1. What about exercises to help strengthen the muscles and prevent collapse?
a) Exercises can have a small positive effect, but they are not a reliable long-term solution for snoring or sleepdisordered breathing.
There is limited clinical evidence (e.g. van der Weijden et al., 2020) showing minor benefits in singers and wind-instrument players, but studies are small and outcomes modest.
By contrast, mandibular advancement splints (MAS) are clinically proven, as is CPAP for more severe cases.
Advancing the mandible also improves muscle tone, which is beneficial.
2. What is the best position we should be sleeping?
a) Sleeping on your side (lateral position) is generally better than sleeping on your back (supine).
Positional therapies can help some patients, but results vary. Those with more significant airway compromise are less likely to see meaningful improvement from positional therapy alone.
3. What about using the tape to maintain the mouth close during your sleep?
a) No. Mouth taping is not recommended.
It is a contentious topic, and most experienced clinicians advise against it due to discomfort and potential risks.
4. What about a patient with HHT and had sutured his left nostril and since he started snoring? What would you do to help?
a) This is similar to patients with nasal obstruction (e.g. deviated septum or polyps).
Where possible, nasal obstruction should be addressed medically. A MAS may still help by improving overall upper airway patency and reducing snoring.
5. The movable MAD is very expensive. What do you say to patients if the device doesn’t work, they are still obstructing. What do you say to them?
a) Patients should be appropriately consented from the outset. Which is what is covered on our full course MAS are clinically proven and highly effective, but compliance and titration are essential. Some patients may need adjustments, and a small number may benefit from combination therapy (MAS + CPAP).
Importantly, efficacy is not always linked to severity, and devices that allow patient self-titration tend to improve both outcomes and compliance.
6. Where do you subscribe for the course?
a) https://www.s4sdental.com/products/snoring-osa-a-role-for-the-gdp-course
7. How can we fabricate the MAS device?
a) Send upper and lower impressions or scans to S4S or S4S London:
https://www.s4sdental.com/pages/send-us-a-case
No bite registration is required for the Sleepwell titratable MAS.
8. DDU have advised that in order to be fully indemnified, a medical professional must assess the patient for
sleep apnea and reach a formal diagnosis before referral to a dentist for a sleep appliance. S4S and Aerox Health allow dentists to provide appliances without formal medical diagnosis. How do I make sure that when providing a sleep appliance, I am fully indemnified?
a) Dentists are providing therapy for snoring and mild–moderate OSA, not diagnosing OSA.
Professor Johal referenced NICE, which supports this approach when clinicians remain within their defined scope and consent appropriately. https://www.nice.org.uk/guidance/ng202. Again the full course covers this in depth on how to screen, support and refer patients.
9. Will sleep appliances work just as well as a cpap on someone that has severe apnea who doesn’t want to wear their CPAP?
a) CPAP remains the gold standard, especially in severe OSA.
However, NICE guidelines allow MAS use where patients are non-compliant with or refuse CPAP. Studies (e.g. Barnes et al.) show MAS can significantly reduce symptoms and AHI in selected cases.
10. Will sleep appliances still work on someone that is overweight?
a) Yes. MAS are effective across a wide range of body types.
While excess weight is an aggravating factor, it does not automatically predict failure. Proper screening helps guide expectations.
11. Do patients have to wear their sleep appliance every single night after they have achieved reduction in symptoms?
a) Initially, yes.
Over time, some patients may tolerate an occasional night off without symptoms returning. Most patients continue nightly wear due to the significant improvement in sleep quality for themselves and their partners.
12. How do they wear Invisalign aligners along with the sleep device? Or how can they wear their essix retainers along with the sleep device?
a) Retainers can be worn for an hour in the morning following night wear for any concerns of orthodontic change to be mitigated, or immediately following aligner therapy, wearing a removable retainer for longer can be done if deemed necessary. MAS’s are full coverage devices that do not intend to allow any orthodontic movement, but wearing retainers in the morning can address any minor perceived change to the patients bite. We often refer to this process as an ‘am aligner’ where the patient feels a thinner device
like a DURATAIN retainer can help them feel ‘back to normal’. If patient is in active aligners we recommend completing alignment then entering into a full time MAD appliance
13. Which appliances allow elastics to help nasal breathing?
a) This question was unclear during the session. In general, MAS devices do not restrict nasal breathing, and elastics are not typically prescribed specifically for nasal airflow.
14. Please can you advise if this device is suitable for an adult patient who is a bruxist, wearing a lower night guard and alternates this with Invisalign retainers - so one night each.
a) Depending on the severity of the bruxism, the Sleepwell MAS can actually help with bruxism as through it’s design it has a form of ‘discluding element’ in the hook and screw mechnanism. This can significantly reduce the ability for the jaw muscles to clench and grind at night, so it is likely that most patients can have a Sleepwell device as a form of mitigating against most bruxism symptoms, while also managing their postortho retention.
b) On a separate note, assuming the snoring wasn’t a concern, we can also manufacture our SCi device in a fullcoverage, retainer-style – so your patient could simply wear this one device each night and get the best of both worlds.
15. What are long term complications to open bite?
a) As mentioned previously, the MAS’s we offer are all full-coverage meaning tooth movement is not being promoted. Nevertheless, in the same way we would consent for any oral appliance, there is a small chance that bite change can occur but this risk is minimal and often not a concern by patients who are suffering from snoring / sleep apnoea.
16. Do we have to be careful that these devices can cause an anterior open bite, even if only worn at night?
a) The risk is very low.
Full-coverage design, absence of orthodontic forces, and overnight-only wear reduce the likelihood compared with appliances such as Dahl splints.
17. Can pts still breathe nasally with MAD?
a) Yes, there is no impact on nasal breathing with a MAS/MAD
18. What is your personal recommendation for the fabrication kit to use for the MAS device? Are there any that have shown better results compared to others, such as ones that use bands compared to the screw adjusted clips?
a) The most clinically proven device on the market is the Sleepwell. S4S offer a whole range of devices ranging from much more basic, simplistic models right up to more modern devices which are manufactured in nylon.
Ultimately, S4S seeks to cater for all preferences, and our technicians would be more than happy to discuss all offerings and their relative pro’s and con’s.
19. With the patient wearing the MAS overnight when growth and remodeling occurs have you found changes in the TMJ anatomy or orthodontic changes in the teeth held in the device? Does it have a functional appliance effect?
a) Essentially no change takes place in terms of Glenoid Fossa/TMJ region OR mandibular growth of any form - reason being they are Adults and do exhibit no growth.
Yes, can see slight change in the occlusion/bite with prolonged use. Professor Johal will go into management of these in depth during his course
20. Can you give a description of how an AM splint is used?
a) Some patients feel their bite feels unusual in the morning after overnight mandibular advancement.
An AM splint is used briefly in the morning as an exercise tool to help the jaw return to a comfortable position.
21. What can be done for patients under 18 years old with sleep apnea?
a) Typically, the easiest answer to this would be to refer them to a GP to get a sleep study. If they aren’t dentally developed it may not be the best move to offer any MAS therapy. Nevertheless, if they are dentally developed and score appropriately, then there is no reason why you can’t follow the same protocol as for adult patients.
22. What clinical strategies would you suggest managing long-term occlusal changes associated with sustained mandibular protrusion in patients undergoing mandibular advancement?
a) 1. Optimum Periodontal health
b) 2. only activate in a stepwise manner to avoid over-activation and pressure on teeth
c) 3. choose a night off
d) 4. Wear clear removable retainers for 1-2 hours/day
23. As a dentist how can I introduce the topic of sleep Apnoea to my patients?
a) A great strategy is of course physical prompts that your dental surgery is equipped to help patients. S4S offers digital and physical marketing in the form of videos, posters, social media graphics etc.
b) As well as this, we see a lot of clinicians able to enter conversations with patients by simply asking on the patient medical history forms ‘rate your quality of sleep from 1(no sleep per night) to 10 (guaranteed 8 hours each night). This allows a gentle way in to broach the topic of snoring, whether the patient (or their sleeping partner) is the snorer or not.
24. How are we (dentists) positioning ourselves for the treatment of OSA against sleep studies? Are we able to screen and treat?
a) Crucially, we as GDP’s are not diagnosing and treating OSA, we are providing an opt-in therapy to help with the symptoms of snoring and mild-moderate OSA. We are safe to screen for this and treat accordingly. This keeps us in our green zone and avoids any over-reach clinically.
In addition, as Dentists, it is a good idea to make contact with local sleep clinics/respiratory physicians.
Some will be delighted to help support, send referrals and follow up sleep studies.
25. Is the full course you hold needed to treat these patients?
a) Most indemnifiers will insist on ‘some formal training on the topic of treating snoring and OSA’. At S4S we do provide comprehensive training and support. Our course is an in depth session on the use of MAD appliances and patient screening which enables each of the delegates to go away and safely treat and screen patients. You should of course check with your own indemnifiers.