Dental Sleep Practice ADA Supplement

FALL 2019 | SUPPLEMENT

Sleep Related Breathing Disorders:

The Role of the

Dentist

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Sleep-Related Breathing Disorders: The Role of the Dentist

by Jeffrey Cole, DDS President, American Dental Association

An ADA Perspective In 2017, the American Dental Association (ADA) took a major step toward helping patients who suffer from sleep-related breathing disorders (SRBDs). That year, the ADA House of Delegates adopted a policy urging dentists to play a role in the care of patients with certain SRBDs. The ADA believes that dentists are uniquely positioned to collaborate with physicians in the care of patients with SRBDs in part, because of their knowledge and expertise in the oral cavity and in oral appliance therapy.

Evidence shows that custom-made, titratable

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Educational purpose:

The ADA’s Policy Statement on the Role of Dentists on treating Sleep Related Breathing disorders arguably triggers more changes in dentist behavior as it relates to the health of their patient than any other policy statement published by the ADA. Dentists who understand the implications found within the statement will impact community health beyond any expectations they might have made during professional training or practice. The purpose of these essays are to bring together the opinions of the nation’s leading experts so every practicing dentist can recognize areas where mastery exists and where further study is necessary.

At the end of this reading, the participant will be able to 1. Discuss with their team and peers the implications of the policy statement for their practice 2. Lead their teams to develop communication skills so the changes can be introduced to patient communications 3. Have confidence their practice is working towards the highest ideals of collaborative medical/dental services.

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oral appliances (OA) can help alleviate the effects of SRBD in adults. While OAs have been generally considered inferior to positive air pressure devices such as continuous positive airway pressure (CPAP), their superior acceptance by patients has shown them to often provide equivalent medical benefit.

Developing the ADA Policy

The ADA started researching the issue in 2015. ADA’s House of Delegates directed that a policy on the dentist’s role in SRBD be developed by the appropriate ADA agencies.

Together, the Councils on Scientific Affairs (CSA) and Dental Practice began investigating the scientific literature for systematic reviews, meta-analyses, and selected randomized trials for the use of oral appliances in the management of sleep-related breathing disorders, primarily obstructive sleep apnea (OSA). In addition, they reviewed and graded clinical practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine on the treatment of obstructive sleep apnea and snoring with oral appliances1 as well as a consensus guideline co-authored and published in 2015 from dental sleep medicine societies in Italy.2 The goal was to develop an overview of the “state of the science” behind the use of oral appliances in the management of SRBDs. This document was reviewed by a CSAassembled workgroup of subject-matter ex-

SPECIALfeature perts, as well as members of the ADA Council on Dental Practice. This phase of the process resulted in an evidence brief, Oral Appliances for Sleep-Related Breathing Disorders.

The first policy draft was posted on ADA. org for external comments and feedback and the response was astounding. More than 87 comments poured in from a wide range of readers, including members of the public, dentists, physicians and other healthcare providers, researchers and professional organizations, including some from outside the United States. To ensure that all the feedback was considered, comments were categorized according by clinical topics, including early intervention/growth and pediatrics, orthodontics, diagnostic, surgical treatment and portable home monitoring, and non-clinical topics including policy language, general comments, and supportive comments.

The Council on Dental Practice then reviewed those comments and determined appropriate changes. A second draft was posted for another round of comments. After considering the 47 additional comments and again amending the policy statement, the Council submitted the policy for consideration by the 2017 ADA House of Delegates in Atlanta, where it was adopted.

What Does the Policy Say?

What Role Should Dentists Play?

Where Do We Go from Here?

The extent to which dentists can implement this policy is determined by state dental boards. The ADA encourages dentists to investigate the scope of practice in this area in their state, educate themselves about SRBDs and, where appropriate, begin to provide care to their patients for SRBDs through screening, professional collaboration and treatment.

The ADA has resources available to help you and your patients learn more about SRBDs. Several CE courses are available on ADA.org, and the topic will be featured in a two-day workshop at the 2019 ADA/FDI World Dental Congress in San Francisco. To help educate your patients, the ADA has developed a brochure on sleep apnea and provides more information on MouthHealthy.org.

The ADA is committed to promote dentistry’s involvement in helping achieve optimal health for all.

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The topic will be featured in a two-day workshop at the 2019 ADA/FDI World Dental Congress in San Francisco.

Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015;11(7):773-827.

Levrini L, Sacchi F, Milano F, et al. Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS). Ann Stomatol (Roma) 2015;6(3-4):81-6.

Jeffrey M. Cole, DDS, MBA, a general dentist from Wilmington, Delaware, is president of the American Dental Association. Dr. Cole served as the ADA Fourth District Trustee. He served as the chair of both the Budget and Finance Committee and the Strategic Planning Committee.

Dr. Cole was a member of the ADA Council on Dental Practice before being elected a trustee. Dr. Cole is involved in several additional dental organizations including the Academy of General Dentistry, where he served as president in 2012–13. He is a Fellow of the International College of Dentists, the American College of Dentists and the Academy of Dentistry International. He was president of the Delaware State Dental Society in 2008–09 and received the Distinguished Service Award from that society in 2015. Dr. Cole received a bachelor’s degree from Villanova University in Villanova, Pennsylvania. He received his doctoral degree from Georgetown University School of Dentistry in Washington, D.C. He later earned a master’s in business administration degree from The Fox School of Business at Temple University in Philadelphia.

The policy encourages dentists to play a DentalSleepPractice.com

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The policy states that dentists can and should play an essential role in the multidisciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients at increased risk of SRBD. SRBDs can be caused by several multifactorial medical issues and are, therefore, best treated through a team approach with collaboration between the patient’s dentist and physician. Properly trained dentists are uniquely positioned with the knowledge and expertise necessary to provide such therapy.

In children, the dentist’s recognition of suboptimal early craniofacial growth and development or other risk factors may lead to medical referral or orthodontic/orthopedic intervention to treat and/or prevent SRBD. Oral appliance therapy is a dentist-provided choice to treat SRBD; surgical modalities and positive airway pressure devices are employed by physicians. Various surgical modalities exist to treat SRBD when CPAP or OA therapy is inadequate or not tolerated.

role in patient screening, and when necessary, to consult with the patient’s physician.

Dentists should assess patients for suitability of OA upon the referral of a physician, and if appropriate, fabricate and titrate the oral appliances and/or refer the patient to other health care professionals as needed for further treatment.

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Screening Patients to Find Who is at Risk of SRBD

by Steven Lamberg, DDS

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he ADA’s position paper on “The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders” establishes that dentists play an “essential role” in identifying and caring for these patients. The document states dentists “should be encouraged” to screen for these disorders as part of a medical and dental history. This call to action is not exactly a mandate. Rather than arguing about the absolute level of responsibility dentists have to screen patients, I will lay out what screening is and let the tides of time calibrate the level of our actual responsibilities.

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Screening is more than handing the patient a questionnaire and reviewing their responses, but it is also not a definitive test for a disease. Screening is intended to identify risk, to indicate who should be sent for ‘the next test.’ Questionnaires such as the STOP-BANG and the Epworth Sleepiness Scale have been “validated”, which means that they have been shown to be statistically meaningful in assessing risk of having SRBDs. Although valuable, a screening questionnaire needs to be combined with a thorough

Table 1 and 2: The LQ-PAS questionnaire and the ARF. Visit www.dentalsleep practice.com or www.lambergseminars to view the complete forms.

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clinical examination to best illuminate the complete health status of the patient. It is important to assert that questionnaires can do much more than assess risk. They can serve to educate patients about the correlation between many medical conditions and airway problems. This knowledge gives patients the opportunity to “treat the cause” rather than the symptom. We also have the opportunity to become airway advocates through political action, to influence public school systems to mandate the use of questionnaires to test for airway problems along with currently mandated evaluations for hearing and vision deficiencies.

The first step is making these questionnaires available to all new patients as well as making it part of your health history update at hygiene visits. Although the amount of health information that can potentially be unlocked by reviewing a patient’s answers is invaluable, not everyone shares this view. In fact, the question of “who do you give the questionnaire to” has been probed by many.

Should every patient be asked to complete one? In 2017, the United States Preventative Services Task Force “USPSTF” concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults.1 The problem with their conclusion is that we don’t have a clear definition of “symptomatic” because of a general lack of appreciation of the correlation between medical conditions and airway problems. As the patient’s basic health history will lay out medical conditions that confer an increased risk of having SRBDs, it becomes incumbent upon us to know the increased odds ratios of having SRBDs associated with all medical conditions. We need to think about the correlation between airway/sleep issues and problems with all of the body’s systems. Oxidative stress and sympathetic activation associated with problematic breathing create an inflammatory load

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Table 3: The Lamberg questionnaire. Visit www.dentalsleeppractice.com or www. lambergseminars to view the complete form.

providing us with a higher level of screening accuracy in the future, at this time we must rely on our clinical examinations and questionnaires to best find the individuals whose health is at risk and recommend more detailed testing for accurate diagnosis.

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US Preventive Services Task Force. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(4):407–414. doi: 10.1001/jama.2016.20325.

Steven Lamberg, DDS, practices all phases of dentistry in Northport, New York. He is a graduate of the Kois Center and serves as a scientific advisor for airway there.

He writes and lectures nationally on topics related to airway health.

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that impacts all of the systems in our bodies.

Adding the patient’s medical condition status to the typical clinical signs and symptoms being evaluated will bring us a step closer to discovering all the patients who require further objective testing to confirm the need for treatment. The Lamberg Questionnaire (LQ) is built on revealing the correlation between airway and overall level of health. I composed the LQ by mining increased odds ratios of having SRBDs from over 300 articles, and it has been refined by experts in the different fields and updated continually.

I have no financial interest in the LQ or the LQ-Pediatric Airway and Sleep (LQ-PAS) and believe that every practice will benefit from making it part of their new patient protocol. (Free download available at www.LambergSeminars.com) Every person will benefit from a more comprehensive approach in your practice that includes understanding risk factors, identifying clinical manifestations, using screening questionnaires, and employing other observations that indicate the need for further testing.

Children should be viewed in a more urgent manner due to the impact SRBDs can have on growth and development. Risk factors for children include: a family history of SRBDs, various syndromes, behavioral problems, and craniofacial abnormalities such as high narrow hard palate, overlapping incisors, and crossbites. Signs and symptoms can be checked off on a simple questionnaire like the LQ-PAS. See table 1 LQ-PAS (Note that this 2 page questionnaire needs to be evaluated along with the medical history and a thorough clinical exam.)

Adults have less concern for ongoing growth and development problems but a careful evaluation of medical history and a clinical examination are crucial. All of the body’s systems must be reviewed to see if there are conditions associated with an increased risk of SRBDs. See table 3. (This questionnaire should be evaluated along with the medical history as well as a thorough clinical exam) With a better understanding of which conditions are correlated with SRBDs, screening the higher risk patients will be accomplished much more efficiently.

Although it is worth mentioning that the relationship between SRBDs and combinations of blood biomarkers show promise in

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Organized Dentistry Takes on Children’s Airway

by Barry D. Raphael, DMD, MS, and Mark A. Cruz, DDS

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he 2017 ADA Policy Statement includes a broad statement regarding the treatment of children with sleep or breathing disorders: “In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.”

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The last portion of the statement charges us with a more comprehensive approach to dealing with children.

There is wisdom in the phrase “optimal physiologic airway and breathing pattern” that goes well beyond having dentists play a supportive role to physicians. Dentists and orthodontists are far better prepared to influence the growth and development of a child’s airway than are physicians.1-6 We can influence optimal wellness to lower risk factors for SRBD. Therefore, it is critical for every dentist to understand the underpinnings of this part of the policy.

Essentially, having an optimal physiologic airway and breathing pattern means that the upper airway – from the tip of the nose to the larynx – is easy to breathe through AND that the child knows how to breathe through it easily.

The basic premise of having an airway that’s “easy to breathe through” is that air should be able to pass unimpeded in any way. Air swirls inside the nose to clean and humidify the air, but once it reaches the softer parts of the airway, we want “laminar flow,” with no turbulence or swirling as the air passes through.7-9 Turbulence creates negative pressure that pulls on the flexible walls of the airway, making it narrower and impeding flow. This is the origin of snoring, Upper

Airway Resistance Syndrome, and obstructive sleep apnea.

Since breathing is such a critical part of our physiology, our bodies will successfully compensate for anything that impedes it.

Like an overresponsive immune system, the struggle to breathe easily has negative consequences, leading to a downward spiral of poor facial growth, poor oral function, poor sleep, and overall poor health.11 Getting a child out of that negative spiral is the essence of the ADA’s policy.

The Consequences of Poor Breathing in Children

It is imporant to know that a child can have flow limitation and fragmented sleep and NOT have sleep apnea or desaturations.

Daytime problems, like mouth breathing, nasal congestion, and over breathing can be the risk factors that lead to nighttime flow limitation.

In other words, the problem is breathing, not just sleep. Children with poor breathing patterns can have problems with brain and neurocognitive development, fragmented sleep, behaviors of hyperactivity or sleepiness, chronic activation of the sympathetic nervous system, disregulation of digestive and metabolic hormones, and more.11-13

Clinical Implications: Screening and Outcomes

Our first obligation is to screen every patient for risk factors of turbulent air flow.

The ADA has sanctioned development of a screening tool that can be easily implemented in the dental practice, using a questionnaire and clinical data.

Simple questions about snoring, restless sleep, bruxism, open mouth posture, and be-

SPECIALfeature havioral issues are included in the initial and periodic exams.

The clinical exam will look for some of the phenotypic risk factors such as a narrow dental arch, malocclusion, a tethered tongue, a long soft palate, and vertical development of the lower third of the face.

Together, they will direct the clinican to either refer the patient directly to a sleep physician or do a more thorough second level screening, which will also be defined in the ADA’s recommendations.

A second task force is looking to define the favorable outcomes that will be the goal of effective treatment and the metrics used to measure them.

Examples of favorable outcomes are: 1) Nasal breathing as the dominant mode, 2) Good lip competence (instead of mouth breathing), 3) The tongue positioned on the palate to support good bony growth, 4) A competent swallow using only lingual, not facial, muscles, 5) Good body posture, 6) A peaceful, rejuvenating night’s sleep, 7) Efficient intake and delivery of oxygen to all body tissues, and 8) Improved health and wellbeing. Many of these outcomes have direct or surrogate metrics that can be used to characterize them.

Clinical Implications: Interventions

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Eichenberger M, Baumgartner S. The impact of rapid palatal expansion on children’s general health: a literature review. Eur J Paediatr Dent. 2014;15(1):67-71.

Mew JR, Meredith GW. Middle ear effusion: an orthodontic perspective. J Laryngol Otol. 1992;106(1):7-13.

Iwasaki T, Saitoh I, Takemoto Y, et al. Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: a cone-beam computed tomography study. Am J Orthod Dentofacial Orthop. 2013;143(2):235-245.

Sayinsu K, Isik F, Arun T. Sagittal airway dimensions following maxillary protraction: a pilot study. Eur J Orthod.

2006;28(2):184-189.

Villa MP, Rizzoli A, Miano S, Malagola C. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath. 2011;15(2):179-84.

Katyal V, Pamula Y, Martin AJ, et al. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2013;143(1):20-30.

Catalano P, Walker J. Understanding nasal breathing: the key to evaluating and treating sleep disordered breathing in adults and children. Curr Trends Otolaryngol Rhinol. 2018;CTOR-121.

Rappai M, Collop N, Kemp S, deShazo R. The nose and sleep-disordered breathing: what we know and what we do not know. Chest. 2003;124(6):2309-2323.

Guilleminault C, Sullivan SS. Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. Enliven: Pediatr Neonatol Biol. 2014;1(1):001.

Molfese DL, Ivanenko A, Key AF, et al. A one-hour sleep restriction impacts brain processing in young children across tasks: evidence from event-related potentials. Dev Neuropsychol. 2013;38(5):317-336.

Horne RSC, Roy B, Walter LM, et al. Regional Brain Tissue Changes and Associations with Disease Severity in Children with Sleep Disordered Breathing. SleepJ. 2018;1-10.

Bonuck K, Rao T, Xu L. Pediatric sleep disorders and special educational need at 8 years: a population-based cohort study. Pediatrics. 2012;130(4):634-642.

Gozal D, Kheirandish-Gozal L. Neurocognitive and behavioral morbidity in children with sleep disorders.

Curr Opin Pulm Med. 2007;13(6):505-509.

Barry D. Raphael, DMD, received dental degree from the University of Pennsylvania School of Dental Medicine and his Certificate in Orthodontics from the Fairleigh-Dickinson University School of Dentistry, Department of Orthodontics. He is a lecturer and staff member at Mt. Sinai School of Medicine, Pediatric Dental Residency; Clinical Instructor at Institute for Family Health. He is a life member of the American Dental Association, a member of the American Association of Orthodontists, and Fellow of the American College of Dentists.

Dr. Raphael is in private practice of orthodontics at The Raphael Center for Integrative Orthodontics Clifton, New Jersey and is owner/director of The Raphael Center for Integrative Education.

Mark A Cruz, DDS, graduated from the UCLA School of Dentistry in 1986 and started a dental practice in Monarch Beach, California upon graduation. He has lectured nationally and internationally and is a member of various dental organizations including the American Academy of Gnathologic Orthopedics (AAGO), North American Association of Facial Orthotropics (NAAFO), Pacific Coast Society for Prosthodontics, and the American Academy of Restorative Dentistry. He was a part-time lecturer at UCLA and member of the faculty group practice and was past assistant director of the UCLA Center for Esthetic Dentistry. He has served on the National institute of Health/ National Institute of Dental & Craniofacial Research (NIH/NIDCR) Grant Review Committee in Washington D.C., and on the Data Safety Management Board (DSMB) for the National Practice-Based Research Network (NPBRN) overseen by the NIDCR, as well as on the editorial board for the Journal of Evidence Based Dental Practice (Elsevier).

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Procedures that help develop an optimal physiologic airway will focus on maximizing tongue space in the anterior of the face using the natural growth of the jaws, guided, if necessary, by appropriate professional intervention.

Optimizing a breathing pattern requires both physical therapies and behavioral modification. First, a clean and clear nose is fundamental. Then, any physical restrictions to good posture or movement of the diaphragm have to be addressed. This may require an interdisciplinary team working with the dentist.

Because habitual compensations are responsible for much of the damage we see to the facial skeleton and airway, it is crucial that these habits be re-trained as soon as they are discovered. No longer is the age for treatment defined by dental staging. Success is not limited to straight teeth.

This is a very exciting time to be in dentistry. The ability to help a child breathe better, sleep better and perform better will give them an head start to a life of good health.

Join us as we take dentistry and our children

into the bright 21st Century. And join us for the Third ADA Conference on Children’s Airway Health in June 2020.

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A New Hope

by Todd Morgan, DMD

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ope, this not about Star Wars or a galaxy far, far away, but it is about the now, and organized dentistry coming to terms with policy regarding the dentist’s role in treating airway disorders during sleep, for adults and children.

This is our ADA responding to the great scourge of OSA, and it is truly, A New Hope.

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The essence of the ADA policy statement issued in 2017 reflects the important role of the dentist in detecting potential sleep apnea among our patients. I consider us as “first responders” to many of our patients’ medical needs, including screening for high blood pressure, auto-immune disorders, and now OSA. The old adage that says: “the oral cavity is the window to overall health” holds true.

Most of the signs of sleep apnea are easy to see in the mouth, and with the help of quick questionnaire(s), screening for potential OSA is easy AND appropriate.

Many of us in leadership have lobbied to for a long time to simplify the screening for OSA and have the ADA come forward with a policy statement on the responsibilities of dentists to screen for this deadly epidemic.

Now that we have this bold move in place, I am pleased that a new task force is working on the prevention of OSA by forming reasonable protocols for screening by pediatric dentists. A growing number of our orthodontic colleagues are well-steeped in airway awareness – be sure to ask those in your community about it.

Promoting the proper growth and development of the airway as well as protecting and healing those adults with Obstructive Sleep Apnea are some of the best things that have happened to dentistry in a long time.

We dentists have an incredible set of tools to improve the lives of our patients – both young and old – like never before. We will need to learn to operate with a team approach and with our medical colleagues to make this happen. A new twist for many of us! Very exciting, but there are some rules.

We stand with a policy in hand that may quickly fall out of date as studies continue. I cannot imagine a wider frontier ahead!

Good scientific evidence has proven the veracity of oral appliance therapy for mild and moderate OSA. We are on very solid ground here, bolstered by the publication

SPECIALfeature of standards of care by the AADSM and the AASM, such as: Dental Sleep Medicine Standards for Screening, Treating and Managing Adults with Sleep-Related Breathing Disorders and Clinical Practice Guideline for Oral Appliance Therapy. So our stage is set for mild and moderate, but OAT is also viewed as a viable alternative for severe OSA when CPAP fails. All of you that have done this work for a while know that we hit home runs often for patients with every level of diagnosis, but we also have our failures; this is exactly why we should always work as a team with our physician colleagues.

Research is the key to successfully relating to our physicians, who have been trained to rely on validated evidence to make all of their decisions about patient care. I remember the first meta-analysis paper I read on oral appliance therapy was published in the Journal Chest (Pancer, Hoffstein, December 1999). They concluded from an analysis of roughly 3000 patients in past studies that “adjustable mandibular positioning appliance is an effective treatment alternative for some patients with snoring and sleep apnea.”

Since then we have proved in many more studies that these results are repeatable and reliable. A very recent meta-analysis publication: “Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: A systematic review and meta-analysis’” (A. Hoekema, et al.) continues to show the benefits of the work we do in DSM. We are armed with the evidence we need to continue our conversations with MDs. Now we must begin to challenge the status-quo that calls for CPAP at every turn and bring oral appliances to the forefront of treatment for OSA. Good communication with colleagues

Our treatment is not inferior to CPAP, and I say it is irresponsible to not fully embrace our duty together, as healers. is at the cornerstone of any successful Dental Sleep Medicine practice.

Dentistry is poised to become the front line of uncovering sleep apnea. OSA patients are everywhere and they need the medical referral we can provide. But dentistry may not have the full confidence we deserve from our MDs – largely because we created that! For example, most physicians I know cringe at the term “TMJ” and retract in fear. Fortunately, dentistry as a profession has become less isolationistic over time, promoting a new expectation of evidence-based data and proof of “best practice” in fields like periodontics, implantology, oral surgery, and now DSM. Notably, DSM has become a unique exercise in promoting collegiate interaction between dentists and physicians. I actually think this is the coolest part of DSM, where we can explore this field together with our knowledgeable friends and share in the glory of our achievements!

This is a time to move toward our medical colleagues instead of away from them.

This is the time to create mutually beneficial relationships that promote the best care our patients can receive. Embrace the New Hope and start a conversation with your MDs on the established validity of OAT and show them the evidence. Our treatment is not inferior to CPAP, and I say it is irresponsible to not fully embrace our duty together, as healers.

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Dr. Todd Morgan is a graduate of Washington University in St. Louis, and became a Diplomate of the American Board of Dental Sleep Medicine in 1999. He is recognized as an expert in the field of Dental Sleep Medicine and lectures nationally and internationally on oral appliance therapy. His team has completed several NIH funded clinical trials, and he has authored several peer-reviewed articles and books on the treatment of sleep apnea and snoring with dental appliances. He has served 8 years in leadership and educational roles with the AADSM. His current areas of interest include pharyngeal exercise for OSA, and the development of phenotyping models for successful Oral Appliance Therapy. He has extensive clinical experience in DSM and is now exploring airway CBCT analysis. Most recently, Dr. Morgan’s team are the recipients of three research awards from the American Academy of Dental Sleep Medicine in 2019.

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Evaluating Patients for Success – It’s More Than What You Can See

by Gy Yatros, DMD

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valuating patients for Dental Sleep Therapy (DST) is an essential part of successful treatment in Dental Sleep Medicine (DSM). Treating patients with DST requires our collaboration with the medical community. Although this may seem like an obstacle to dentists new to DST it is an incredible opportunity to broaden our reach as healthcare providers in our community. Through our interactions, physicians can help us better understand our patients’ medical condition as we have an opportunity to enlighten them on our medical dental concerns such as systemic oral health issues in addition to OSA. Our collaboration requires that our patients have a medical diagnosis from a sleep physician, copies of their clinical notes, a prescription for DST and a Letter of Medical Necessity (LOMN). In addition, we should regularly communicate with our DSM team on our patients’ progress. Not until our patients have a medical diagnosis and we have fully communicated with our patients’ other health care providers should we begin to treat our OSA patients in the dental office.

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Once our patients have a diagnosis of OSA, we can begin our evaluation for DST. Candidacy evaluation is a multifactor process that requires a step-wise approach by a trained DSM dentist. At a high level the goals of the DSM evaluation are to determine if the patient’s craniofacial anatomy and treatment goals are conducive to a positive treatment outcome. That may sound straightforward but in reality, it often isn’t. Complex dental histories, TMJ issues, missing dentition, nasal airway problems and patient compliance can complicate the former while unstandardized, debated and ill-defined treatment goals can muddy the latter. A successful DSM exam begins with the realization that we are heading into grey areas of medicine which often conflict with the dentist’s analytical and precise nature. But don’t give up hope – with education and experience, dentists can help patients navigate this complex process to achieve life altering and lifesaving outcomes.

Let’s begin in the dentist’s comfort zone with a physical evaluation for DST candida-

SPECIALfeature of the dentition to help us determine the stability of the teeth. We should look for short roots, periodontal bone loss, abscesses and other conditions that could affect our treatment outcomes. We recommend a CBCT for our patients, which also allows evaluation of the sinuses, TMJ’s, nasal and oral airways.

Unless you are an expert in radiology, it is advisable to have a radiologist interpret these large fields of view to ensure proper evaluation and documentation.

This may sound like a lot of information, but when proper systems are utilized, the DST evaluation can be completed in a minimal amount of time. Ultimately, the evaluation will determine if the anatomy is stable enough for DST, which device is best suited for the individual patient, and the three-dimensional position where the device will be constructed.

The ADA guidelines call on us to determine if fabricating an oral appliance is ‘appropriate.’ Patient autonomy and proper medical practice means that we must take into account their preference, history, and our judgement of likelihood this therapy will be successful. The dentist and patient should discuss the likelihood of achieving the agreed upon goals, the risks associated with DST, and other treatment options. By discussing the information in a knowledgeable, caring, and sincere manner, most qualified patients will readily choose DST to treat their airway problems. In 30 years of practicing dentistry, nothing even comes close to the satisfaction I have experienced in providing this valuable service. With experience and conviction, the dental team will soon realize the benefits of bringing Dental Sleep Medicine into their practices while helping their patients live better and live longer.

Dentists can help patients navigate this complex process to achieve life altering and lifesaving outcomes.

Dr. Gy Yatros has practiced dental sleep medicine for over fifteen years and is a key opinion leading international lecturer in the area of sleep-disordered breathing and dental sleep medicine. He has offices in Bradenton, Sarasota, and Tampa, Florida devoted exclusively to the treatment of sleep disordered breathing. He is Co-Founder and CEO of Dental Sleep Solutions and the DS3 System for Dental Sleep Medicine Implementation. He is a Diplomate of the American Board of Dental Sleep Medicine (ABDSM) and is an Affiliate Assistant Professor of the Department of Internal Medicine with the University of South Florida, College of Medicine.

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cy. Our evaluation should include a review of the patient’s dental history, an oral facial evaluation, and a review of short-term future dental needs. Simply stated, if the patient is to utilize DST, will the teeth, TMJ and other craniofacial anatomy be able to tolerate the forces generated by the device while producing minimal unwanted side effects?

Careful examination of the dentition is required. Are there missing teeth, periodontal issues, or teeth with minimal undercuts which could result in retention challenges?

Are there any immediate dental needs? This is where the dentist must put on their DSM hat which may often conflict with our focus on optimal oral health. We will routinely need to make challenging decisions while weighing restorative needs against the possibility of postponing DST. The importance of the dental needs must be weighed against the patient’s OSA severity, co-morbidities, age and other available and attempted treatment alternatives. Our job is to help guide our patients in making the best treatment choice based on these many variables.

Our DSM evaluation should also include evaluation of the oral cavity, nasal airway, TMJ and the muscles of the head and neck.

While evaluating the oral cavity, we look at things like tongue size and position, arch form, and tonsillar and Mallampati classifications. We must carefully document our findings as to how these items affect the airway and we will ultimately use all collected data to steer device selection for the patient.

One mantra you will often hear in DSM is “Don’t forget the nasal airway!”. Nose breathing is extremely important for DSM success as well as the patient’s overall health. There are chapters and books dedicated to this one subject but suffice it to say that patients who breathe through their noses while sleeping will have improved success with DST. A careful TMJ and muscular exam is a mandatory part of our examination. We must look for internal joint derangements, muscle tenderness and evaluate the patient’s range of motion. Instruments like the George Gauge or Pro Gauge can help measure the patient’s ability to protrude the mandible. Maximum incisal opening, sore muscles, TMJ issues and history of bruxism will come into play during our evaluation and device selection process.

Lastly, our craniofacial examination should at a minimum include radiographs

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SPECIALfeature

Informed Consent in Dental Sleep Medicine

by Ken Berley, DDS, JD, DABDSM

“D

entists should obtain appropriate patient consent for treatment that reviews the proposed treatment plan, all available options and any potential side effects of using OAT and expected appliance longevity.1”

ADA

Accurate and relevant information must be provided in a form and language that the patient can understand.

12 DSP | Fall 2019

Consent is an act of reason, accompanied with deliberation, the mind weighing as in a balance the good or evil on each side. It means voluntary agreement by a person in the possession and exercise of sufficient mental capacity to make an intelligent choice to do something proposed by another.2 Every patient possesses the legal right to determine the treatments and procedures which will be employed to control any disease or condition that he or she may have.

Medical informed consent is the legal embodiment of the concept that all patients of sound mind and legal capacity have the right to make decisions affecting their health. It is generally accepted that patients should be informed of the potential risks and benefits flowing from their medical decisions.3 Dentists must become familiar with any state statutes which regulate the informed consent process for your particular state or jurisdiction.

Medical informed consent is ethically, morally, and legally mandated by the fiduciary duty flowing from the doctor-patient relationship. Ethically, dentists are legally bound and morally obligated to identify the best treatments for each patient on the basis of available medical evidence. A discussion must then occur where the patient is informed of the hoped-for benefits and the potential risks associated with the proposed treatment. Dentist are required to disclose the risks associated with the proposed procedure

and the risks of the alternatives to enable patients to make knowledgeable decisions.4 A patient’s understanding of the potential risks of a proposed treatment is critical to medical informed consent.

Elements of Valid Informed Consent

For consent to be valid, it must be voluntary and informed, additionally, the person consenting must have the capacity to make the decision.

Disclosure Informed consent must be preceded by disclosure of sufficient information; however, the specific information varies based on the patient and procedure. Accurate and relevant information must be provided in a form (using non-scientific terms) and language that the patient can understand. Informed consent is NOT a patient’s signature on a dotted line obtained routinely by a staff member. Patients should be given the opportunity to ask questions.

The information disclosed should include:5 • The condition/disorder/disease that the patient is having/suffering from • Necessity for further testing • Natural course of the condition and possible complications • Consequences of non-treatment • Treatment options available • Potential risks and benefits of treatment options

SPECIALfeature • Duration and approximate cost of treatment • Expected outcome • Follow-up required For DSM, consent must address dental complications associated with oral appliance therapy, as well as, systemic health consequences of non-treatment of SRBD. Properly trained dentists understand the myriad of complications that can arise from OAT – the author specifically warns EVERY patient of all of the possible negative side effects, and that complications related to oral appliance use have been minor. Patients are warned that it is their responsibility to immediately inform our office of any issues and to adhere to recommended management appointments.

Other treatment choices for the patient’s specific conditions should be discussed and appropriate resources provided so they can seek the information they need to inform themselves.

Expected longevity of an oral appliance varies greatly depending on the appliance chosen and the clinical presentation of each patient. Therefore, it may be difficult to accurately predict. The author cautions against presenting information which might cause the patient to think that it is guaranteed to last a certain period of time.

With appropriate disclosure, patients may be treated under conditions which are less than ideal, such as risky periodontal support or a history of TMJ disorders. Practitioners should disclose the information necessary to achieve informed consent based on the particular patient’s clinical presentation.

It is possible that consent can result in a refusal to proceed with therapy. Documentation must show the information that was provided and that the patient refused treatment with full knowledge of the seriousness of the decision.

Documentation A well written informed consent document is mandatory to minimize legal risk and be able to present the evidence in court that a consent discussion occurred. A patient is always free to contest the validity of the informed consent, despite a signed consent form.6

Conclusion

Informed consent is a most important document in your medical record to prevent malpractice lawsuits. Most plaintiff’s attorneys are hesitant to pursue a cause of action when the injury that the patient is complaining of is clearly listed on a consent form.

Each practitioner should establish protocols that ensure proper consent is obtained from every patient. These simple steps can lead to better patient communications and less overall risk to you and your practice.

1.

2.

3.

4.

5.

6.

ADA Policy Statement: The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders. Adopt ed 2017 Blacks Law Dictionary 6th Edition West Publications Faden, Ruth R.; Beauchamp, Tom L.; King, Nancy M.P. (1986). A history and theory of informed consent. New York: Oxford University Merz JF, Fischhoff B. Informed consent does not mean rational consent: cognitive limitations on decision-making. J Leg Med. 1990;11(3):321-350.

Etchells E, Sharpe G, Walsh P, Williams JR, Singer PA. Bioethics for clinicians: 1. Consent. CMAJ. 1996;155: 177–80.

Parikh v Cunningham, 493 So 2d 999 11 FL L. Weekly 309 (Fla, 1986).

Dr. Ken Berley is a dentist/attorney with over 35 years of dental experience and over 22 years in the legal profession. For the past 10 years, he has focused his practice on the treatment of Sleep Disordered Breathing and TMD. As the only DDS/JD/Diplomate of the American Board of Dental Sleep Medicine, he stays busy lecturing and consulting in the areas of risk management and the development of a successful dental sleep medicine (DSM) practice.

Dr. Berley has written numerous consent forms that are used in general and dental sleep medicine practices. He is the co-author of The Clinicians Handbook for Dental Sleep Medicine (Quintessence). With his unique background he provides consulting services for various insurance companies and actively defends and advises dentists who are facing legal challenges. Dr. Berley is the President of Dental Sleep Apnea Team, a consulting firm offering in-office training on Dental Sleep Medicine, consent forms and other documents to assist the DSM practice.

DentalSleepPractice.com

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Legal Capacity Patient has adequate capacity if he/she is able understand the information presented, make medical decisions, and communicate the decision to another party. Since severe sleep deprivation has been adjudicated to limit the capacity to provide informed consent, patients should be evaluated on their ability to actively participate in a conversation. When a dentist feels that a patient may be incapacitat-

ed, if no legal guardian has been appointed, a close family member should participate in all discussions and sign as a witness to the informed consent document.

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SPECIALfeature

An Ounce of Prevention: Avoiding Oral Appliance Therapy Related Side Effects

by Jamison Spencer, DMD, MS

W

ith serious systemic health consequences being clearly linked with not treating SRBD, any potential dental side effects related to treatment of such disorders are a small price to pay. After all, tooth movement and occlusal changes rarely result in heart attack, stroke or death. Still, the caring dentist wants to minimize problems for their patients.

ADA

The keys to avoiding these troubles are: 1. Recognizing in advance if the patient may be at greater risk for any specific side effects.

2. Proper appliance choice and fabrication.

3. Utilization of methods to help the patient re-align their habitual occlusion and regularly check for tooth movement and bite changes.

4. Proper follow-up.

To be clear, the most common side effects related to oral appliance therapy are transient and typically of little concern to the patient.

Localized discomfort in a single tooth or a few teeth, increased salivation, disrupted sleep as they get used to wearing the appliance, localized muscle soreness and occasionally discomfort in one or both temporomandibular joints are relatively common and tend to improve quickly without any modification to the appliance or intervention.

Patients should be educated that such temporary effects are to be expected and are part of the normal accommodation process.

14 DSP | Fall 2019

1. Recognizing in advance what side effects for which the patient may be at greater risk.

I strongly support the statement in the ADA’s policy directing dentists to continually update their knowledge and training of dental sleep medicine with continuing education.

This knowledge and training MUST include understanding temporomandibular disorders and principles of muscle pain.

While a complete list of all potential OAT risk factors is beyond the scope of this article, here are several conditions I believe are important.

Periodontal disease: Patients with periodontal disease are at higher risk of tooth movement or loss of teeth. The dentist should decide if OAT is the best option or if CPAP, in combination with comprehensive periodontal therapy, might be necessary until acute conditions are managed.

Internal Derangements: Reducing and non-reducing disc displacements and degenerative arthritis may make a patient more likely to develop occlusal changes and/or discomfort in one or both jaw joints.

Reducing Disc Displacement (RDD): The articular disc is off the condyle when the teeth are together and on top of it when the mandible is forward, such as with OAT. Until the tissues adapt, the patient feels a ‘pop’ when the disc moves off and on the condyle.

We discuss this carefully with every patient, including the rare occurrence of a permanently repositioned disc which can create a posterior open bite.

Non-Reducing Disc Displacement (NRDD): When the disc is chronically displaced or dislocated anterior to the head of the condyle in all mandibular movements. Usually a history reveals popping that ‘went away.’

As with RDD, oral appliance therapy is not contraindicated. Patients need to be educated on what is likely going on and that OAT may exacerbate a condition that has not bothered them in a long time, including a return of the ‘clicking.’

Unlike RDD, the most likely side effect with NRDD is joint pain and retrodiscitis (which may result in a transient posterior open bite, but due to swelling related to inflammation, not changes to disc position).

SPECIALfeature These patients are treated and encouraged in the same way as any minor injury with inflammation.

2. Proper appliance choice and fabrication.

While there are many considerations in choosing the best appliance design for overall efficacy, patient comfort, and compliance, it has not been shown that specific appliance designs are more or less likely to result in side effects such as pain, tooth movement or bite changes.

Patients with tooth wear may have a reduction of their bruxism with treatment of their SRBD. I choose an appliance that will allow the patient to move their mandible in the same way that they had to in order to create the wear. They may continue to brux and be at higher risk of damaging or prematurely wearing out appliances. This should be explained so that the patient knows that these are side effects of their bruxism rather than the appliance.

A common error is not “wrapping” the distal of the most posterior mandibular teeth.

Whenever possible the lab should wrap the distal, which will make it less likely that the other teeth in the arch will be pulled forward, resulting in open contacts.

3. Utilization of methods to help the patient re-align their habitual occlusion and regularly check for tooth movement and bite changes.

It has become common to provide some

sort of “morning occlusal guide” to help the patient recover their normal bite. I strongly encourage you to provide every patient with such a device and verify they understand how and why to use it.

We explain to the patient that if they notice their previously tight contacts are now easier to floss or they now seem to be hitting harder on the front teeth, they are to contact us immediately. When we catch things early it is much easier to deal with the issues.

In my experience, patients who develop tooth movement or bite changes are usually either not doing what you asked The most common them to do or they are doing it wrong. side effects related This is why regular follow-up is vital.

4. Proper Follow-up

Regular visits confirm the therapy is still effective and allow the dentist to recognize and manage changes, many of which are unnoticed by the patient. With oversight, it is much less likely that a patient will develop significant dental side effects.

to oral appliance therapy are transient and typically of little concern to the patient.

Conclusion

Even though many medical problems associated with not treating OSA are far more serious, the patient must understand the potential side effects of OAT and their role in avoiding them, their responsibility in keeping follow-up appointments, and decide to move forward with therapy. The dentist must be able to recognize and manage common side effects or refer to those who have the necessary expertise.

DentalSleepPractice.com

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Jamison Spencer, DMD, MS, is the director of Dental Sleep Medicine for the Center for Sleep Apnea and TMJ, in Boise, Idaho and Salt Lake City, Utah. Dr. Spencer has personally treated thousands of patients with sleep apnea and TMJ problems, and now focuses on helping dentists help their patients with such problems.

Dr. Spencer is the Past-President of the American Academy of Craniofacial Pain (AACP), a Diplomate of the American Board of Craniofacial Pain, a Diplomate of the American Board of Dental Sleep Medicine, a Diplomate of the American Board of Craniofacial Dental Sleep Medicine and has a Masters in Craniofacial Pain from Tufts University. He taught head and neck anatomy at Boise State University, is adjunct faculty at the University of the Pacific School of Dentistry, and the University of North Carolina at Chapel Hill. Dr. Spencer has been invited to give lectures on TMD, Dental Sleep Medicine and head and neck anatomy throughout the United States at every major dental meeting, Canada, Central and South America, the Caribbean, Australia, Europe and India. Dr. Spencer created Spencer Study Club, an online education, mentoring and implementation program to help dentists and their teams help more of their patients with sleep apnea and TMJ disorders.

Dr. Spencer now lives in Pleasant View, Utah with his wife of 28 years, Jennifer, and their 3 children of 6 who are still at home.

Dr. Spencer can be reached at Jamison@JamisonSpencer.com, 208.861.5687 or www.JamisonSpencer.com.

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SPECIALfeature

Defining Successful Therapy

by W. Keith Thornton, DDS

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discussion of the ADA Policy Statement and recommendations for long term treatment (disease management) must be predicated on the definition of sleep related breathing disorders (SRBD), the various treatments, the severity of the condition, and the understanding of the patient’s desires and objectives. Only then can a cogent algorithm for management be proposed to apply precision medicine to the individual.

SRBD

ADA

The term describes the behavior of the passive pharynx during sleep: a continuum from snoring, flow limitation, Upper Airway Resistance Syndrome (UARS), to obstructive sleep apnea. The continuum is called pharyngeal instability. Only when it reaches the end stage of significant under-breathing and oxygen desaturation (hypopnea) or cessation of breathing (apnea) does it rise to the level of a medical disease called obstructive sleep apnea (OSA) and defined by the ApneaHypopnea Index (AHI). Most people with SRBD do not have OSA. All breathing is controlled by a central, chemical controlled, feedback loop (Fig.1).

Dr. Magdne Younes in 1989 found that both the pharynx and ventilation were unstable (loop gain) instead of just the pharynx. This understanding has been applied more recently to SRBD and OSA (White

Figure 1

16 DSP | Fall 2019

Figure 2

2005). A better term for SRBD should be Sleep Pharyngeal-Ventilatory Instability (SPVI). It is interesting that the ADA Policy states that SRBD is “caused by anatomical airway collapse and respiratory control mechanism.” Thus, treatment efficacy must include titrating the mandibular position, affecting pharyngeal stability, but also by addressing loop gain.

Ventilatory instability can be improved by eliminating mouth breathing, taping the lips or using a mouth shield with an oral appliance. Even daytime breathing exercises can improve loop gain. The dentist is in the unique position of being able to manage all levels of SRBD including severe OSA, complex OSA, and even some central sleep apnea (CSA), utilizing a systems approach.

Most physicians are aware that CPAP therapy is problematic due to compliance. Studies are showing that CPAP does not improve cardiovascular outcomes. Approximately 75% of patients fail a minimum CPAP use of 4 hours per night 5 days per week. It would seem logical that oral appliance therapy would be tried first. A barrier to this approach is the lack of standard of care in dentistry, including screening, appliance selection, titration, and follow up. The complaint of sleep physicians is that most devices are not predictable, fail to reach the success criteria (an AHI<10, a reduction by at least 50% and the elimination of symptoms), and are very expensive. A great advantage of CPAP is that a trial is always done before a purchase. Studies show that the only consistently successful appliances are titrated objectively, while even the best fail without titration. A key trait is the ease of patient titration.

SPECIALfeature Screening and monitoring

Whether a patient with suspected SRBD is a patient of record, referred for treatment, or has failed PAP, standardized objective and subjective screening should be done prior to any therapy to determine need for referral or as a baseline for titration, monitoring and clinical decisions. Examples of subjective tests are Epworth Sleepiness Scale and Thornton Snoring Scale. Consumer sleep technologies, such as smartphone apps, may also be helpful. Objective tests include oximetry, cardiopulmonary coupling, and even home sleep apnea tests (HST). Tests should be simple, inexpensive, and reliable. With a failed CPAP patient or with a patient who prefers an oral appliance, the goal of titration would be to achieve a high negative predictive level that would assure the patient doesn’t have OSA while wearing the device. Pulse oximetry meets these criteria well and has been used by the author for 26 years. If time below 90% oxygen saturation is less than 1% of the night, there is less than a 2% chance of having OSA, particularly with elimination of the patient’s symptoms (Series 1993). Traditional oximetry and HST measure only pharyngeal instability and only for OSA, not all SRBD. However, high-resolution pulse oximetry appears to be able to measure both pharyngeal and ventilatory instability and can detect everything from flow limitation to OSA, and even CSA. It also classifies the severity of the SRBD including cycling time and depth (Figs. 1-3). The analysis includes all of the traditional parameters, providing doctors the greatest amount of information to make clinical decisions.

Oral Appliance Therapy

Standard of Care in the Dental Office

Once the decision has been made to provide OAT, both a before and after objective

screening to measure the efficacy of the appliance for OSA is required. A sleep physician is almost always involved with pre-treatment testing and provides baseline data that the dentist can use during therapy to gauge success of the OA. The dentist should be welltrained on any testing device that is employed and collaborate with the patient’s physician on how the data is interpreted. Increasingly, trial MADs are being used to evaluate patient response even prior to formal sleep testing; the dentist must be well trained and alert for subtle signs of ongoing problems. For example, cessation of snoring should not be assumed to be the end point of therapy.

Yearly appointments with objective monitoring are mandatory. Devices may need to be re-titrated due to changes in weight, medical conditions, or medications. Critical to success is both the efficacy and effectiveness of the device – does it work and are they using it. If not efficacious, another appliance should be tried or other treatment options discussed. Communicating and collaborating with the patient’s physician(s) is an integral part of the process.

W. Keith Thornton, DDS, is a third generation dentist who practiced restorative dentistry for 40 years in Dallas. His practice is limited to the treatment of airway and breathing disorders. He is a member of nine different dental and medical organizations and has had numerous leadership positions. He has been a member of the American Academy of Dental Sleep Medicine since 1993 and was an original Diplomate of the American Board of Dental Sleep Medicine. He is a visiting faculty member at A&M College of Dentistry, and is a consultant to the Army, Navy, Air Force and the VA. He has developed a number of medical devices that treat snoring and obstructive sleep apnea and has 72 issued patents. He is the founder, owner, CEO and chief technical officer for Airway Technologies, Inc.

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The greatest weakness in treating SRBD by oral appliances is the inconsistency of the outcomes with the various appliances. With over 120 cleared appliances, there is a need to determine which ones have the capability of managing all levels of OSA including severe and then titrate them appropriately.

The best source for evidence comes from the 2015 AASM/AADSM Guidelines on Oral Appliance Therapy – every dentist should study those guidelines and choose devices that demonstrate the best outcomes on the 40 RCT that were included.

Figure 3

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SPECIALfeature

Surgical Management of Sleep Related Breathing Disorders by Edward Zebovitz, DDS

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irway surgery is a viable option when alternative treatments have been deemed intolerable, ineffective, or if the patient desires correction instead of management of the disease. Dentists are uniquely positioned with a varied skill set to address SRDB in the growing child to develop a normal airway and to manage adults with anatomic airflow restriction. Indications for surgical management include: targeting subjective and objective signs and symptoms, correcting underlying dentofacial deformities, addressing anatomic airflow restrictions, and redirecting airway-related compensations, such as forward head posture and jaw protrusion.

18 DSP | Fall 2019

Addressing the airway restriction in the OSA patient requires careful diagnosis by means of direct clinical visualization of airway anatomy while awake or asleep (by drug induced sleep endoscopy) and imaging: CT, CBCT, MRI static and dynamic. Airway restriction can be the results of anatomic issues in any part of the upper airway and oral cavity â&#x20AC;&#x201C; the craniofacial respiratory complex.

Airflow restrictions can be located anywhere between the nares and the larynx â&#x20AC;&#x201C; including structures bounded by bone such as the piriform aperture and nasal airway, and soft-tissue-defined areas like the naso-, velo-, and oropharynx. If the palate is elon-

gated or the lymphoid tissues (adenoids and tonsils) are hypertrophied, the airway may be narrowed.

Oral cavity airflow restrictions can be related to constriction in available 3D volume for the tongue and the subsequent effects on the oropharynx. The size of the tongue is variable; while it can accommodate the surrounding structures, the available space for the tongue can be restricted by deformity of anatomic oral structures (e.g. palatal or lingual tori, ankyloglossia), narrow maxillary and/or mandibular arches, and deficiencies in the antero-posterior position of the mandible, maxilla, or combination of both.

Intranasal or oropharyngeal soft tissue airflow restrictions are typically referred to our otolaryngologist colleagues to address. Their typical procedures include: adenoidectomy, tonsillectomy and, less often, uvulopalatopharyngoplasty (UPPP). Other options include tongue base or epiglottal surgery, septoplasty, inferior nasal turbinoplasty, nasal valve stenting and palate-stiffening procedures.

Addressing the specific areas of oral airflow restriction related to width or transverse deficiencies can be addressed by techniques to expand the arches: there are three primary approaches for the adult SDB patient. First, expansion orthodontic mechanics by means

SPECIALfeature decisions are based on careful, detailed and educationally focused pre-operative consultations with the patient and the oral and maxillofacial surgeon. Additional decision making is influenced by idealizing the occlusion and determining if maxillary repositioning surgery is required to bring the palate forward, away from the posterior pharyngeal wall. If indicated, intranasal issues can be addressed simultaneously (e.g. septoplasty, turbinate reduction or piriform rim widening). This is advantageous in reducing the number of surgeries and recover- The goals are a ies. Maxillomandibular advancement (MMA) surgery differs from traditional more forward two-jaw orthognathic surgery in mag- tongue posture, nitude and focus, with MMA surgery primarily focused on addressing airway less restricted nasal related issues with a goal typically in airflow and increased excess of 10 mm of advancement.

Additional adjunctive airway proce- oropharyngeal size. dures are available and can be utilized in isolation and in combination with MMA, genial tubercle, or hyoid suspension procedures. Precise assessment of structures, possible with CBCT, MRI and clinical measurements, allows the airway surgeon to maximize increases in posterior pharyngeal space.

In summary, surgical options can be performed with predictable results and should be considered for patients with anatomic issues who are younger, or any who wish to attempt correction of their airway and/or have failed conservative therapies to address OSA. Dentists and surgeons work together to help patients avoid the medical implications of untreated sleep related breathing disorders.

Edward Zebovitz, DDS, an accomplished oral surgeon by day, and generous humanitarian, dedicated husband, father and international citizen after hours. Making the most of his gifts and talents, Dr. Zebovitz is as comfortable practicing in his state-of-the-art office as he is in rural primitive facilities, serving the needy across the globe, and across the street. Since 2006, Dr. Zebovitz has served as Chief of Oral and Maxillofacial Surgery at Anne Arundel Medical Center in Annapolis, Maryland. He is certified by the American Board of Oral and Maxillofacial Surgery (ABOMS) and is a Fellow of the American Association of Oral and Maxillofacial Surgeons (AAOMS). Dr. Zebovitz’ thriving practice, established in 2000, is located in Bowie, Maryland. He is quick to share his success with his loyal, gentle and patient centered staff.

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of traditional orthodontics or clear aligners.

The magnitude of expansion is 1-5mm and limited by maintaining the roots within the alveolar housing. When the roots are close to the buccal or facial cortical plate, root dehiscence and gingival recession are potential complications. The second option, Surgical Facilitated Orthodontics (SFOT) or Periodontally Accelerated Osteogenic Orthodontics (PAOO), is ideal for expansion requirements of 5-8 mm. These involve surgical exposure of the alveolar process and cortical bone scoring of the alveolus, outlining the roots on buccal/facial or palatal/lingual aspect, or both, depending on the proposed vector of tooth movement desired, followed by augmentation with allogenic bone graft material and meticulous soft tissue closure. Early and forceful application of well controlled force vectors is required. A 12-week window of opportunity exists, labeled “regionally accelerated phenomena” (RAP). This procedure also allows for simultaneous connective tissue grafting for root coverage and addressing mucogingival issues. The 3rd option, micro-implant rapid maxillary expansion (MARPE), is indicated for expansion requirements in excess of 8mm and in cases with intact periodontal support. This approach utilizes 1.7mm diameter implants placed to engage palatal bone on both sides of the suture.

Additional procedures include surgically assisted rapid palatal expansion (SARPE) which add palatal osteotomy, lateral maxillary wall osteotomies and pterygoid plate release to allow more 3D expansion of the maxilla.

The goal and results of these procedures allow for a more forward and relaxed tongue posture, less restricted nasal airflow and increased oropharyngeal size.

Surgical management of antero-posterior deficiencies are focused on anterior repositioning of the posterior nasal spine, which positions the velum, and the genial tubercle, which directly applies tension on the genioglossus muscle. This tension results in antero-inferiorly positioning of the hyoid bone and advancement of the tongue base, which increases the posterior pharyngeal space in both antero-posterior and transverse dimensions – a true 3-dimensional enlargement.

Decisions of the magnitude of genial tubercle advancement is based upon cephalometric and clinical evaluations to idealize facial proportions and maximize airflow. These

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SPECIALfeature

Narrowing the Gap Between What is Known and What is Practiced

by Chelsea Erickson, DDS

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ADA

leep is such an essential part of health that humans spend a third of our lives doing it. 1 in every 5 Americans have Sleep Apnea (one of the most common sleep disorders) and nearly 40% of Americans suffer from some type of sleep disorder in their lives. As vital as sleep is to our overall health and wellbeing, its an area of health, that has been vastly overlooked for centuries in Western Medicine. A survey in 2002 of 500 medical doctors showed that none of them felt they had an excellent understanding of sleep and 90% of them rated their knowledge as fair to poor. In 2011 a nationwide survey done by Goh found that medical students are getting about 3 hours of sleep education in their curriculum. In comparison, they receive about 2 hours on dentistry and oral health.

Sleep medicine wasnâ&#x20AC;&#x2122;t recognized as a specialty in medicine until 2003 and itâ&#x20AC;&#x2122;s still not recognized in dentistry.

This demonstrates that we know very little about such an important aspect of every day life.

20 DSP | Fall 2019

SPECIALfeature As our knowledge and understanding of sleep has grown over the last 20 years so has the field of sleep and dental sleep medicine.

We as dentists have distinct advantages when it comes to helping people who suffer from these disorders. Many of the symptoms of SDB either originate or manifest in the oral cavity. Not only are we highly trained to recognize poor oral health patterns as a part of disease, but we also can relate it to skeletal issues that many other professionals cannot identify. Few, if any other medical providers can make these assessments and correlations. This knowledge makes us a vital part of a team of providers necessary to comprehensively treat a patient who suffers from airway related sleep issues. Once they are properly diagnosed, dentistry may be called upon again to help with treatment.

We are fortunate in dentistry that even though many of us practice by ourselves, we are still very much a collaborative community. We have study clubs, private and public education institutes, large group organized learning, and small group learning. We have blogs, Facebook pages and Instagram feeds.

We can do week long focus courses or we can sign up for weeknight meetings. We have an abundance of information sharing but what we truly need as a dental community is more providers who are seeking out this information.

When we focus on sleep as a part of overall health and comprehensive care, we all win. We are healthier, happier and safer in a community that is well rested. I personally feel that we have a double standard when it comes to medicine and our desired role.

We want to be involved and regarded well in the medical community as a valuable re-

A continued interest and commitment to keeping up with current research and education is essential. source, but we also want nothing to do with the current medical structure of patient care.

From billing and coding to the time we get to spend with our patients, we have tried to insulate ourselves from the main stream medicine world. Sleep and airway form a large bridge between medicine and dentistry and the overall health of our patients, and dentists are the gatekeeper. It is an important role which is vital to the health of our community.

We are still early in our learning and understanding of sleep and treatment for sleep disorders. We are one of the primary providers of therapy to deal with the consequences of airway issues whether it be a MAD, orthodontics, or another type of therapy that address the airway directly. Because of the incredible growth of sleep knowledge and its importance to our patients and their care we must continue to learn from the growing research. It simply isnâ&#x20AC;&#x2122;t enough to take a week long course or even to become a Diplomate of the ABDSM. It isnâ&#x20AC;&#x2122;t enough to rely on the same appliances, approaches and research day after day. These are great accomplishments but a continued interest and commitment to keeping up with current research and education is essential. Dental sleep medicine is rewarding and completely life changing for both the provider and the patient and we owe it to ourselves, our profession and our patients to provide the best possible care with the most current standards.

Drs. Johnathan Parker and Chelsea Erickson

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Chelsea Erickson, DDS is a North Dakota native and attended the University of North Dakota and graduated with Bachelor of Science in Chemistry in 2006. She then attended Creighton University in Nebraska where she graduated with her degree as a Doctor of Dental Surgery in 2010. She practices full time in East Grand Forks, MN. She has a passion for continuing education and travels often to learn the most update information especially regarding comprehensive care including airway, TMD and sleep. She is a member of 5 study clubs, is a visiting faculty member at the Pankey Institute in Key Biscayne, Florida and loves to help educate as well.

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We’re Not in This by Ourselves – Communicating with Other Medical Professionals

by Ronald S. Prehn, ThM, DDS

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xcellent care is separated from standard care by the quality of communication between providers. The dentist treating SRBD with excellence does more than is required by policy and law. The ADA policy statement addresses communication to both the patient’s referring physician and to other healthcare providers. The content of this communication concerns treatment progress and recommended follow-up treatment recommendations.

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The recommended follow-up reports are to all the other members of the sleep treatment team. After the history and examination of a patient identified as having risk factors for a sleep related sleep breathing disorder, a referral to another healthcare provider may be indicated as either monotherapy (such as to an ENT for tonsillectomy) or adjunct ther-

22 DSP | Fall 2019

apy in combination with oral appliance therapy (myofunctional therapy or weight loss).

There are many professionals with therapy expertise that can help resolve SRBD – and all deserve complete communication.

The referring provider could be a PCP, ARNP, specialist physician or a board-certified sleep physician. The foundation of all communication lies within the diagnosis by the physician. During the process of a diagnosis, the physician considers the history and examination, the objective findings (testing), and the subjective symptoms (patient’s complaint). The sleep dentist should determine and record similar subjective symptoms as did the physician. If there are discrepancies in the subjective symptoms, then communication with the physician is essential to determine the patient’s chief complaint. The objective findings of the testing done by the

SPECIALfeature Another example would be if the subjective symptoms were resolved (patient is happy with sleep), but the objective testing indicates too much time spent (>1% of the night) under 90% blood oxygen. A referral back to the sleep physician to determine further treatment would be essential to success.

In both of these cases, one would be looking for, as one choice, combination therapy to achieve therapeutic goals. Combination therapy has great communication as its foundation. There are many combinations to be considered; the most common is to use an oral appliance concurrently with PAP therapy. The physician would be prescribing PAP therapy and you as the treating Good communication sleep dentist would be managing oral is what is best for appliance therapy at the same time.

A dentist cannot treat sleep related the patient and breathing disorders without a foundation of good communication with a phy- builds professional sician. Beyond that, some challenging satisfaction in all cases can only be successfully treated with close, frequent exchange of infor- providers. mation between providers. Reinforcement from everyone on the health care team may be essential to help the patient remain in oral appliance therapy as either monotherapy or in combination therapy.

Good communication is what is best for the patient and builds professional satisfaction in all providers. It is also what will help to keep a collaborative relationship between our two professions…Medicine and Dentistry.

Ronald S. Prehn, ThM, DDS, is a third generation dentist who focuses his practice on complex medical management of Facial Pain conditions (TMD and Headache) and Sleep Disordered Breathing. He received his degree at Marquette School of Dentistry in 1981 and post graduate education at the Parker Mahan Facial Pain Center at the University of Florida and the LD Pankey Institute in the years to follow. He is a Board-Certified Diplomat of both the American Board of Orofacial Pain and American Board of Dental Sleep Medicine, of which he is president-elect. While being an adjunct professor at the University of Texas Dental School in Houston, he is published in several journals on the subject of combination therapy for the treatment of obstructive sleep apnea. He is a sought-after speaker on this subject at the national level. He currently limits his practice to management of complex sleep breathing disorders at the Koala Sleep Center in Wausau, Wisconsin while enjoying with his wife, Linda, the outdoor life style and people of North Central Wisconsin. He can be contacted at rprehn@tmjtexas.com.

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ADA

physician should be well understood by the sleep dentist. The diagnosis is the foundation of all medical judgments for each patient.

Therefore, the clarity of communication at this level is critical to making good treatment decisions.

After diagnosis by the physician, the essential communication begins when we inform them the patient has been examined and a treatment plan has been recommended. It is critical to keep the physician informed about the patient’s treatment decisions. Did the patient accept treatment? Has therapy been initiated, delayed, or rejected?

Send a letter with your clinical notes, including your intention to have the patient return to the physician for final determination of the resolution of the sleep related breathing disorder. The depth of communication with the diagnosing provider and others on the health care team depends on the role each has in the diagnosis and treatment.

During the titration phase of Oral Appliance Therapy, the effectiveness of the oral appliance in stabilizing the airway is being determined by subjective symptoms (e.g. written questionnaires and verbal inquiry) and objective testing (e.g. wrist pulse oximetry). Once your therapeutic goals have been reached, the patient is to return to the physician for confirmation of efficacy of the oral appliance – resolution of the sleep related breathing disorder. At this point communication should include your objective and subjective records of the appliance titration, as well as your protocol for long term monitoring of the oral appliance therapy. State clearly in your cover letter that you feel the patient is ready for therapy confirmation testing. Yearly communication and update of your patient’s condition should be sent to the patient’s providers.

If you are unable to meet therapeutic goals with the oral appliance, enhanced communication to the boarded sleep physician becomes essential in order to help resolve the patient’s sleep related breathing disorder.

For example, if you are able to reach objective goals with your oral appliance (blood oxygen levels above 90% more than 99% of the night and low heart rate variability), but unable to resolve subjective symptoms (e.g. fatigue), then a referral back to the sleep physician would be essential for additional medical workup.

23

SPECIALfeature

After the Symptoms are Resolved

by Mark Murphy, DDS, and Eddie Sall, DDS, MD

W

ADA

hen we would embark on a trip, my kids used to wonder, and my grandchildren still ask, “are we there yet”? Honestly, sometimes I felt the same way. As you arrive at the gates of Disney or the hotel/resort you chose, there is a sense of relief, celebration and the satisfaction that you have safely completed the mission. So, too it is with treating obstructive sleep apnea for our patients. Are we “there” yet? Defining “there” is more gray than black and white. An AHI of 5 or less may be ideal but when a CPAP failure patient who started their journey with an AHI of 60 has been improved to 12, that may an incredible success. They may have more energy, less dependence on medications, reduced morbidities and a higher quality of life, but we are certainly not in a position as their dentist to determine if that is an acceptable treatment outcome. We should let the diagnosing provider make that call.

24 DSP | Fall 2019

After periodontal therapy, many patients can maintain their teeth in acceptable comfort, function and esthetics even if they have some residual pocket depths greater than 3

millimeters. Many clinically acceptable endpoints are not black and white, yet someone must make the call. As dentists, we are well trained to work interdependently with the periodontist to determine the survivability of the dentition in less than perfect outcomes, but we have far less expertise in medicine.

The evaluation of the effectiveness of the outcome and the follow up responsibility for disease management is and should be in the realm of medicine. We should participate, but not direct or be responsible for the treatment efficacy or follow up for the development or recurring OSA, relevant symptoms or comorbidities. Nor should our partner in health care, the physician, direct the follow up care with regards to the fitting, adjustment, titration or replacement of the precision oral medical device that is driving the treatment.

This policy emphasizes the obligation and importance of dentists in screening patients for OSA and outlines the importance of continued education in this field as well as the need to collaborate with physicians.

This collaboration is designed to optimize the skill sets of the two professions and rein-

SPECIALfeature force the scope of practice in dentistry and medicine. Dentists are in a unique position to screen patients for SRBD as part of the comprehensive medical and dental history and, as healthcare professionals, they have the best expertise to evaluate the oral cavity and associated structures. Once appropriately screened, the patients should be referred to sleep physicians for a proper diagnosis. The ADA and the American Academy of Dental Sleep Medicine recognize that dentists play a critical and integral role in evaluating their patients with potential sleep-related breathing disorders but require the diagnosis of these disorders to be made by a physician.

We are better together. When the treating dentist encourages the patient to return for the follow up sleep test to confirm the treatment efficacy, partnership strengthens. Patients feel better and have usually received some interim feedback like pulse oximetry to confirm they are on the right track. Without a follow up sleep test, we do not have verification. The best way to help the patient near the end of the treatment cycle is to have the conversation at the beginning of that cycle. By creating the expectation of a follow up test and maybe even including it in the written treatment plan, testing compliance will improve. Similarly, when physicians and dentists confer and create a treatment agreement document, it will help serve as a roadmap of treatment protocol for the collaborators.

Setting expectations up front for the professionals and patient improves outcomes and adherence.

The ADA statement delineates the dentistâ&#x20AC;&#x2122;s role and clearly emphasizes the importance of communication by the dentist with the referring physician and other healthcare providers. The policy emphasizes that follow-up sleep testing by a physician is imperative to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.

Setting expectations The advent of home sleep tests (HST) has created some confusion and am- up front for the biguity as to who should perform and professionals and or interpret the post treatment efficacy studies. While dentists may utilize HST patient improves to assess the objective interim results of outcomes and Oral Appliance Therapy, the ultimate efficacy studies should be interpreted by adherence. the sleep physician. The complexity and comprehensive treatment of SRBD is best achieved when there is open communication between the treating dentist (with the proper training and expertise) and the sleep physician. The dentist managing a patient with SRBD using a mandibular advancement device should have a system for regularly evaluating their patients for ongoing use and efficacy. The ADA policy statement is consistent with the best practices approach to optimize treatment of SRBD and is in the best interests of our patients.

Mark T. Murphy, DDS, has practiced in the Rochester area for over 35 years. He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of Funktional Sleep, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and as a Regular Presenter at the Pankey Institute. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaulâ&#x20AC;&#x2122;s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion.

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ADA

Dr. Edward T. Sall is Medical Director for ProSomnus Sleep Technologies. As Medical Director, Dr. Sall focuses on enhancing physician acceptance of Oral Appliance Therapy for patients with Obstructive Sleep Apnea. He obtained a DDS from Columbia University School of Dental and Oral Surgery in 1980. Due to his interest in facial pain and temporomandibular disorders, he decided to return to medical school for additional training.

He attended SUNY Upstate Medical Center and received an MD in 1987, followed by a 5-year residency in Otolaryngology/Head and Neck Surgery. Since 1992, Dr. Sall has practiced in Syracuse, New York as an Otolaryngologist and Dentist with an emphasis on TMD, facial pain, general Otolaryngology and the surgical and medical management of sleep disorders. He obtained an MBA from SUNY Binghamton in 2000 with an emphasis in healthcare.

Dr. Sall became board certified in Sleep Medicine and has treated over 3,500 patients with Oral Appliance Therapy.

25

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Special Section: ADA Policy Statement by Jeffrey Cole, DDS, et al 1.

2.

3.

4.

The goal of the ADA in developing the Policy Statement was to ________ a. Justify oral appliances to insurance companies for payment b. Develop an overview of the ‘state of the science’ for oral appliance therapy c. Check off completion of another inconsequential resolution of the House of Delegates d. Drive a wedge between dentists and sleep physicians to make dentists more important When using questionnaires for screening adults for risk of SRBD, _______ a. Only adult patients who demonstrates obvious symptoms should be included b. Handing patients a list of questions and providing a score is sufficient for most practices c. Detailed questions can reveal which patients who require further objective testing d. The best person to discuss the results is always the doctor In children, the screening process is designed to find children at risk so that appropriate therapy can be initiated to: __________ a. Make sure their front teeth don’t cause social problems during grade school b. Avoid the embarrassment associated with prolonged bed-wetting c. Correct malaligned teeth as early in life as possible d. Use evidence-based treatment to develop an optimal physiologic airway and breathing pattern Good scientific evidence has proven the veracity of OAT for OSA. In the future, _______ a. Dentistry is poised to become the front line of uncovering sleep apnea b. TMJ troubles will prevent OAT from every becoming the first option of therapy c. Physicians will come to rely less on research and more on dentists’ clinical experience d. New policy statements will be needed to make dentists and physicians work together

26 DSP | Fall 2019

5.

6.

7.

8.

After a patient is identified with OSA, the dentist’s skills are required in order to proceed with OAT. What must be evaluated includes: __________ a. A step-wise approach in order to conclude that the patient is a good candidate (or not) for a specific oral appliance chosen by the trained dentist b. High resolution pulse oximetry to determine if the patient should be on supplemental oxygen c. A CBCT to assess the correct jaw position to keep the airway open at night d. The range of motion of the tongue – from Mallampatti score to an abnormal frenum attachment – no oral appliance can overcome a bad tongue posture.

An informed consent document for OAT to treat SRBD protects the dentist by: ________ a. Listing every known hazard with treatment and with a refusal of treatment b. Requiring the patient and their spouse, guardian, or parent to co-sign c. Fending off lawsuits because notarized informed consent papers deter patients from successful conversations with their lawyers d. Providing documentation that a consent discussion took place between the doctor and the patient.

Side effects of OAT can be avoided, for the most part, by _______ a. Paying attention to four key commitments related to patient risk, appliance choice, clinical details, and proper follow-up b. Using only metal-free devices, eliminating allergy concerns c. Only treating patients with no history of TMJoint problems d. Blocking the phone numbers of suspected troublesome patients The dentist, patient, and health care team want to make sure therapy is successful. The dentist can assess this by measuring _______ a. resolution of the patient’s felt need (chief complaint) b. objective data to compare therapy to baseline diagnostic data

c. the amount of protrusion of the oral appliance d. the change in minimal cross-sectional area of the oropharynx using CBCT or pharyngometer imaging 9.

Surgery for correcting SRBD is indicated to _______ a. correct underlying dentofacial anomalies b. redirecting airway-related compensations c. address the wishes of patients seeking resolution, as opposed to management, of SRBD d. All of the above

10. The reasons why dentists should continue to learn about sleep, sleep medicine, dental therapy for airway support, and current research include: ______ a. it isn’t enough to take a week long course or even become an ABDSM Diplomate b. your study club needs an expert; it might as well be you c. primary care doctors learn little about sleep and want you to tell them about it d. everyone needs CE hours for licensure – sleep is one of the ‘easy’ subjects 11. Appropriate communication between dental and medical professionals ______ a. Takes more admin time than the fee for service pays for b. Burdens both the dental and medical staff with excessive unbeneficial tasks c. Separates excellent care from standard care d. Must be done by secure email 12. Once the patient’s symptoms are resolved, _______ a. The obligation of the dentist is limited to maintaining the integrity of the OA b. A system for regularly evaluating the patient for ongoing use and efficacy is deployed c. Treatment is complete and no further interaction with the physician is necessary d. An efficacy test is completed by the dentist to assure the patient that their SRBD is gone.

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