Pediatric space management is often the key to the prevention of potential disastrous abnormal conditions and/or dental problems which could persist into adulthood.

Once thought to be the sole responsibility of medical GP’s, the incidence of Obstructive Sleep Apnea is increasing significantly…and there is compelling evidence that many adult airway issues begin in childhood.

Many kids today that are diagnosed with ADHD (and prescribed medication accordingly) may suffer from an underdeveloped maxilla, a posterior placed mandible, and an airway problem which effects their oxygen saturation level.

Even something as simple as interceptive therapy to maintain space can positively affect the intraoral volume, two things can happen: (1) loss in arch length and (2) the creation of an abnormal occlusion and abnormal jaw position.

A loss in arch perimeter diminishes the intraoral volume necessary to ensure normal tongue position. It can cause the tongue to drop back and block the airway.  

An abnormal occlusion (anterior or posterior crossbite) can alter the position of the mandible enough to allow the tongue to block the airway.

The fact is, airway obstruction physiologically impacts health and normal function in every single part of the body.

In order to give a child a chance at not just normal teeth, but also a normal airway, normal jaws in a normal position, a better night’s sleep and a normal life…the dentist must intercede immediately when it is evident that a child’s airway is compromised.

Early recognition and treatment of orthodontic and orthopedic issues is critical to the prevention of abnormal conditions and/or dental problems, which – if minimized or ignored – can persist (often disastrously, always expensively) into adulthood.

Consider the profound, continuing need for interceptive pediatric care -- especially in light of all we are discovering regarding the nature and treatment of Obstructive Sleep Apnea. The message is clear: EVERYBODY benefits from it – often in potentially BIG ways.

Now compare the cost of early interceptive care to that of extensive orthodontics, surgeries, crowns and veneers, sleep therapy, and potentially psychiatric or behavioral care in later years (after the damage has been done).

Early interceptive care wins hands down.

Is your dental office still trapped in the stone age of traditional impressions? Not only is this method slow, it can also prove dangerously inaccurate!

The newest generation of intra-oral scanner – notably the Condor Scanner -- is better than ever. We’re talking 3D color digital impressions that pop up instantly on your computer and can be sent directly to your dental lab of choice.

Not only does an intra-oral scanner dramatically cut down on the time it takes to complete an impression, but it also delivers more accurate results. The result: better oral device from you, better outcome for your patient.

Worried about the cost? Keep in mind that because choosing an intra-oral scanner route cuts down on your seating time, you can see more patients in a day

What does the future hold? In addition to that steady stream of new designs spoken of earlier …and ongoing research and development into the utilization of low level oxygen delivery/mechanisms for treating OSA, there’s another emerging trend/concept/awareness that has my immediate attention: the application of microchips in what I term “accountability therapy.”  

The next step toward higher percentage sleep therapy effectiveness needs to be made in the area of patient accountability. We must be able to make sure that our appliances are actually being used. Taking a sleep test to show that the appliance works when it’s worn just isn’t enough. We’re going to have to show that the patient is actually wearing the appliance – similar to what is already being done in CPAP therapy. That level of accountability promises to be a definite game changer in the field of sleep.

And talk about game changers…early prevention. Most sleep appliances today are essentially band-aids. They manage the problem of OSA but they don't prevent it. The future of sleep is active prevention and active treatment of the entire spectrum of sleep disorders.

The possibilities, as they say, are endless. Confidence in the here and now of sleep appliance therapy is a function of first embracing the fact that selecting the right appliance for your patients is never a case of one size fits all. Even when you’ve chosen what you believe to be the perfect appliance, it may still fail for a host of other reasons, e.g. inaccurate records, incomplete information, reluctance to consider combination therapy. Match the materials and technological componentry to the existing dental landscape of each individual patient….and then explore the third variable – the possibility that combined therapy may just be the “fitting” solution

Because every patient is different, here are some sample combination approaches for your consideration:

The Aligner Sleep Appliance™ (ASA)   and  the DNA Appliance

I think it’s fair to say that there is a direct correlation between malocclusion and sleep apnea. Research will back me up on this. Those of you who are treating malocclusion patients –aligner or adult patients -- with an appliance approach, need to evaluate those patients for sleep apnea. They may be your orthodontic patients, but you should also view them as potential sleep patients. 

Luckily for those undergoing alignment therapy, we have an appliance – the ASA -- that can be utilized during alignment treatment and will allow you to treat that patients apnea concomitantly.   

To be successful in deciding upon the right sleep appliance, you need to know:  

1. Materials, qualities, design and functional specifics of the different appliances. Hard acrylic? Cad-Cam Appliance? Does it allow lateral movement? Is it easily adjustable for patient and/or doctor? How is it retained – ball clasps and clasps? Is it lined with thermoplastic material? Can you adjust it and realign it easily?

2. What are the controlling parameters in relation to the patient? You will need to perform a full and complete dental sleep examination and a TMJ exam. What are the number of teeth in both arches? Any signs of periodontal disease or decay? Are there…

broken fillings or crowns that need to be replaced? Signs of lateral bruxism? Does the patient open and close comfortably? What is the range of lateral movement? What is the range of movement from centric relation to the most protrusive position. What is the size of their tongue, the size of their arches, the patency of their nasal airway?  Look at the tonsils, adenoids, the soft palate, hard palate. Do they have a high vaulted palate? Are they a skeletal class l, ll, or lll?  As a dentist we should be looking at all possible levels of obstruction: nasal, oral and hypopharyngeal airway spaces.

After you have treated your first two or three sleep patients it likely becomes quite clear (if it wasn’t already) that no one appliance will fit the bill (or the dentition) for every patient

Each appliance has it’s own limitations and every patient is different. For example:

• One type of appliance may hold the upper and lower jaw firmly together. For someone who is a mouth breather, this…

can prove to be nothing short of torturous. Claustrophobia… and failure.

• Or let’s say your appliance of choice is retained in the patient’s mouth by grabbing the undercuts that naturally occur in the dentition.  If the patient doesn't have enough back teeth to anchor the appliance, the appliance will not stay in the patient’s mouth. That can prove to be an expensive mistake.

Getting your young and teenage patients to wear their retainers regularly can be a bona fide challenge. You can explain that retainers serve the necessary function of “retaining” their teeth after braces. You can jog their memory to the fact that their parents have worked hard to help them have a beautiful smile.  Promise, plead, cajole…

Realistically, these approaches are likely destined to fall on deaf ears – especially in view of the fact that most young patients are not really “invested” in their retainer. They didn’t pay for it, they didn’t pick it, they didn’t help design it

Why not improve their compliance by providing them with multiple retainer designs to choose from – stripes to rainbows, colors to camouflage, flames to flowers?  Not only will they be more likely to wear their retainer, they’ll show it off proudly.

It’s never a bad idea to shop around every once in a while to make sure you’re getting the best quality, best service, and best prices on the products that you buy the most often.

This is especially true when it comes to your dental practice. If you’ve been working with certain vendors for many years, you may not realize that you could be getting better deals.

For example, does your dental lab typically ship later than promised? Misplace your files? Get your order wrong? Loyalty is admirable, of course, but chances are, other dentists you know are getting better service…perhaps even the same appliances for a better price.

In order to maintain both esthetics and function achieved via orthodontic therapy, final retention is not merely an option. It’s a necessity.

Since most patients never return to the orthodontist after treatment after is completed, the general dentist is the sole line of defense for providing continuing and indefinite retention services – specifically, a regular post-orthodontic/permanent retention program for his or her patients.

PRIORITIES

Include retention information as part of every patient’s formal pre-treatment informed consent documents. They should remind patients at the end of orthodontic treatment that indefinite retention is a must – even when they leave the orthodontists care and return to the care of their general dentist.

1. Inform the patient of the necessity of indefinite retention – regardless of pre-existing malocclusion, treatment modality, or length of time spent in treatment.