuous Positive Airway Pressure device after a sleep test in December 2009 produced a medical diagnosis of Obstructive Sleep Apnea. After his amalgam revision in August of 2010, HR presented with the following during our consultation regarding his airway issues:

Subjective

  • Daytime fatigue, needing a nap every day
  • Low back pain annoying
  • Hypertension 140/90+
  • On CPAP for 3-4 months
  • Epworth Sleepiness Scale: 15
1

Click to view full-sized.

Objective

  • Obstructive sleep apnea medically diagnosed; AHI = 9.9 in REM sleep
  • Sleep Efficiency 79%, with only 16% in REM sleep
  • Generally balanced facial features with mild forward head, posterior head rotation, suggestive of airway deficiency
  • No periodontal inflammation or pockets > 4 mm, and no caries.
  • Generalized abfractions, gingival recession, and matching wear facets implicates sleep bruxing
  • Cephalometric analysis: Skeletal Class III with B point of mandible 5 mm ahead of A point of maxilla, and deficient vertical by 13 mm
  • Moderate crowding of mandibular incisors points to deficient development in maxillary anterior region
  • Oral Pharynx: Friedman Tongue Position Grade 4 (4)
  • Cone Beam CT (CBCT):
    1. Minimal AP width of oral pharyngeal airway = 5.5 mm
    2. Airway Volume (top of C1 to base of C3) = 15.5 cc
2

Click to view full-sized.

Assessment

  1. Class III malocclusion with significantly reduced vertical dimension
  2. Reduced oral volume drives the tongue into oral pharynx
  3. Oral pharynx becomes partially occluded or collapsed during sleep, when the patient is supine, combined with gravity pull and loss of muscle tone to produce snoring and sleep apnea

Plan

  1. Biomimetic Oral Appliance Therapy (DNA Appliance) to remodel airway by epigenetically re-develop maxilla in width and AP dimensions
  2. Oral appliance with occlusal coverage to increase vertical dimension
  3. Patient instructed to wear the appliance 14-16 hours a day, including hours of sleep, and turn the expander screw once (0.25 mm) a week
  4. Nutritional counseling on weight loss with low carb/high fiber/quality protein diet and exercise
  5. Sleep hygiene including A) small dinner at least 4 hours before bed time; B) blackout blinds for bedroom and no TV or cell phone in bedroom; and C) in bed by 10:30 pm and asleep by 11 pm
  6. Return once a month to monitor progress and adjust occlusion
  7. See own physician and chiropractor as needed

Treatment

8/8/2011: Per patient request to “keep it simple,” Mandibular Advance Device (MAD) was tried first, but failed to help his symptoms. The patient then opted for DNA Appliance.

4/25/2012:Biomimetic Oral Appliance Therapy (DNA appliance)

Results

Comparing pre-treatment of 3/23/2011 with progress records of 4/18/2013:

  • Minimal AP width of oral pharynx: 5.57 vs. 9.56 (72% gain)
  • Oral pharyngeal airway volume: 15.5 cc vs. 21.7 (40% gain)
  • Epworth Sleepiness Scale: 15 => 8, or 47% gain
  • Inter-incisal opening: 57 – 62 mm
3

Click to view full-sized.

Patient Comments

After 1 Week

After 1 Year

Patient has scheduled follow-up sleep test for August 2015, and the result will be posted as an addendum to this case report.

Patient is interested in continuing his non-surgical development of his airway using oral appliance therapy.

Discussion

  1. In the author’s experience, airway obstruction is a frequent finding in patients free of amalgam, root canals, periodontal inflammation and yet who still don’t feel well.
  2. Cone Beam Computerized Technology (CBDT) is useful in assessing OSA:
    • “A 3-dimensional Cone Beam CT airway analysis could be used as a tool to assess the presence and severity of Obstructive Sleep Apnea.” (5)
    • “3-dimensional CBCT airway analysis could be used as a tool to assess the presence and severity of OSA.” (6)
    • “CBCT provides a low-radiation rapid-scan capability to assess patient’s airway. (7)
    • “The upper airway was significantly smaller in apneic than normal subjects, especially at the base of palate and tongue.” (8)
    • Compared to non-snorers, snorers have “significantly smaller pharyngeal (throat) cross sectional area, which is even smaller in snorers with Sleep Apnea.” (9)
    • “Structural defects have been linked to boney and tissue abnormalities, which load the pharynx and predispose to airflow obstruction during sleep.” (10)
  3. Airway dictates, and the rest of the body accommodates. Teeth grinding is now sleep bruxing. Dentists with proper training can help screen and treat snoring and sleep apnea before implant or restorative reconstruction.
  4. “The Triad of TMJD, Sleep Disordered Breathing, and Tori may co-present as undiagnosed crnaiofacial underdevelopment.”(11)
    hr6
  5. In the author’s experience,
    • Mandibular anterior crowding can be a fourth indicator to the Triad suggestive of deficient airway.
    • Mandibular advancement devices (MAD) do not work well in patients with retruded maxilla.

References

  1. Young T, et al. Eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31:1071-8.
  2. Singh GD, Heit T, Preble D. Changes in 3D midfacial parameters after biomimetic oral appliance therapy in adults. J Ind Orthod Soc 2014;48(2):104-108.
  3. Singh GD, Wendling S, Chandrashekhar R. Midfacial development in adult obstructive sleep apnea. Dent Today 2011;30(7):124-127.
  4. Johns M. What the Epworth Sleepiness Scale is and how to use it. Available at: http://epworthsleepinessscale.com/about-epworth-sleepiness/.
  5. Barcelo X, et al. Oropharyngeal examination to predict sleep apnea severity. Arch Otolaryngol Head Neck Surg 2011;137(10):990-996.
  6. Enciso R, et al. Comparison of cone-beam CT parameters and sleep questionnaires in sleep apnea patients and control subjects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:285-293.
  7. Tso HH, et al. Evaluation of the human airway using cone-beam computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:768-776.
  8. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis 1993;148:1385-400.
  9. Bradley TD, et al. Pharyngeal size in snorers, nonsnorers, and patients with obstructive sleep apnea. NEJM 1986 Nov 20;315(21):1327-31.
  10. Isono S, et al. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects, J of App Phys 1997 April 1;82(4):1319-1326.
  11. Singh GD, et al. Case report: Effect of mandibular tori removal on obstructive sleep apnea parameters. Dialogue 2012; 1:22-24.

Copyright 2015 Felix Liao, DDS

Become a Member

Join IABDM Now

Join Now