Mandibular Advancements in the Treatment of Obstructive Sleep Apnea

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on Twitter @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology - Head and Neck Surgery by following @CleClinicHNI on Twitter, that's CleClinicHNI. And new this year, find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today, I'm excited to speak with Dr. Todd Coy, Section Head of Dentistry and Oral Surgery in our Head and Neck Institute. Dr. Coy, welcome to Head and Neck Innovations.

Todd Coy: Thanks for having me.

Paul Bryson: Let's start by having you share some background on yourself for our listeners, where you're from, where you trained, and how you came to Cleveland Clinic.

Todd Coy: Yeah. Sure. Well, I'm an Ohio native and I moved to Cleveland in the '90s after undergrad and actually worked in a medical research lab for the VA hospital. As I moved through that, I became interested in dentistry and applied to a number of dental schools. Case Western Reserve is where I ended up going and training. It was a great experience.

And as I came to the end of the program, a classmate told me about a residency program at Cleveland Clinic, which I applied for and fortunately was selected to come. It was one of the best decisions that I've ever made. It turned into not only a training program in residency, but a long-term career.

Paul Bryson: That's great. And I have another old friend who also did a residency after dental school. Can you tell the listeners maybe some of the value of that? Because it's not always a path that graduates take after dental school. What were some of the highlights and advantages that you got to experience as a part of your residency program?

Todd Coy: Yeah, for sure. Dental residency is not a requirement. So, you can finish dental school and be licensed and go into private practice. And some people certainly do that and have great experiences. For those who maybe have a special interest in a particular specialty, there are specialty training programs that are dedicated to those specialties. Or if you have an interest in hospital related dentistry for some of the complex medical patients and certain comorbidities that you may not have had as much exposure to in dental school, hospital residency is a great way to get comfort with some of the complex procedures beyond what you learned in dental school and a level of proficiency at just understanding a little more about their medical history, medications, and how those might play a role in what you're doing.

Paul Bryson: Yeah. So much complexity. And we'll talk a little bit more about that, but I know it seems almost like a way to really not only round out your training and add complexity to it, but you take care of complex patients, patients that may not have routine access to a dental care, but then really benefited as a part of their multi-specialty care for another health issue.

Todd Coy: Absolutely. Absolutely. We take care of a number of patients as they prepare for organ transplants, cardiac valve surgeries, head and neck cancer, and a whole number of conditions that really lend themselves to a collaborative nature of helping this patient through this care path.

Paul Bryson: Yeah. There are so many things that families and patients may not think about as they're approaching a particular medical problem, but it's really critical. I commend you on the work with the transplant team and with the cardiac program.

And I wanted to highlight, too, there may be some listeners who may not have awareness of the dental program at the Cleveland Clinic. Can you talk a little bit about your team's program, some of the offerings? And you mentioned some of the collaborations. Do you want to just expand upon the program that you have built here?

Todd Coy: Sure. So interestingly, I just learned yesterday after talking with one of the archivists at the Cleveland Clinic that the first dentist was in 1922, just a year or so after the Cleveland Clinic was founded. And the dental program was maintained and very small for a number of years and really started to expand then in the '80s.

And at this point now, we've got about 10 professional staff and I think a total group of about 30 who provide comprehensive full scope dental care. We have general dentists who provide that general care. That's limited to Cleveland Clinic employees and retirees. But then we have specialists like periodontists, oral surgeons that provide that specialty care on a referral basis from within the hospital or community. And then we've got some dentists as well who focus on TMJ problems. And then a colleague and I focused on sleep issues.

Paul Bryson: Yeah, that's great. And I wanted to talk a little bit more about improvements in treating sleep apnea. As you know, patients sometimes come in a lot of different shapes and sizes and not all sleep apnea is the same. And perhaps I'm wrong, but a lot of people aren't as fired up about getting positive pressure ventilation for their sleep apnea if they can avoid it. Can you speak about some of the treatments and some of the assessments that you do for sleep apnea as sometimes very excellent options for sleep health and hygiene?

Todd Coy: Definitely. CPAP remains the gold standard. It's an amazing treatment, highly effective, all those things. But admittedly, a lot of people have trouble tolerating it or maybe have quite mild sleep apnea and can adequately treat it with other options.

And so, we've been fortunate to become part of the team and can treat some of these sleep apnea patients with mandibular advancement devices. So, we would have them come as a referral after diagnosis of sleep apnea from their medical provider and evaluate them for whether or not they're a candidate. So, we look at the overall stability of the remaining dentition. We look at if they have a proper range of motion of the jaws, those sorts of assessments. And then if that all looks appropriate, then make a mandibular advancement device, which essentially holds the mandible forward. And that forward motion opens up the airway. And for a good portion of people, that can really lower the severity or manage sleep apnea.

Paul Bryson: Yeah. No. That's great. It's a nice option for some patients, and I think there's often an interest from patients, "What else can I explore? What else can we do if I'm not jazzed up about positive pressure if I can avoid it?"

And I guess finally, what other surgical options are there? I know as surgeons and providers, there's a ladder of rehabilitation for sleep apnea. Are there any other surgical procedures that you and the team perform for maybe some of the more severe types of sleep apnea?

Todd Coy: Yeah. So, we have actually developed a section of sleep apnea alternatives to PAP therapy, and those include not only these oral appliances, but also surgical options. So, we've got soft tissue surgery like UPPP and then bone surgery like orthognathic surgery, and then as well hypoglossal nerve stimulation like Inspire. And so, we have a group of otolaryngologists and oral surgeons and as well as collaborative back and forth with sleep medicine. And as a group, we really can provide a lot of great options, surgical and otherwise.

Paul Bryson: That's great. So, if I'm a primary care provider or somebody in the region who is interested in these services for a patient, as a provider that might refer into you and the team, what can one expect with regards to plan of care, patient experience in terms of who they're meeting with? What does the appointment entail? Just briefly, if you can, walk us through that.

Todd Coy: Sure. So, with a variety of screening tools, overall sleep apnea risk can be assessed and then usually followed up with a sleep study needed to confirm the diagnosis. And once that's in place, then a referral can be placed with me or one of my colleagues. And we would start with a consultation and explain the process to the patient, how it works, what it looks like. And as we move through that process, we would set up a time to make impressions or molds of the teeth. And then we'd work with a laboratory that fabricates any number of devices, and there are over a hundred little varieties of these oral appliances.

But we would then start them in use. And some patients actually just need to stabilize the jaw. It doesn't have to go terribly far forward at all. Could be just stabilizing the jaw in a neutral position, and that might be enough to help keep the airway open. As the process goes on over a month or two, we assess the patient's symptoms, mostly subjectively, and may in smaller increments move the mandible further and further forward until their symptoms are reported as resolved.

And then we refer back to or you send them back to the referring physician or medical provider to confirm basically that the appliance is being effective. And usually, that's, again, with a repeat sleep study while wearing the appliance and finding out exactly what more objectively is being done with it.

Paul Bryson: Yeah. No. I appreciate that. It sounds like once you get in, the process goes, and you see what works and maybe what doesn't. Does the sleep study have to be performed in our sleep laboratory, or can a patient with a referral come with their sleep study so that you're able to look at it and add it in?

Todd Coy: Yep. They can absolutely come with a sleep study from anywhere else that they've had done, and we can work with providers within the Cleveland Clinic or outside. I'm happy to coordinate either of those pathways.

Paul Bryson: That's great. As we wrap up, I was hoping for some final take-home messages, but I also wanted to let the listener know that it seems like you're overseeing a period of growth for the group. I've heard that there's going to be increased capacity at our main campus for patients and possibly in the region in the future, and that there's actually some great employment opportunities to grow your team. And can you elaborate on that as we wrap up?

Todd Coy: Yeah, absolutely. It's a really exciting time to be part of dentistry and oral surgery. Here, we are expanding our footprint at the main campus with additional treatment rooms, and therefore we'll be able to see and treat even more patients.

And then the need and demand for our services has fortunately increased such that we think it's time for us to have some regional presence. And so, we've looked at a few sites actually, East Side, West Side in Cleveland initially here to expand what we can offer outside of main campus and make it easier for patients to travel to those sites closer to their homes. So, it's an exciting time, lots of growth happening. So, we feel fortunate.

Paul Bryson: Well, that's great. I look forward to seeing where the group goes, and it's already a great group. So, congratulations and I really appreciate your time today.

Todd Coy: Absolutely. Thanks for having me.

Paul Bryson: For more information on sleep apnea treatment options at Cleveland Clinic, please visit ClevelandClinic.org/SleepApnea. And to connect directly with our section of dentistry and oral surgery, visit ClevelandClinic.org/Dentistry or call 216.444.6907. That's 216.444.6907.

Dr. Coy, thanks for joining Head and Neck Innovations.

Todd Coy: Thank you.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access real-time updates from Cleveland Clinic experts in otolaryngology - head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.