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Is your Snoring bothering you? Obstructive Sleep Apnea – Mandibular Advancement Splints

Podcast Transcript

The medical information communicated in this podcast is of a general educational nature. If you were feeling unwell, please seek the attention of a medical practitioner. Any advertisements promoted throughout the podcast are not endorsed by the presenter or any of the guests interviewed.

Danae
Hi there, welcome to talk, a medical podcast, talking all things medical in a way that you can understand. You’re with Danae. Around one in four men over the age of 30 have obstructive sleep apnea. Obstructive sleep apnea involves repeated episodes of airway obstruction during sleep, which happens when your upper airway collapses. Do you snore? Suffer daytime sleepiness, wake up gasping for air. Well, mandibular advancement splints may be prescribed by a sleep physician as a treatment for OSA. Today, we’re going to speak with Associate Professor Christopher Pantin, who is a dentist who has specialized in sleep dentistry, who will let us know all about them.

Danae
Today, we’re with Christopher Pantin Christopher.Tell us a little bit about who you are and what your specialty is.

Christopher
Okay. So, Danae, thanks for asking us to come along and have a chat. I’m a dentist. I work in Perth, and my special interest is treating sleep related disorder breathing, which really means snoring and obstructive sleep apnea.

Danae
So how does a dentist work in sleep ?

Christopher
Well, Danae Happy days. Yes. So basically, the reason you have or you do snore or you do have sleep apnea is because the airway collapses during sleep to varying degrees and sometimes only a little bit. So it flaps in the breeze just like a sail. And sometimes it completely obstructs and you can actually breathe. And that’s obstructive sleep apnea. So what this what I do is I put a splint in the mouth that pulls the jaw forward because all the things that collapse are directly or indirectly attached to your jaw.

Danae
Okay, so what is a mandibular splint then? Okay, so in lay terms a mandibular advancement splint, that’s the important bit because we pulled the bottom jaw forward. Basically is like two mouth guards. So you have a top mouthguard and a bottom mouth guard and the big feature of it is that your bottom jaw cannot slip backwards. So we put something on it that stops it going back, holds it forward

Danae
And that would then open up the airway. So then you don’t snore.

Christopher
Correct. So for snoring, it’s like stiffening up all the floppy bits, like pulling that sail in that we referred to. And for sleep apnea, the actual collapse, it’s tensing up the muscles so they can’t collapse.

Danae
Okay, so does that mean that anyone that wants a mandibular advancement splint can see any dentist for one of these devices? Yeah. Now this is where it gets a bit interesting.

Christopher
Yeah. The problem is that providing the splint is within the normal scope of practice of every dentist, and it’s easy.The actual mechanics of making a splint is easy. The problem is you’ve got to understand what you’re treating. So therefore you have to understand all the tricks on manipulating and adjusting that splint to get the desired outcome, whether it’s snoring or stopping obstructive sleep apnea.

Danae
And I, in fact, have a dad that has gone to a dentist. And you’re right, the work started after actually having a mandibular advancement being made. And unfortunately, he didn’t get that support and he bought a splint, got the splint made, and he’s never used it.And I think you’re right, it’s about really patients asking where they’re going and if they’re going to get that support after a mandibular advancements have been made. So so you’ve gone to a dentist and perhaps yourself and you’re having made a mandibular advancement splint.What’s the process?

Christopher
Okay. Well, it’s really simple. First of all, you come in for a consult. So we sit down, we have a chat and we find out what you’re after. So do you want to stop your snoring or do you want to stop your excessive daytime sleepiness because you can’t drive the car without falling asleep as a raft of things that we aim to to control or to manage. But basically we talk about the expected outcomes and how realistic your expectations are of us to achieve those outcomes.You then come back to a second visit and we take some impressions and we take a bite and we then send them to the lab. Three weeks later, you come back and you get your splint. We show you all the tricks of how to adjust it. And we have some quirky little tools that we use. I can’t tell you now, Danae, because I probably have to kill you, but if you decide to come along, we tell you how to do it. And then, of course, we review you a couple of weeks later and we give you more strategies. So it’s not a simple set and forget go to Coles, buy a piece of plastic off the shelf see you later, Happy days.It actually requires some work. It’s a bit like exercise in a way.

Danae
So you can’t just go and use a mouth guard from a pharmacist, that’s not going to stop you snoring.

Christopher
Good point, yes and no. So that we call them boil and bite. That’s a generic term because you boil them up, bite into them in happy days. The problem is most of them do not protrude or advance your bottom jaw very far. So you may get a false negative because it’s not adjustable. And the guidelines from the AADSM, which is an American group, suggest that a mandibular advancement splint needs several features. The first thing feature needs to be that it’s titratable or adjustable. The second one is that it’s custom made, so it fits your teeth perfectly because otherwise it will be uncomfortable potentially move your teeth around and potentially not not work because it falls off of your teeth.

Danae
And if what’s the ramifications of if you use a mouthguard or a splint that hasn’t been so, you know, you’ve gone and bought a cheap one, perhaps not gone to someone that’s actually specialised in sleep dentistry like yourself say you’ve gone somewhere. What’s the implications of what damage can be done if you’re wearing a splint that doesn’t fit to your to your needs, to you?

Christopher
Okay, so that’s a double edge. That’s a dual purpose question. So buying the boil and bite, believe it or not, is probably not terribly harmful because the chances of you complying or using it long term is so low that it can’t do damage that quickly. The bigger danger is going to someone who doesn’t know what they’re doing, who thinks it is just a piece of plastic and thinks that within their scope of practice so therefore they can do it.That’s the bigger worry because we do get changes in teeth position and we also get changes in jaw position. And the jaw reposition is completely preventable if you’re made aware of it and you reviewed appropriately. And the teeth movement is very minor in in my world because I’ve been doing it for 30 years and pretty much was the first person in Perth doing it in association with Sir Charles Gardiner Hospital. We sort of wrote the book on it so we know what what can happen.

Christopher
But unfortunately, not everyone does know. And what that means in real life is that I get all the mistakes so the mistakes end up with me and they are nearly always preventable if the knowledge of the person providing the treatment was better than it is.

Danae
What about when a patient has gone and gone and got a mandibular cheap mandibular splint or they’ve worn a mouthguard gone into the pharmacist, they’ve said, you know, use this mouthguard that’s going to stop your snoring and they’ve persisted with that, but then they’ve started getting jaw pain or they’ve gone back to their GP and then they referred to someone like yourself, someone who’s actually very specialized in sleep, dentistry. What is what are some of the things you’ve seen in these sort of cases?

Christopher
So we go back to what I told you about the boil and bite or the ones from the pharmacy. They’re just not tolerated, so they can’t stay in there long enough to do damage. But what’s interesting is that you’ve got as much chance of getting jaw repositioning and tooth movement with a custom made perfectly, you know, perfectly made appliance, as you do with one from the chemist. So the chemist is not really putting you at any more risk than any other splint.And so what we do find, as I mentioned before, we do get tooth movement long term and we can get jaw repositioning, but we can prevent jaw repositioning. So a really good study has come out recently. If we look at custom made mandibular advancement splints, they generically fall into two categories. One of them pulls the jaw forward and one of them pushes the jaw forward. What they found was that the appliances that pulled the jaw forward are more likely to cause tooth movement than one that pushes the jaw forward.So, again, you need to go to a dentist who actually reads the evidence and works on an evidence based background. And certainly because we’ve written a graduate diploma in dental medicine, of which I’m the associate professor who runs it and wrote it. So I have a vested interest, I guess, in it. But I’m encouraging all dentists who want to work in the area to actually get this qualification. There are a half a dozen dentists in Perth who do have it, and so it’s probably worth tracking down one of them.They probably have a higher level of knowledge than, well, certainly the average dentist. Unfortunately, the average dentist goes to, you know, a two hour lecture and thinks they know it all. In fact, the graduate diploma takes two years part time ninety. six hours of contact , four cases that have to be reported on, it’s a very involved degree and that’s why we’re confident that people who do that really do know what they’re talking about. But by the same token, I have after 30 years, I have a lot of patience and we think it’s around the 15 per cent mark, 15 per cent of patients have a risk of significant truth movement.But it’s interesting because it doesn’t affect function. And one of the fallacies of the medical profession, they are in this belief, which is not true, that it actually causes problems with the temporary mandibular joint or the TMJ. Yes, I’ve heard about it actually doesn’t do nothing. So the evidence is out, the studies are out that show it does nothing to it. It will potentially move your teeth, but your teeth move throughout life anyway. And when you go to the orthodontist, they get moved for you.So this is a very mild version of that. And if you’re really upset about that, have them moved back. I can tell you over 30 years that no one has ever gone to have their teeth moved back. No one’s ever died of a bite change. So if you’ve got high blood pressure and risk of cardiovascular disease. Yes. You can’t die of a bite change. You can die of the other by not being treated, however. So we although they’re important and the more knowledge you have about it, the better you can manage it and minimize the change.The change does happen. The problem is that people who don’t know what they’re talking about catastrophize it. So it’s this catastrophe that never happens.

Danae
OK, and so what I’m hearing is if MAS is an investment and basically really we should become very informed consumers. And if you are looking at needing a mandibular advancement splint, ask have you know the dentist? Have you got a specialty or are you specialized in sleep because the work actually happens after having a splint made and how, you know, you’re managing your sleep with this treatment for sleep or snoring, is that correct?

Christopher
Absolutely perfect. That’s exactly right. So we within the profession, because we’ve had a lot of resistance to Mandibular Advancement Splints, but we do studies called comparative effectiveness studies. And when you do that, you’re comparing the outcome of CPAP, the gold standard to Mandibular Advancement Splint, and they’re basically the same. And the reason it’s the same is because the compliance or the ability for people to wear the splint is about double what that is for CPAP. So CPAP might be better, but you can only tolerate on average for four hours, whereas the splint may not be quite as good at controlling your airway. It will control a bit, maybe not quite as well, but the fact you wear it for seven or eight hours makes up for that. And there is a study that proves that if if you’re geeky enough to look at this study by Anandam in 2013, it’s a comparative effectiveness study. And there’s a lot of them, a lot of them have come out of Sydney because as a sleep specialist in Sydney who’s passionate about mandibular advancement sprints and believes that it is the next best choice to CPAP. And in fact, I think quietly he thinks it’s the best choice over CPAP mainly because people will use it. But of course, he’s working in a research environment where everything’s done perfectly. And so that’s why you want to go to a dentist who can do it perfectly.

Danae
Yeah, no, that makes sense. So what are some lasting key points for patients to know when they’ve been diagnosed with sleep apnea or they’re having issues with their snoring and they really want to look at mandibular advancement splints as a real option for them?

Christopher
What we find is that although it’s comparatively as good as a comparatively viable option compared to CPAP, what we find is that patients are not told of it. So it’s because the sleep specialists probably aren’t confident in promoting that type of treatment because they’re not confident that the patient will get the outcome they’ll get with CPAP . And so it gets back to who puts it in, who manages you, who gets your outcome. So what you’ve got to do is really demand from the sleep specialists and say, look, I know about mandibular advancement splints.Can you please advise me who I could go and speak to and just do your research. And certainly within our practice, a lot of our consults finish with now you fully informed. Get back to us if you want to go ahead. It’s not you now fully informed. You’re suitable. Bookchin We’ll see you next week because that’s not the way to do it, because the big thing about all treatment with sleep apnoea is compliance. If you’re not going to stick to the treatment, don’t embark on it, because really it’s a it’s a costly exercise.Mandibular Advancement Splints absolutely comparable in cost to CPAP, so it’s not like one’s cheaper than the other or one’s more expensive than the other, the ongoing costs of splint, it’s probably cheaper than CPAP because there are really no consumables. You just need review, maybe once a year, etc. So you’ve got to demand to be presented, the option at least,

Danae
And know that I think when you’ve decided that you want to have some form of treatment and a mandibular splint and a mandibular advancement splint, that you’re going to get that ongoing support if you need it by someone who specialized, I think. Is there a good website perhaps? Have you got some really good resources on your website if you’re starting the research journey, I think Google’s fabulous, but I think where sometimes we get we all get stuck with Google is that you can end up in places where you’re not really getting credible information. And that’s why I’ve sort of embarked on this podcast. But can you suggest some really good, credible resources for people?

Christopher
So I have a really I’m always very cognizant of being of having a vested interest in giving advice. But I I’m quite happy to say, you know, the disclosure is it’s my my website I’m going to recommend you to go to. Yeah. It’s called Absolute Sleep. Like Absolute Snore No more. We have one there as well, but absolute sleep now on absolute sleep. There is a whole lot of information and there’s about eight videos covering different questions of cost, comfort, etcetera, females, everything. They are a bit funny. Well, I hope they’re very amusing, but, you know, the information’s good and then it gives you good sites to go to as well. So there aren’t a lot of sites, to be honest, but we think ours is a very honest and upfront site.

Danae
And I think it’s about getting you know, people are going to do their research on the Web, but it’s making sure we’re getting credible and local as well.There’s no point in sort of going to websites that aren’t local telling you about things that don’t exist in Australia or in in where you live. So I think directing people to your website is definitely the way forward. I think a local website is better. The other thing I want to throw in to the importance also of what we call adjuncts now within our field, we we have the Splints are our primary treatment, but we often (these are the bits i will have kill you if you repeat) because this is the secret to it. So adjuncts are looking at things like sleep position, weight gain, nasal breathing. What else is there? We commonly look at head position,etcetera. So things like that that we may need to address as well as the splint. So it’s not uncommon to do positional therapy, which means something that encourages not to sleep on your back as well as the splint. And that’s why our outcomes are so good, because we manage the patients like that.So we start with very basic intervention. And then until we get our outcome, we have a lot of.

Danae
And what sort of positional therapies do you mean? What do you mean by that?

Christopher
The one we like most is called nightshift. So it’s a little vibrating collar that moves you off your back. But you can use a simple back pillow. You can use a pillow between your knees as an anti rotational device to keep you on your side.

Danae
I had a GP asked me the other day about pillows for positional therapy so there’s better ones out there.

Christopher
Yeah, so there’s one called backpack and that is just a matter of tracking that down. You can probably track that down on the net, but you’ll be really surprised if you Google

Danae
And that information’s on your website?

No, you’re going to do that independently. Yeah, because the pillows change all the time. There’s blow up ones now. Yeah. And someone’s trying to develop one where that’s got a motor sensor. So when when you just wear it as a belt and then when you go on your back it triggers the motor to inflate it and then pushes you over like that.

Danae
It’s incredible.

Danae
That’s really brilliant.

Christopher
Yeah. And same with those pillows, you know, snore pillows on that net. Flexion is huge. So our group, at WASDRI to have done a lot of research on neck head position, which means if your necks flexed or extended and certainly if its flexed, that really increases your risk of sleep apnea or exacerbates it. So quite often you might need a splint, but also something to keep it propped back as well. So that’s called an adjunct. So that pillow would be an adjunct. So that’s what someone who works in the area, that’s what you want them to have the knowledge of, not just about giving you a splint where you turn a screw and hope for the best, because that will not be the outcome.

Danae
Yeah, well, it sounds like going to a sleep, a dentist that specializes in sleep. Hopefully we’ve all learned.I certainly have a little bit more about mandibular advancement splints. Thanks for joining us today, Associate Professor Christopher Pantin.

Danae
Thanks for listening, everyone. Please send me an email of any medical topics you would love to learn more about by simply emailing me at Danae @MEDITalk.com.au. You stay well and let’s talk soon.

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