Essay Example on Overview Oral Appliances

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Obstructive Sleep Apnea Overview Oral appliances OAs can significantly reduce the apnea hypopnea index respiratory disturbance index respiratory event index AHI RDI REI across all levels of obstructive sleep apnea severity in adult patients The odds of achieving the target AHI is significantly greater with continuous positive airway pressure CPAP than with OAs CPAP has been found to be superior to OAs in reducing the AHI arousal index and oxygen desaturation index and improving oxygen saturation therefore CPAP should be the first line option for treating OSA Oral appliance therapy can be considered in inmates who are intolerant or have failed CPAP therapy Oral appliances OAs used in the treatment of obstructive sleep apnea are designed to open the airway by positioning the mandible and tongue forward The greater the advancement the better the treatment effect This must be balanced against the possible side effects Maximizing advancement is especially critical in more severe OSA Oral appliance therapy must be prescribed by a physician and a qualified dentist should use a FDA approved custom titratable oral appliance Custom titratable OAs have been shown to improve daytime sleepiness reduce the AHI arousal index and oxygen desaturation index and increase oxygen saturation to a greater extent than do no custom OAs BOP dentists must be privileged to provide oral appliance therapy Regional Chief Dentist RCD review and approval is required prior to fabrication of an OA by BOP dentists BOP dentists providing an oral appliance for the treatment of OSA must have training in the overall dental management of OSA

Oral appliances may result in both short term and long term side effects Possible short term side effects the dentist should be cognizant of include jaw discomfort tooth tenderness excessive salivation dry mouth temporomandibular joint pain bruxism and headache Long term side effects tend to be minor and are generally tolerated by most patients Possible long term effects may include decrease in overbite and overjet tooth movement flattening of the Curve of Spee and increase in lower arch width If the patient s annual assessment reveals symptoms of worsening OSA or the potential need for additional adjustments to the device then the dentist shall communicate this information to the patient's physician



The dentist will have at a minimum 25 hours of certified continuing education from either the American Dental Association or the American Academy of General Dentistry in dental sleep medicine Dr Lockhart and RADM Makrides will need to decide on if appliances will be done by BOP specialists such as BOP Prosthodontist or BOP General Dentist with a certain amount of training Will dentist go to patient or patient to dentist These issues are above my pay grade Protocol The primary physician will write a medical to dental consult in the electronic medical record A signed Informed Consent form must be obtained from the inmate prior to initiation of treatment A thorough dental examination to include panoramic and other indicated radiographs as well as a comprehensive periodontal evaluation occlusal status overbite overjet measurements range of motion and documentation of the current TMJ function dysfunction status must be accomplished prior to submitting a review and approval request to the RCD Upon RCD approval the inmate will be placed on Medical Hold until the oral appliance is completed and final adjustments have been made Diagnostic casts maintained within the dental clinic for as long as the inmate is using the device

Diagnostic casts are a frame of reference to monitor occlusal and skeletal changes If the inmate transfers to another BOP facility the patient s diagnostic cast is to be forwarded to their designated institution s dental clinic along with a referral to the receiving dentist Dental treatment will be reprioritized An inmate with a confirmed diagnosis of OSA who has a written order for an OA will be exempt to the established national dental routine wait list The inmate is eligible for accelerated routine dental care All surgical operative and periodontal treatment must be completed prior to fabrication of an OA The inmate should have a minimum of six to eight periodontally sound teeth in each arch with negligible attachment loss to provide for adequate retention of the oral appliance Inmates with periodontal disease will not receive an OA until the etiology has been addressed A periodontal consult will be required for those cases with an uncertain periodontal status Maximizing advancement is especially critical in more severe OSA Titration above 50 of maximum opening was shown to increase side effects

Thus slow advancement of the jaw to open the airway will minimize joint and muscle pain Inmates with a history of significant Temporomandibular Joint Disorders TMJ TMD disorders may not be appropriate candidates for an OA and if treated should be treated with caution and carefully monitored for TMJ TMD symptoms Once titration and final adjustments to fit has shown to improve symptomology a referral to the sleep medicine physician will be made for a follow up polysomnography to confirm appliance effectiveness on decreasing AHI Continuation of Care Inmates treated with oral appliances for OSA should return for periodic follow up visits with a qualified dentist Follow up appointments should be scheduled every 6 months for the first year and at least annually thereafter The purpose of follow up is to monitor the patient adherence evaluate device deterioration maladjustment or alteration of the device evaluate the health of the oral structures integrity of the occlusion and assess the patient for signs and symptoms of worsening OSA Intolerance and improper use of the device are potential problems for inmates using oral appliances which require patient effort to use properly

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