In 2000, Everything Changed An Interview with Dr. John Remmers Continuing Education Epigenetics and Sleep Disordered Breathing by Amalia A. Geller, MD FALL 2022 | dentalsleeppractice.com Supporting Dentists Through PRACTICAL Sleep Apnea Education PLUS Focusing on Outcome Leads to Discovery by Mark Abramson, DDS
The only end-to-end HST Solution for Sleep Dentists! Sleep MD telemedicine consults with Rx for HST & Oral Appliance FREE titration testing using NightOwl® Sensors Referrals from physicians Scan the QR code to learn more or email sales@hsatpro.com Indices Normal Result pAHI: ApneasUnclassified apneasOxygen Desaturation Index (≥ 3%): Average AverageMaximumMinimumMaximumSpOSpOMinimumSpOLowestdesaturationpulsefrequencypulsefrequencypulsefrequency No. of desaturations : Oxygen Saturation 90% Oxygen Saturation ≤ 85% Oxygen Saturation 80% 154.00154127min 3 min 0.9 min 25.9 61.711543 10069699321.4 < 5 < 5 94% 98% 50 70 bpm 60 90 bpm Oxygen Saturation ≤ 89% Oxygen Saturation ≤ 88% 5 min 4.5 min Oxygen Desaturation Index (≥ 4%): 13.1 5 Ectopic beats 1.3 Baseline SpO 94 ANALYSIS Home Sleep Test - Summary ReportPhysician InformationNitin Gumgaonkar,43284 W ARIZONA AVEMARICOPA, Arizona 85138Phone: +919503144636NPI: 1366978462Recording Start : 03/24/2022 11:21:56 PM End 03/25/2022 05:55:25 AM Duration : 6 hours 33 min 29 sec Test Condition: On Room Air Patient InformationJo C , Florida 33076Phone: +1954907180Gender: Male Date of Birth: 1/7/1981Height: 67 in Weight: lbs BMI: 10.49 Sleep Efficiency 94.44% 5 hours 56 min 22 sec Result (25.93) HSATPRO ID: 1653 Device: NightOwl Mini Disposable Serial #: 1123 HSATPRO Private and Confidential Page 1 of 1 Note: pAHI calculated using 4% oxygen desaturation
Learning is Energizing Again!
Over the past seven weeks leading up to this writing, I’ve been privileged to attend six meetings, conferences, and study club gath erings of my colleagues and friends. That beats the total of the last two years – even with that packed schedule, the collective energy of these gatherings only spurs me on to do
Backmore.home, confusion about gathering is still a thing. Medical facilities hew to higher standards of PPE than grocery stores. What do we do when a bunch of medical profes sionals want to get together in small or large groups? Unlikely every attendee is comfort able with whichever iteration of ‘the rules’ applies to that gathering. It’s part of meeting planning life to make sure the event is ‘worth it’ – which drives learners to choose the best program, find the optimum environment, and balance the scales of risk vs. benefit in favor of the positive. If you choose to go, make sure you maximize the value you can get. Much of that is up to you. It’s easy to recall the efficient, effective learning that happens in a great lecture with an inspiring speaker, reinforced by sharing what you heard over lunch, cocktails, or dinner. Harder to make that happen after a virtual learning experience, but those are here to stay. You can choose to passively pay attention to the screen, or dig in, make notes, and call your colleagues after to discuss what you heard. Fine red or white, or craft IPA, optional. Make even the solo act of accessing a recorded video a commu nity event by coordinating with a friend. We’re told to make ourselves account able to an exercise partner to improve our fitness – why not invite a fellow learner to be your accountability buddy to conquer a block of learning objectives? Be sure to include how you are going to put the new information to work. The humans in your clinic want first to be heard and understood. Experiences form community between experts – us, with our medical knowledge, and them, the only ones who can truly judge success of therapy. Think about when you start learning a new subject – you seek out the expert, then apply the learning to your own practice. That’s exactly what our patients are doing. Channel the best teacher you know, sit eye-to-eye, focus, listen, listen, listen, and create community with the human seeking better health.
Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing the quiz online at https://dentalsleeppractice.com/continuingeducation/ after reading the article “Epigenetics and Sleep Disordered Breathing” by Dr. Amalia A. Geller, which starts on page 30. Channel the best teacher you know, sit eye-to-eye, focus, listen, listen, listen, and create community with the human seeking better
INTRODUCTIONhealth.1DentalSleepPractice.com
Steve Carstensen, DDS Diplomate, American Board of Dental Sleep Medicine
Humans are community creatures. We thrive as a species because we are drawn together. While sometimes tribalism detracts from a community experience, more often gathering with like-minded humans fuels creativity, mutual encouragement, and focus on problem solving.
2 CREDITSCE MEDICAL
An Interview with Dr. John Remmers
Cover FocusingStoryon Outcome Leads
Special SleepGreaterSectionNewYorkSymposium Highlight of Speakers and Sponsors Great opportunity to build collaboration knowledge.
2 DSP | Fall 2022 CONTENTS
Continuing Education Epigenetics and Sleep Disordered Breathing by Amalia A. Geller, MD Read about the role of epigenetics and craniosacral-fascial therapies on sleep disordered breathing.
From the beginning, collaboration has been his path to success. Medical Insight
A Much Needed Paradigm Shift to Cardio-Sleep by Alan D. Steljes, MD, FACC, FRCP, and Lee A. Surkin, MD, FACC, FCCP,
30 In826ClinicianSpotlight2000,EverythingChanged
WhileFASNCthere is a known association between OSA and cardiovascular disease (CVD), but could sleep apnea be the cause of CVD? to Discovery by Mark Abramson, DDS Life provides opportunities to choose how much impact you wish to make.
12 54
PRO3-353-A 844 537 PatientProSomnus.com5337Preferred OSA Therapy™ 3 WARRANTYYEARPATENTED Join the growing number of clinicians who trust ProSomnus devices for excellent patient experiences and outcomes. Flexible, Easier Delivery | First Time Fit | Durability | Comfort | Biocompatibility | Precision | Featuring MG6™ Technology 1Mosca E; Remmers J; et al. In-home mandibular repositioning during sleep using MATRx plus predicts outcome and efficacious positioning for oral appliance treatment of obstructive sleep apnea. Journal of Clinical Sleep Medicine. Vol. 18, No. 3, March 2022. 2Sall E. Precision Oral Appliance Therapy: The Prime - Time Treatment for OSA. World Sleep Congress. Rome, Italy. Poster Abstract #289. March 2022. 3Smith K; et al. Efficacy of a Novel Precision Iterative Device and Material. World Sleep Congress. Rome, Italy. Poster Abstract #081. March 2022. 4Murphy M; et al. Device Design’s Impact on Dose in Oral Appliance Therapy. Journal of Dental Sleep Medicine. Vol. 8, No. 3 2021. Abstract #004. ProSomnus Precision Means Efficacy that Will Help You Sleep Better A recent independent, prospective clinical study published in the Journal of Clinical Sleep Medicine1 reported: of Mild & Moderate Patients Successfully &(ODIEfficaciouslyTreated<10h-1) 94% of Patients of all Severities Successfully &(ODIEfficaciouslyTreated<10h-1) 81% of Patients Reported Reduction in VolumeSnoring 97% of Patients Achieved Their Treatment Goal 85% Studies indicate that ProSomnus precision OAT devices are the first to demonstrate efficacy on par with CPAP for mild and moderate OSA1,2,3,4 Call 844 537 5337 or scan the QR code for a free starter kit.
4 DSP | Fall 2022 Calculated6CONTENTSPublisher’sPerspectiveRisksAdd Up to Greatness by Lisa Moler, Founder/CEO, MedMark Media 16 Bigger CompensationPictureNation by Dr. Bahar Esmaili Distorted form does not allow optimum function. 18 Communications Corner You Can be the Hero in a Patient’s Sleep Apnea Journey by Emma Cooksey The right comment in the right moment can trigger action. 20 Clinical Focus Could Breathing Re-Education Answer the Need for Personalized Sleep Apnea Treatment? by Patrick McKeown With coaching, people can improve the function of the respiratory system on their own. 29 Board Member Alan D. Steljes, MD, FACC Meet our new medical editorial board member Dr. Steljes. 36 Product Spotlight The Forces Devices:MandibularBehindAdvancementABriefExplanation by Diane Robichaud Science helps us understand forces on teeth. 44 Product HealthyStart’sSpotlightDisruptive Software Solution for Pediatric Sleep-Disordered Breathing by Beth Rosellini, DDS, AIAOMT It’s like having a team of clinicians all helping one patient. 48 Education Spotlight Meeting With the Global Leader of Pediatric Dental Sleep Medicine: Dr. Audrey Yoon This dual-trained orthodontist and pediatric dentist has pioneered a growth modification protocol. 50 Product Spotlight Less Time Between Screening & Treatment with a Trusted Partner by Drs. Geoffrey Skinner & Joseph Zelk Common language between doctors achieves better clinical outcomes. 52 Product Spotlight The Problem is 80% Tongue & 20% Environmental! You Need to Address Both The multi-patented device focuses on giving the tongue someplace to go. 60 Practice Management Sleep Marketing Tips Not for the Faint of Heart by Jonathan Fashbaugh Serious rewards from major committments. 64 Sleep Humor The Lighter Side of Sleep Apnea Fall 2022 Publisher | Lisa lmoler@medmarkmedia.comMoler Chief Dental Editor Steve Carstensen, DDS, stevec@medmarkmedia.comD.ABDSM Chief Medical Editor Lee A. Surkin, MD, FACC, FCCP, FASNC drsurkin@n3sleep.com Editorial Advisors Steven Bender, DDS Jagdeep Bijwadia, MD (Pulmonary, Sleep) Kevin Boyd, DDS Karen Parker Davidson, DHA, MSA, M.Ed., MSN, RN Kristie Gatto, MA, CCC-SLP, COM Amalia Geller, MD (Neurology, Sleep) William Hang, DDS, MSD Christopher Lettieri, MD (Pulmonary, Critical Care, Sleep) Pat McBride, PhD, CCSH Jyotsna Sahni, MD (Internal Medicine, Sleep) Ed Sall, MD (ENT, Sleep) Alan D. Steljes, MD (Cardiology, Sleep) Laura Sheppard, CDT, TE DeWitt Wilkerson, DMD Scott Williams, MD (Psychiatry, Sleep) Gy Yatros, DMD National Account Manager Adrienne Good | agood@medmarkmedia.com Sales Assistant & Client Services Melissa Minnick | melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius | emedia@medmarkmedia.com Social Media & PR Manager April Gutierrez | medmarkmedia@medmarkmedia.com Webmaster Mike Campbell | webmaster@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 | Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rate: 1 year (4 issues) $149 ©MedMark, LLC 2022. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher. 38 Clinical Focus Objective Airway Measurements by Karen Parker Davidson, DHA, MSA, MEd, MSN, ARPN There’s more to it than ‘how well do you breathe through your nose?”
Lisa Founder/CEO,Moler MedMark Media
6 DSP | Fall 2022 PUBLISHER’Sperspective
Do you like what you are reading in DSP? Do you have ideas you want to share about what works in your practice? Our Chief Dental Editor Dr. Steve Carstensen is happy to consider essays from any reader! Contact him at stevec@medmarkmedia.com.
– William Shakespeare
Each of us has our own idea of greatness. While some want to stand in the spotlight, others want to aim the spotlight. It’s all a matter of perspective and how you choose to see the light. On the news and social media, we see people who have achieved success. Copycats abound – whether it’s wearing the same styles or seeking the same lifestyle. But, what really is success? After so many years in the publishing business, I have seen many people, both doctors and non-clinical, achieve success. But the ones who achieve greatness have something in common. They don’t do what everyone else is doing. They find their passion, think out side of the box, and take calculated risks to reach their goals. One of the most interesting parts of being a publisher is that I get to meet people and read articles by people who take calculated risks. In the dental business, that usually entails devising new techniques or products. Sometimes it seems that everything that could be invented has already been invented. Who would have thought that implants could have a success rate of up to 98% or that sleep-disordered breathing could be treated at a dental practice? Remember when braces were just metal wires, brackets, and bands? Now, we can chose from lingual braces, 3D printed brackets, clear aligners, and many other ways to create perfect smiles in less time than ever before. Endodontics also has come a long way too – lasers, files of differ ent shapes, sizes, and materials, and clean ing and disinfection instrumentation that leads to less pain and positive outcomes. All thanks to dentists, scientists, and non-clini cal people who saw a problem that needed not just a solution, but their solution.
Calculated Risks Add Up to Greatness
In the fall issue, our innovative authors have provided us with interesting and educa tional content. Our cover story by Dr. Mark Abramson explains the philosophy and sci ence behind the development of the OASYS Oral/Nasal Airway System™. In her CE, Dr. Amalia A. Geller delves into the fascinating topic of epigenetics and how genes affect craniofacial development and treatment. Our Clinician Spotlight shines on Dr. John Remmers who talks about how clinicians can use current evidence to guide therapy and make a difference in longevity, sleepi ness, and death from cardiovascular disease. Don’t forget to check out our Special Section about the Greater New York Sleep Sympo sium featuring event speakers and sponsors. Whatever profession you chose, and whatever path you take, make sure that you follow your passion. Work hard and build a trusted team to help reach your goals. While your dreams are becoming reality, there are sure to be some nightmares, even during the day. But the things you lose sleep over can bring you satisfaction beyond your wildest dreams. We all have greatness in us. We just have to have the courage to discover it and share it.
“Be not afraid of greatness. Some are born great, some achieve greatness, and others have greatness thrust upon them.”
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Balancing the 22 years between discov ery and 2000 with the same number of years since, Dr. Remmers is retired from clinical practice but as involved as ever in pushing the treatment of OSA to better outcomes. He has a lot to say about how clinicians can use current evidence to guide therapy and ulti mately serve community health.
We also noticed some patients with tra cheostomy also stopped breathing. No ob struction there, so what’s going on? This was named ‘central sleep apnea’ – a new term. Our tidy, easy, sleep field was disrupted. What’s happened since 2000? Once we started looking at epidemiologic data we found evidence of premature death in peo ple with OSA – this is a bad disease. More and more people were turning up with OSA in our population, so we knew we really had to get a handle on it. With obesity, the num Changed
An Interview with Dr. John Remmers
John Remmers, MD, has been part of all the changes in sleep medicine. As a young physician, he discovered the collapse of the upper airway that resulted in breathing in terruptions being named “obstructive sleep apnea” (OSA) in 1978. For 22 years, follow ing a conference he chaired in Chicago, the AHI, apnea-hypopnea index, was the defin ing term, the evidence, used by medicine to label and evaluate disease and the means to treatInit.2000, another Chicago conference changed everything when studies, some led by Dr. Remmers, began to show that AHI was an insufficient marker. A gap widened between AHI measurements and patient-re ported symptoms. Medicine came to a break point. New definitions were needed.
8 DSP | Fall 2022 CLINICIANspotlight
In 2000, Everything
Evidence drives the best medical decisions. Therapy changes when the evidence leads us to see things differently. When the data points to a different path, treatment follows, but the old protocols are not thrown out. Think of it like changing lenses on glasses – a more precise shape provides better vision, but the frames stay the same.
DSP: Dr. Remmers, what’s new in our understanding of OSA since the beginning?JR: From 1978 to the year 2000, most of us thought about sleep apnea as a disease of old fat guys – we understood the airway closure, we had a treatment that worked, ev erything was cool. Two things happened in 2000: The Wisconsin Sleep Cohort showed two really important things. It wasn’t just old fat guys – up to 10% of all adult males had a high AHI – that was staggering, scary. The other thing it showed was only half of them were sleepy! The other thing that happened in 2000 was the second conference in Chi cago. Dr. Guilleminault’s AHI scale, which was supposed to give us the way to describe everyone with OSA, lost the correlation be tween the scale number and whether the pa tient felt good – were they sleepy or tired. I’ll never forget standing next to my poster and having Phil Westbrook ask: “What’s going on here? Why are all these people not sleepy?”
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10 DSP | Fall 2022 CLINICIANspotlight
bers were getting crazy – with so many diag nosed, is this really a disease?
Some giants of research looked at this and realized the anatomy might influence other responses – there were measurements to be defined. The concept of endotypes – how easy are you to arouse, what is your sensi tivity to oxygen changes, how long does it take for the muscles to respond? This wasn’t my work – I missed it. I think dentists didn’t get it, either – they like to think about airway. It’s important, but not the whole story – there are neural factors determining what the AHI is and the response to therapy.
AHI, Hypoxic Burden predicts Death, from all causes, including cardiovascular dis ease”. That’s pretty cool – we have a better index. AHI was created by Dr. Guilleminault by observing events – their importance was a set of a priori assumptions. These years later, we think about what happens to the person because of the obstructions and we have ev idence to connect with outcomes.
CPAP, for example, works better because it not only opens the collapse of the airway, but it increases the lung volume and oxy gen balance, but it also addresses some of the neurologic factors, particularly high loop gain. Maybe oral appliances don’t work as well because they can’t help loop gain. Not every dentist, physician, or the ones that teach others, appreciate the connections be tween airway and the neurologic factors.
Some people had AHI over 100 that didn’t seem too sick. Is AHI a good way to describe OSA? Is the airway the only thing that matters?
DSP: Keeping airway as a focus, then, or, more accurately, managing everything from the perspective that keeping the airway from collapse, is notJR:enough. That’s it! We kind of fell into it with CPAP. Knowing it could prevent collapse, we used it and later we found out it hammers the loop gain – a benefit we didn’t know about before 2000. Smart researchers from Har vard, and Magdy Younes before them, were learning about how the brain and respiratory centers respond to oxygen. I got started with dentists in 1984 – and it was a neurophysiologist that invited me to a conference at University of British Co lumbia to talk about the new disease I had discovered. The scientist was studying airway muscles and thought he might have a han dle on how to keep the airway from collaps ing. The researcher turned out to also be an orthodontist, Dr. Alan Lowe. I helped fund clinical trials of stents, we called them, to see if the airway could be kept open – we used thermosensors, did randomized control trials and compared them to CPAP. I helped direct Canadian federal funds and some in dustry money to develop what came to be the Kleerway. I met Keith Thornton about the The oxygen signal is a great one –I’ve been a fan for decades.
AHI, then is a failure – it just doesn’t take enough of the evidence that’s come out since 2000 into account. Better is what results from the closed airway – the effect on oxy gen. We have another index, ODI (oxygen desaturation index) that is better than AHI. It leads us to be able to measure Hypoxic Burden (HB) – and that factor predicts death from cardiovascular disease. Now we’re do ing something smart. In fact, this sentence ought to be over the door of your office and my office: “Unlike
The big problem physicians have with dentists, and I’ve talked with lots of sleep docs as part of what I’m doing these days, is lack of control of the patient care plan. They think first that oral appliances don’t work and second that losing control to dentists will hurt their patient outcomes.
CLINICIANspotlight 11DentalSleepPractice.com
What I’m kind of curious about is whether the differences in appliances might be part of it – does a metal hinge vs. a smooth milled device result in different outcome because of the design itself. Not just the amount of protrusion, but the actual way they function. Need to study that. Not ready for clinical recommendation yet, no evidence, but I’m curious. Something to think about.
DSP: What about using some of the new technology, with shared portals for data. Will that make it work better?JR:
same time, worked with him on the TAP, all while thinking airway collapse was the thing that needed to be prevented and the patient would get the same benefit as CPAP. After 2000, even though we knew CPAP had these good outcomes, the epidemiolo gy clearly showed that polysomnography and CPAP wasn’t going to be able to keep up with the expanding population that need ed our help. The first home sleep apnea test devices and auto-adjusting PAPs came from me. Neither of these were well-received by the medical community, and, along with my work with dentists, caused me to be rejected by most of medicine. Look at today, though, with HSAT and autoPAP being most of the testing and treatment and I guess I was right.
JR: We have sleep docs who are keeping their heads down, ignoring all the evidence that CPAP is not getting results we expected from pre-2000 thinking. We can’t continue ignoring research that shows that CPAP lacks evidence to support long term desired out comes – reduced sleepiness, longer lives, less cardiovascular mortality. Medicine must try something different if we want to have any hope. Oral appliances are probably part of the answer, but we lack evidence there, too. I’m trying to change that and get FDA to approve manufacturers to be able to recom mend mandibular advancement for all AHI levels – there’s no clear superiority any more for CPAP so why not? By the way, any clini cian can use OAT for any level of AHI – for severe, it’s just ‘off label’ use – something we do in medicine all the time.
Just like it’s no good for a sleep doc to hand out a CPAP and “See ya later,” that’s no way for a dentist to use oral appliances, either. The oxygen signal is a great one – I’ve been a fan for decades. We can get it from many places – the company I’m working with now is developing technologies that combine oxygen data gathering and oral de vices in a way that is useful for sleep docs and dentists. Talk about being able to moni tor for Theresults!medical profession, sleep docs and dentists, needs to look to the next 22 years and be able to say we’ve learned. We want to make a difference in longevity, sleepiness, and death from cardiovascular disease. Technology and a closer working relationship looks like the best way we can use the evidence we have now to make that happen. Who knows, though, what we’ll say after 22 more years?
DSP: Please tell me your thoughts on dentist-physician collaboration go ing forward. What does the next 22 years look like?
It could, if the sleep doc sees the pa tient annually or so, and the sleep dentist pays attention to the data. If things are not going well, or if the patient is getting off course with compliance or has residual events, the dentist should be actively involved with the patient.
Like we’ve been talking about, airway is a big part of the problem – the collapse of the oropharynx that I found in 1978, but since 2000 the neurologic components are show ing up to be just as important. There’s more to treatment than holding the jaw forward!
A lot of the principles that I incorporated in my TMD patients were applicable to air way health, so I began my career in DSM. Being part of Stanford, I started attending the didactic lectures and grand rounds at Stan ford Sleep Center. An interesting merger of these two worlds, sleep and mindfulness, came as I was reading the pivotal book on the research into mind/ body medicine that spoke of the impact of stress on health including cardiovascular health, immunity etc. I recognized that the stress reactions that we have in our awake lives were identical to the physiology and reactions that we have in sleep with apnea events or sleep disturbances.
When I heard about airway and dental sleep medicine, I realized the importance of the oral system on sleep and breathing.
Focusing on Outcome Leads to Discovery
Fortunately, others had similar ideas for mindfulness in medicine. Jon Kabat-Zinn at UMass hospital started such a program that quickly spread throughout the world. Upon seeing what he had done, I immedi ately incorporated his program. I was able to start a class in my local hospital and Kaiser Permenente medical system and finally was asked to bring the program to Stanford Uni versity Medical Center and Medical School.
I assembled a presentation called “Paral lels in Mind/Body Health and Sleep Apnea.” I was eventually allowed to give the presen tation at Stanford Sleep Center grand rounds on these findings comparing the impact of daytime stress and sleep stress. To be quite honest, I was nervous on how it would be received. After all, I was a dentist present ing these principles to a group that included Bill Dement, Christian Guilleminault, Clete Kushida, and 60 scientists from Stanford Research Institute. Fortunately, the lecture was very well received, and Bill Dement asked me to lecture in his Sleep and Dreams course at Stanford. I continue lecturing in the class after 20 years and Dement’s passing. The incredible thing about the Sleep and Dreams lecture was that it afforded me the opportunity to spend a great deal of personal time with Bill Dement. Not only was Bill the father of a whole new field of medicine, he
12 DSP | Fall 2022 COVERstory
The road that led me to becoming a practicing dentist spe cializing in oral facial pain and dental sleep medicine really started at the age of 14. I was hit by a car, as a pe destrian, on a sidewalk and was immobilized for 10 weeks in traction in a hospital bed and in a lot of pain. In my process of recovery and work ing with the pain, I realized that I couldn’t depend on medications due to the addictive nature of them. I realized that trying to fight the pain just made it worse and the suffering greater, and there was another option avail able. I could focus my mind to connect with what was going on deep inside of me and feel it without reacting to it – to come to the cen ter of the storm in my body. I found that this practice had a profound therapeutic effect – physically, mentally and even spiritually. I later come to understand that what I was practicing was mindfulness meditation now known as a useful tool in pain management. In dental school, I was interested in general health. I was looking for how to integrate what I knew from my life expe rience with pain management, but only the drug options were taught in school. I was fortunate to get a residency at the Palo Alto VA hospital in 1975 and began exploring ways to use what I knew in the field of dentistry. I realized that the place to do this was in cranial facial pain treatment and dedicated my life to that area. At that time, treating TMJ was gnathologically oriented to retrusion. I realized I needed to go in a different direction and preferred to free up the man dible with lower flat plane splints. I also explored integrative medicine approaches to address the underlying craniofacial dysfunctions with physical therapy, ther apeutic injections, and acupuncture. I brought mindfulness into the pain management for my individual patients, but I saw that mindfulness was important in many health conditions and wanted to broaden mindfulness training for the larger medical community.
by Mark Abramson, DDS
was also a wonderful person and a friend to all. We would meet as his house in Stanford Professorville and sit and talk in his study before he drove me to class in his “Sleep and Dreams” golf cart. After the cart drive back to his house, we would hang out and talk some more. He would show me the original articles and historic papers on things like his discov ery of REM sleep. We had a chance to talk of shared interests like music and politics. This presentation went on to be the foun dation for a stress reduction presentation did at an AADSM meeting and a stress reduction program recorded for the ADA effort to sup port dentists in mental health. (The presenta tion can be seen here: tinyurl.com/hd9t6znj.)
COVERstory 13DentalSleepPractice.com
The Development of the OASYS Oral/ Nasal Airway System™ During my VA residency, I had five weeks of general anesthesia training. They treated me as a medical resident, and I did anesthe sia for everything from open heart surgery to joint replacements. At one point, they tested me on maintaining airway. I was to put the patient out without intubation, and I had to bag the patient to keep him breathing. This was 1975 before pulse ox, so the only way to know if the airway was patent was to see the chest rise. I remember clearly thrusting the jaw forward as best I could, tilting the head back, and sealing the face mask as tightly as I could as I squeezed the bag watching for the chest to rise. I was happy and relieved when the supervising doctor allowed me to intubate. I saw that mandibular reposition ing was effective and necessary to keep an unconscious airway open. As I began to look at oral appliances, I realized the purpose of mandibular reposi tioning was to bring the soft tissue with it, especially the tongue. But the appliances that were popular had all kinds of components in the tongue space. So I designed an appliance that stabilized the mandible forward with a shield in front of the upper anterior teeth without any intrusion on tongue space. I also realized that mandibular repositioning was just part of the story, because I had the prob lem of restricted nasal breathing. Just bring ing my mandible forward without addressing nasal patency would be incomplete, and it was a critical part of my airway condition. No one was addressing nasal resistance. I set out to find a way to effect nasal patency and with the goal of incorporating it into an oral appliance. One day, I did the Cottle Maneuver on myself and immedi ately felt the ease of breathing. I realized that a Cottle maneuver could be achieved with extensions off of the upper shield that I already had incorporated in my appliance. These extensions would preform the Cot tle maneuver and dilate the nasal valve and drain the sinuses all night long. That was the birth of the OASYS Oral/ Nasal Airway System™... Okay everyone shortens the name to OASYS, so I surrender. The word “system” is very important here, because this is a system of care effecting mul tiple areas of resistance and blockage of the upper airway. In the process of getting FDA 510K for the OASYS, which is through the Dr. Mark Abramson is a TMJ and Sleep Apnea dentist, serv ing patients in Redwood City, in the San Francisco Bay Area. He attended the University of Maryland School of Dentistry where he graduated in 1975. Upon graduation, he came to California to do a general practice residence at the Palo Alto Veterans Hospital. After residency, he limited his dental prac tice to treating the special needs of those suffering with TMJ and headache and facial pain. Dr. Abramson directs Stanford University’s Mind fulness Based Stress Reduction Clinic and teaches ongoing classes on this pro gram through Stanford University School of Medicine. Dr. Abramson is a staff physician at Stanford University Hospital. Dr. Abramson is a Diplomat, Ameri can Academy of Orofacial Pain; Diplomat, Academy of Pain Management; Dip lomat, American Academy of Dental Sleep Medicine; and a Fellow, American Academy of Craniofacial Pain Management. He is a member of the American Dental Association, California Dental Association, American Academy of Den tal Sleep Medicine, American Academy of Craiofacial Pain Management, and Cranial Academy. Dr. Abramson developed the O2 OASYS Oral/Nasal Airway System™ and in 2004 received FDA approval for this device. Dr. Bill Dement (left) with his “Sleep and Dreams” golf cart and Dr. Mark Abramson (right)
Jim Addiego and Dr. Abramson at the Dream Systems Dental Sleep Laboratory booth Scan the QR code above to view the OASYS Splint – Therapy for Bruxism, Speech, and Tongue Thrust webinar
I opened Dream Systems Dental Sleep Laboratory in Roseville, California in 2011 with the help of Jim Addiego, a dental lab oratory executive who is passionate about treating sleep apnea.
The tongue guides are also incorporated into a lower flat splint called the OASYS Myosplint™ which is useful for both TMD treatment of severe clinchers to get the tongue to counterbalance the clenching properly and free up space between teeth.
The other areas I have contributed to in the field of sleep medicine is when medi care required a hinged appliance. I felt that the hinges available were hard to adjust and awkward. I set out to create an appli ance with a hinge that was easy to adjust; I designed a new hinge for appliances that is easily adjusted by an Allen wrench with two turns clock-wise to advance one mm and two turns counter clock-wise to back off one mm. It can be further back in the dental arch with the body parallel to the occlusal plane.
I was recently on a group webinar for Nierman Practice Management (https:// vimeo.com/437854811) with most of the appliance companies, and someone asked us all what animal we would say represents our appliance. I initially thought what a stupid question, but when it came time to respond about the OASYS, it popped out “Camel”…the OASYS looks awkward but functions great in many environments. It is actually quite easy to deliver and adjust; it is quite comfortable to patients especially those who feel the ease of breathing nasally. The tongue guides fit in the space at the root of the tongue and usually are not even noticed or can be easily adjusted for comfort. If you haven’t tried the OASYS or OASYS Hinge, give Dream Systems a try. Jim is always there to give you help and guidance. Contact Dream Systems Dental Sleep Lab at (916) 865-4528 or by visiting https://www. dreamsystemsdentallab.com.
DSP | Fall 2022 COVERstory 14
John Bixby, dental director of Sleep Dynamics in New Jersey was the second to try the tongue guides. He had previously failed oral appliance therapy and was using CPAP. Then he tried the OASYS with the nasal dilation, and his AHI went from 56 to 22. When we added the tongue therapy, his AHI went to 7. He went on to exclusively use the OASYS. With his clinics great follow through, they documented 164 consecutive patients with pre- and post-treatment sleep studies. The results of his documentation were published in Sleep and Vigilance Effi cacy of Oral Appliance Therapy in the Treat ment of Severe OSA in CPAP-Resistant Cases
The next area that I focused on was to address tongue/throat function. I observed a number of patients whose tongue rolled up in the back of the throat and did not follow the mandible forward in repositioning. Once again, I had a good guinea pig, myself. I had a lateral tongue thrust that I could not change even though I studied myofunctional therapy and tried diligently to change my pattern of swallow. It was like having an accent in speech that I couldn’t change. I tried to create shelves under the front of the tongue and quickly found it pushed the tongue back into the throat. I found this also to be true with large mandibular tori. I then realized that I was targeting the wrong end of the tongue, and I needed to tar get the root of the tongue. I applied the same principles as the nasal dilation to create pads that go down to the root of the tongue to mechanically lift the back of the tongue to the soft palate, but it also makes you have to dynamically use all the muscles of the hyoid apparatus in swallowing. You can’t be lazy with your swallow. My swallow improved with two weeks of usage; my tongue natu rally locks up to my palate when I am in rest posture. It has changed the dynamics of my throat, facial muscles, and airway.
[Deepak Shrivastava, John K. Bixby, Douglas S. Livornese, Felix Urena, Michael J. Bixby & Vikrum Jain. Sleep and Vigilance volume 2, pages119–125 (2018)].
dental division of the FDA, they said the nasal dilation had to be reviewed by the ENT divi sion. It turned out that it was a good process to show the dilation effect, and I ended up with FDA approvals from dental for mandibular repositioning to treat OSA and from the ENT to treat nasal patency through nasal dilation.
The OASYS Hinge™
In working with a local speech pathol ogist, we found the tongue guides effective in working with kids with speech patholo gies. After a few months of night time wear of a splint with the tongue guides, dramatic changes are observed by the speech pathol ogist. Tongue function improved to the point that the speech therapists could fine tune the remaining speech issues. It similarly is used for myofunctional therapy.
16BIGGERpicture DSP | Fall 2022
a top-down or ‘descending issue’ originates from blocked nasal passages and a soft diet. Children reared in post-indus trial households are subjected to poor air qual ity and highly processed, genetically modified foods, resulting in chronic and systemic inflam mation. Such inflammation leads to hormonal imbalances which result in enlarged turbi nates and dysregulated nasal cycling, restrict ing nasal passages. Resultant mouth breathing deprives the body of many vital functions of the nose, including warming, humidification, and filtration of the air, supply of Nitric Oxide, and neural signals to the brain of speed and flow of air. Moreover, blocked nasal passages lead to low tongue posture and dysfunctional swallowing, which negatively impacts facial growth and aesthetics. Soft diets, requiring less functionally-directed growth and swallowing patterns, contribute to these compromises as the body must compensate. Both ascending and descending culprits create compensatory muscle recruitment pat terns in walking, standing, breathing, swallow ing, and chewing. As such, patients with these patterns of compromise can rightly be said to be ‘financing the airway with poor posture.’ This is the beginning of a domino effect that disrupts the eruption of the teeth, interferes with the correct neurosensory pattern (garbage in, garbage out), and shows itself in maloc clusions such as excess overbite and overjet, underbite, and crossbite. Malocclusion cre ates avoidance patterns and negative feedback loops that slow or even arrest normal growth and development. Additionally, crossbite pre vents free and unimpeded latero-trusive mo tion of the lower jaw. Inhibition of normal range of motion of the mandible emerges as an additional postural issue, as the neck goes into forward translation during gait, motion and swallowing. These and other positive and negative feedback loops lend ongoing support to the oft-quoted observation of architect Frank Lloyd Wright: Regardless of whether one is re
The human kinetic chain is a closed loop of ligaments, fascia, bones and fluid, with two hard boundaries: the ground as the contact point of the feet and the occlusal surfaces of the teeth as they come in contact. Any com pensation between these two boundaries is manifested in and along one or more of the systems which comprise the kinetic chain. Anatomy and compensation determine static and dynamic posture. Posture is a profoundly simple yet reliable reflection and indication of the Autonomic Nervous System (ANS) at work to overcome obstacles which interfere with and even prevent normal bodily functions, in cluding breathing and balance.
The Autonomic Nervous System controls the position of the mandible in relation to the maxilla (inter-arch relationship), cervical spine (parapharyngeal space), cranium (TMJ), and the hyoid bone (tongue posture) through sev eral innate reflexes. Mandibular positioning to facilitate optimum nasal flow, from the ala of the nose to the epiglottis, can be determined using these reflexes: Breathing; Maintaining the Balance of the eyes with the horizon; and Keeping the Brain over the center of gravity during static posture and gait. This is the core principle of the Rule of the 3B’s: Breathe, Bal ance, and Conversely,Brain.
Compensation Nation
The Tell-tale Story of Epigenetically Modified Humans by Dr. Bahar Esmaili Humans express their full developmental and structural potential by epigenetic influences such as the masti cation of hard, fibrous foods and walking barefoot on soft, uneven ground. Post-industrial life is mostly devoid of these triggers. Humans live with unexpressed potential for ideal development and instead are subjected to factors which trig ger compensatory responses of one form or another along the kinetic chain. For example, walking on hard, level surfaces in stead of uneven surfaces and grass is an ascending issue which can negatively affect the arches of the feet and how the spine is aligned over the hip. This is observed in exaggerated spinal curvature: Hyper-lordosis in lumbar spine leads to unstable hip posture, and kyphosis in cervical spine limits the ribcage expan sion necessary for proper diaphragmatic and nasal breathing.
The mandible is an integral component of posture which is itself expressed by the func tionality of the kinetic chain, influencing the position of the head over the spine as well as the alignment of the cervical spine in order to support the weight of the head over the cen ter of gravity. As a consequence, the mandible moves in the opposite direction of the head, very often resulting in postural distortion.
• Can the diaphragm fully relax and contract?
• Is the hip neutral?
• Can the patient breathe through the nose?
compromisePatients by ‘financing the airway with poor posture.’
Obstruction of the nasal airway at any point from the nasal valve to the base of the tongue will trigger an upregulation of the sympathetic branch of the ANS in order to negate the limita tion of air flow. Forward head posture to clear the airway leads to spinal curvature and pos tural imbalance which is a secondary source of stress on the spine, in turn keeping the ANS in high sympathetic tone to execute functions as simple as sitting, walking and breathing. Clinicians can utilize postural assessment as a simple, no-cost, non-invasive and objective screening measure effective at assessing the sympathetic activity. Together with simple na sal flow screening, effects on the human kinet ic chain can be demonstrated to both the clini cian and to the affected person.
• Is the rib cage able to expand with out restriction?
ferring to buildings or bodies, Form Follows Function, and Dysfunction leads to Deformity.
Dr. Bahar Esmaili grew up in Iran and immigrated to the United States when she was 20 years old to persue her dream of becoming a doctor. Since graduating with honors from the University of Colorado School of Dental Medi cine in 2009, she has completed numerous advanced Continuing Education courses in the fields of craniofacial pain, TMJ disorder, and airway dentistry, and currently focuses her clinical practice on the connection between oral and whole-body health. She holds the prestigious position of being one of 24 North American consultants with 3M as part of the Council of Innovative Dentistry. She is a passionate educator and goes out of her way to help her patients understand the ‘why’ behind the ‘what’ of the issues for which they’re seeking help. She is a certified personal trainer, specializing in corrective posture and is passionate about the interconnectedness of the human body – from head & neck posture to jaw joint alignment to facial muscle tonicity to gait. In light of her profound realization that straight teeth cannot fit on crooked bodies, she is on a mission to enlighten practitioners of their ability to impact compensatory mechanisms that ultimately lead to the breakdown of our bodies and our health. She is excited to launch Project Compensation Nation and to inspire patients and professionals alike.
The first line of diagnosis should start with a head-to-toe examination of the patient to identify ascending and descending issues. Be curious about the level and degree of compen satory mechanisms, keeping the Rule of 3B’s in mind. The order of inquiry is as follows:
• Does the architecture of the airway in cluding maxillary shape and position, nasal passage size and tissue health, and the posture of the tongue and palate allow unrestricted airflow?
• Does spine have the normal curva ture in all segments?
When the head assumes a forward posture (an teriorization and extension) as a compensato ry breathing mechanism, the mandible moves in the opposite direction to guide body mass to support the head, and this in turn results in excessive overjet. During growth and devel opment, the distalized mandible leads to im paired condylar growth and collapsed vertical dimension of occlusion (increased overbite), negatively impacting the retroglossal portion of the airway and cervical spine alignment.
• Is the head over the spine or in front of it? If you are wondering whether you have the clinical expertise to ask these questions, con gratulations! You are a curious clinician, a life long learner. Master the meaning behind these questions and enjoy helping your patients to even better health.
17DentalSleepPractice.com
BIGGERpicture
18 DSP | Fall 2022 COMMUNICATIONScorner
You Can be the Hero in a
My symptoms began in my early twen ties. I would show up to the doctor’s office in a flood of tears and explain my symptoms the best I could between sobs. Despite sleep ing at least 8 hours per night, I struggled with daytime sleepiness every day. I had every possible symptom of sleep apnea but few of the risk factors. As a thin, active woman who didn’t have the thick neck or excess weight so many doctors would look for, I was re peatedly told I was “stressed” or “anxious”. I had the morning headaches, teeth grind ing, snoring, anxiety, and frequent bathroom trips at night. None of the doctors I saw in my twenties spotted my obstructive sleep apnea, but here’s another truth: my dentist didn’t either. All those years I wasn’t being referred for a sleep study, I was diligently having my teeth cleaned every 6 months. Not only did I have every symptom of sleep apnea, but I also had all the tell-tale warning signs right there in my mouth. The stress on my teeth from constant teeth grinding, the scalloped edge of my tongue – and that’s before we even start on my narrow, high-arched palate and mouth breathing. It’s a dubious claim to fame but if there were a poster child for ob structive sleep apnea, I’d be in the running.
Patient’s Sleep Apnea Journey by Emma Cooksey
Iwent undiagnosed with obstructive sleep apnea for more than 10 years. One day I was driving home with my baby daughter in the backseat, and I found myself struggling to stay awake. I blew air on my face and focused on the license plate of a large white truck in front of me. One moment the letters on the license plate were blurring in the distance and the next moment they were crisp and clear, coming straight toward me in slow motion. I slammed on my brakes to avoid a collision, but that incident was my wake-up call (see what I did there?) – I could no longer ignore this problem.
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In the summer of 2020, I started a pod cast called “Sleep Apnea Stories” to provide a platform for people living with sleep ap nea to tell their stories. My goal was to help my audience, and myself, feel less alone in our sleep apnea journeys. I wanted to share uplifting and helpful stories from people representing very different backgrounds and choosing different treatment options. In doz ens of episodes, I have interviewed male and female athletes, moms, young people, old people, and parents of kids with sleep ap nea. They have shared about CPAP therapy, oral appliance therapy, orthognathic surgery, nasal and throat surgery, hypoglossal nerve stimulation, palate expansion, NMES, my ofunctional therapy, breathwork, and even didgeridoo playing.
Emma Cooksey is a podcast host and writer. She was diagnosed with obstructive sleep apnea at the age of 30, after more than a decade of unexplained health problems. By sharing her journey and encouraging others to tell their stories, Emma has been breaking down stereotypes of sleep apnea while also raising awareness of symptoms and treatment options. Emma hosts the weekly podcast, “Sleep Apnea Stories” and writes articles for Health Union’s patient support website. In January 2022, Emma was appointed to the board of directors of Project Sleep, a 501(c)(3) non-profit organization raising awareness about sleep health and sleep conditions. Learn more about her podcast by visiting www.sleepapneastories.com or www.instagram.com/sleepapne astories.
COMMUNICATIONScorner 20 DSP | Fall 2022
If my dentist had asked a few simple questions about my sleep, my obstructive sleep apnea diagnosis may have come a lot sooner....I would have been forever grateful and considered that dentist my hero.
As a busy mom of two kids, I spent hours listening to podcasts every week as I sat watching my kids’ sports prac tice and waiting to pick them up at school events. When I searched sleep apnea in my podcast app, I didn’t come up with the clear information I was looking for. I wanted to hear from pa tients directly about their experiences with oral appliances, and all manner of other treatment options I was yet to discover. Since I couldn’t find it, I set about creating the podcast I wanted to listen to.
Early in 2020, I was sitting in a doctor’s office waiting room when an article in one of the health magazines caught my eye. At that point, I had used CPAP for 12 years since my diagnosis in 2008. The very last paragraph of that article mentioned dental appliances available to obstructive sleep apnea patients as an alternative to PAP therapy. I had nev er heard of any treatment other than CPAP, despite regularly seeing a sleep specialist for 12 years. I felt annoyed that no one had shared this information with me before and I realized in that moment just how little I really knew about the OSA which had such a big impact on my quality of life.
Aside from learning a LOT about the different treatment options for OSA, I also learned a lot about what is and isn’t working for patients in the current system. A huge problem is the number of people going sig nificant periods of time without a diagnosis. That’s a monster crisis with a simple solu tion: If every dentist were properly screen ing for sleep-disordered breathing in every patient, millions of people currently undiag nosed could be identified and offered sleep studies. I hope that primary care physicians receive more training in sleep disorders and are better able to spot these symptoms too. However, it’s dentists and hygienists who are up close to the problems sleep apnea creates. Wear on teeth, scalloped tongues, mouth breathing, enlarged tonsils, tongueties and narrow palates – it’s hard to ignore these things when you are made aware of them.Aspatients, we want to be offered all the treatment options available for OSA so that we don’t have to read about them for the first time in a waiting room magazine. We also want healthcare providers who care enough to ask questions about our sleep before we reach a crisis point and fall asleep at the wheel. In my early twenties, if my dentist had asked a few simple questions about my sleep, my obstructive sleep apnea diagnosis may have come a lot sooner. Not only would I have been treated more quickly, I would have been forever grateful and considered that dentist my hero. You have the power to be that hero in someone’s life today, I hope you’ll use it.
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22CLINICALfocus DSP | Fall 2022
Pcrit is used to measure the collapsibility of the airway in sleep-disordered breathing. It represents the pressure of negative suction required to close the airway during sleep. Contributing factors include airway narrow ing and collapsibility due to dysfunction in the airway dilator muscles. A narrow airway increases resistance, making it more vulner able to collapse. Fat around the pharynx, torso, and abdomen, all restrict function of the upper airway. This is exacerbated when breathing is hard and fast, especially through an open mouth. The apnea/hypopnea is characterized by a drop in airflow, but these events are often heralded by excess breath ing volume. After each apnea, the patient resumes breathing with a large gasp, perpet uating further apneic events.
by
The four phenotypes of sleep apnea, de fined by Eckert et al. in 2013, are pharyn geal critical closing pressure (Pcrit), loop gain, upper airway recruitment, and arousal threshold. Later research further refines this concept into one of four endotypes, facilitat ing a model of personalized treatment.
Could Breathing Re-Education Answer the Need for Personalized Sleep Apnea Treatment? Patrick McKeown
A problem exists in the treatment of sleep apnea. Traditional CPAP treatment, which focuses on the anatomy, is subject to poor compliance and often fails to fully resolve the condition. Therapies such as weight loss, electrical stimulation of the tongue, and treatment of nasal obstruction with steroids, surgery, or airway stents, also focus on anatomical correc tion. However, an understand ing of the traits that contribute to sleep apnea indicates an underlying issue at the root of symptoms. One that none of these methods address: Dysfunction al breathing. The Root Cause of Sleep Apnea
Pcrit
Pcrit is closely related to oral breathing. When the mouth is open, the upper airway is more vulnerable to collapse, independent of any nasal obstruction, and even of breathing route. This is due to mechanical obstruction caused by upper airway narrowing, and in efficient contraction of upper airway dila tor muscles. Mouth breathing is linked with greater oxygen desaturation and can also cause CPAP non-compliance. During nasal breathing, the tongue can sit in its correct resting place in the upper palate and is less likely to block the airway. Nasal breathing is also important for adequate dia In the last decade, the field of sleep medicine has changed radically. Sleep apnea was previously considered a purely anatomical issue, but we now know this is not the case. Re search has identified three non-anatomical phenotypes, signi fying a combination of contributing factors. Upper airway col lapsibility and craniofacial anatomy are, of course, still relevant, but the underlying cause of sleep apnea differs from one patient to another.
phragm excursion, which supports lung vol ume, and helps keep the airway open. Regu lar practice of diaphragm breathing exercises can improve Pcrit by enhancing the strength of the respiratory tract and improving the or ganization of breathing from the central ner vousOften,system.after nasal surgery or adenotonsil lectomy in children, symptoms return be cause the habit of persistent oral breathing is not addressed. Therefore, restoration of nasal breathing, day, and night, must be the first step in breathing re-education. My own clin ical experience indicates that the only way to ensure nasal breathing during sleep is to use supports such as paper tape across the lips, chin up strips or MyoTape® Loop Gain Loop gain reflects chemosensitivity to carbon dioxide (CO2). Patients with high loop gain have an excessive physiologi cal response to small changes in CO2. This is directly related to low breath-hold time. Indeed, chemosensitivity can be easily de termined using breath-hold time after ex halation – a measurement fundamental to breathing
Duringre-education.anapnea,breathing stops. CO2 is unable to leave the body via the lungs and builds up in the bloodstream. Because CO2 provides the primary stimulus to breathe, an increase in the pressure of CO2 of just 2-5mmHg can more than double ventilation. When breathing re-starts after an apnea, a patient with high loop gain will experience exaggerated breathing in response to small changes in CO2. This can trigger hyperventi lation, inhibiting the respiratory signals and causing a central apnea to occur. At the same time, unstable breathing contributes to air way collapse, producing an obstructive ap nea. There is evidence that some sleep apnea patients with high loop gain during sleep are also highly sensitive to changes in CO2 while awake.Around 30% of sleep apnea patients have high loop gain. As this is a non-anatomical trait, mandibular advancement devices do not tend to be effective. However, the che mosensitivity to CO2 and low breath-hold time synonymous with loop gain can be improved using breathing exercises that nor malize breathing rate and minute ventilation.
Upper Airway Recruitment
This refers to the mechanical efficiency of the upper airway dilator muscles. The human pharynx lacks rigid, bony support, but there are more than 20 muscles in the upper air way. These muscles are involved in respira tory and non-respiratory functions, and their activation counters the negative suction pres sure created during inhalation. Depending on the dynamic balance between negative suction pressure and neural drive to the up per airway dilator muscles, the airway can be vulnerable to collapse during sleep. Upper airway recruitment threshold is de fined by the level of stimulus required to acti vate the upper airway dilator muscles. When the muscles do not respond well to airway muscle collapse, the severity of sleep apnea canPatientsincrease.with sleep apnea tend to have poor control of the upper airway dilator muscles during inhalation, whether they are awake or asleep. They also tend to have weaker airway muscles.
Breathing re-education includes exercises that improve the strength and function of the breathing muscles, especially the diaphragm. It also restores the proper resting posture of the tongue. Tongue position is important in sleep apnea, as the genioglossus muscle in the tongue plays a role in maintaining an open airway. For oral breathers, it can be helpful to re-educate the tongue muscles and improve tone and function in the upper air ways using Myofunctional Therapy (MT). MT can restore nasal breathing during sleep – a Patrick McKeown is a leading authority in the field of breath ing for health, performance, and sleep. He was educated at Trinity College Dublin, completing his clinical training in Rus sia. In 2002, he was accredited as a breathing coach by re nowned physician, Dr. Konstantin Buteyko. Patrick is a Fellow of the Royal Society of Biology, creator and Master Instructor at Oxygen Advantage®, and founder of Buteyko Clinic Inter national, the leading Buteyko breathing clinic in the UK. For the last 20 years, he has taught functional breathing to help children and adults with asthma, sleep apnea, and many health conditions. Patrick’s 2021 book, “The Breathing Cure,” contains comprehensive research into breathing for sleep, and offers practical solutions for chronic conditions. His article, “Breathing Re-Education and Phenotypes of Sleep Apnea: A Review,” co-au thored with Drs. Carlos O’Connor-Reina and Guillermo Plaza, is published in the Journal of Clinical Medicine.
CLINICALfocus 23DentalSleepPractice.com
It is time to get to the root cause of symptoms in sleep apnea treatment.
Arousal Threshold Arousal threshold reflects whether the pa tient is a light or deep sleeper. This is defined by the levels of airway pressure and change in arterial CO2 concentration required to wake the patient. Those with a low arousal threshold and poor upper airway recruitment will awaken before the dilator muscles have activated. They will experience frequent, unnecessary arousals, sleep fragmentation and daytime fatigue. Low arousal threshold is linked to insomnia, autonomic imbalance, and mood disorders. What’s more, men and women with low arousal threshold are at the greatest risk of all-cause mortality. When the upper airway muscles do not work properly, sleep that is too deep can also be problematic. If the patient fails to awaken during an apnea, breathing can stop for lon ger, causing significant and damaging oxy gen desaturation. Nasal breathing supports deeper sleep, lowering arousal threshold. It slows the breathing rate. Conversely, heightened venti lation induces arousal from sleep, regardless of its cause. This is one reason low arousal threshold and insomnia often coexist. Slow, nasal breathing activates the parasympathet ic nervous system via the vagus nerve, while mouth breathing, which is often fast and into the upper chest, is associated with the stress response. Those patients with chronic stress and high anxiety struggle to fall and stay asleep. Breathing exercises that involve a respiratory rate of six breaths per minute optimize parasympathetic tone and reduce stress, ensuring deeper, more restful sleep with fewer arousals.
24 marker of successful upper airway treatment. It also reduces snoring and improves CPAP compliance and adherence. Moreover, na sal breathing harnesses the gas nitric oxide, which helps maintain tone in the airway di lator muscles.
Key Takeaway Breathing re-education has substantial potential benefits for patients with sleep ap nea. The goal should always be to reach a comfortable breath-hold time after exhala tion of 25 seconds. Nocturnal mouth taping is effective, but it is not enough. Daytime breathing must be functional too. It is time to get to the root cause of symp toms in sleep apnea treatment and find a way to fully resolve the condition. A simple pro gram of breathing exercises offers an acces sible, personalized approach.
The Four Phenotypes and Breathing Re-Education
Functional Breathing Breathe Light, Low, and Slow Biochemical Breathe light Biomechanical
Breathe low FrequencyResonance Breathe slow BreathingNasal DSP | Fall 2022 CLINICALfocus
Given the connections between breath ing volume, CO2 tolerance, oral breathing, and nervous system balance, it makes sense to address the root cause of symptoms on an individual basis, using the breath. Breathing re-education restores func tional breathing from three dimensions: biochemical, biomechanical, and resonant frequency (cadence), with a foundation of full-time nasal breathing. Nasal breathing is vital for dental health, but it can also support treatment of all four phenotypes of sleep ap nea, increasing the chance of fully resolving the Therecondition.is,as yet, limited research into the relationship between dysfunctional breath ing and sleep apnea. However, successful novel approaches involving breathing con trol have included myofunctional therapy, wind instrument and didgeridoo playing, di aphragm breathing, singing exercises and the Buteyko Breathing Method.
Welcoming All Cardiologists to Collaborate by Alan D. Steljes, MD, FACC, FRCP, and Lee A. Surkin MD, FACC, FCCP, FASNC
But why are cardiologists, specifically, so interested in sleep apnea? Because so many of their patients have it. OSA prevalence is as high as 40% to 80% in patients with the entire spectrum of cardiovascular disease (CVD.) This includes such diverse disorders as elevated blood pressure, congestive heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation and stroke. Severe sleep apnea is associated with sub stantially higher risk of cardiovascular death. Why this association between OSA and CVD? Is it coincidental? Possibly. After all, the risk factors for sleep apnea are male gen der, advancing age, and added body weight – the same as risk factors for CVD. Further more, sleep apnea is commonly associated with diabetes mellitus – another risk factor for ButCVD.could sleep apnea be the cause of CVD? Proving a cause and effect relationship requires several conditions. First, we would have to have a physiological explanation as to how sleep apnea could stress the heart. We would then have to have objective data confirming such an effect. Finally, we need proof that treatment of sleep apnea, favor ably affects the course of the CVD.
There is no doubt that untreated OSA is very stressful to the heart and CV system. OSA is characterized by repeated obstruc tion of the upper airway. The patient strug gles to breathe against the closed airway. This effort generates negative pressure within the chest. Additional blood is drawn into the chest at the same time as outflow of blood from the chest is impaired. These mechani cal effects of low barometric pressures stress the right ventricle (RV) and left ventricle (LV), respectively.Theconcept of transmural or transmyo cardial pressure is worthy of understanding given its role in the pathophysiology of this association. As stated above, airway obstruc tion results in a tremendous increase in neg ative intrathoracic pressure. Keeping in mind that the heart is basically in the center of the thoracic cavity, it is subjected to a pressure gradient simply calculated as the intra-cardi ac pressure minus the extra-cardiac pressure.
A real-world example to better elucidate this is to imagine that a typical left ventricular systolic pressure is 120 mmHg (intra-cardi ac) and when the airway is obstructed and the person is sucking against a closed airway, the negative pressure can rise to as high as 200 mmHg (extra-cardiac). So simple addi tion and subtraction to determine the trans mural or transmyocardial pressure is 120-(200) which is 320 mmHg. Now, imagine this happening repeatedly during the night and the negative impact this has on cardiac he modynamics and myocardial stress during a
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A Much toParadigmNeededShiftCardio-Sleep
Readers of this magazine are passionate about obstructive sleep apnea (OSA). They recognize that treatment of OSA leads to better sleep and better daytime functioning. Re sults are often life-changing.
time that the heart is normally subjected to the lowest pressure of the 24 hour period. The marked increase in transmural or transmyocardial pressure will lead to a shift in the interventricular septum from the right ventricle to the left ventricle which reduces left ventricular filling and thereby cardiac output. There is then a reflex vasoconstriction in the periphery. Coupled with this is usually hypoxia which results in vasoconstriction of the pulmonary arteries further straining the right ventricle. So, a cascade of events occur that are all deleterious to the heart. Considering other metabolic effects, with out airflow to the lungs, the carbon dioxide levels begin to rise, making the blood more acidic. The heart is now bathed in a low oxy gen, high acid milieu, further impairing heart function and contributing to heart rhythm problems.Theseevents sound the alarm. The body reacts by activating the sympathetic nervous system – the so-called fight or flight mecha nism. Adrenaline pores into the blood stream. Heart rate accelerates. Blood pressure rises. Heart rhythm becomes irritable. And this is just one cycle. This process can be repeated 100’s of times per night, night after night, month after month and year afterTheyear.sum of these mechanical, chemical and hormonal responses are measurable.
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We see elevated markers of inflammation, oxidative stress, endothelial dysfunction and hypercoagulability – all well known path ways to cardiovascular disease These processes are not limited to night time. The adverse effects persist into daytime. For example, blood samples show persistent activation of the sympathetic nervous system (SNS). Ultrasounds of the heart may show im pairment in heart function, both in chamber filling and emptying. Pressures in the pulmo nary artery are elevated to dangerous levels. In short, everything that happens during sleep apnea is bad for the heart and the car diovascular system. This understanding of these events, presents a plausible mechanism of how untreated sleep apnea may exacer bate pre-existing cardiovascular disease. It is also a plausible explanation on how sleep apnea may also be one cause of CV disease. What is the impact of treatment? Treat ment which is effective to eliminate OSA, will lower the SNS activation. It will improve cardiac function and elevated PA pressures. It will reduce heart rhythm irregularities. We see these benefits almost daily in our clinical practice. Furthermore, there is evidence that treat ment improves clinical outcomes. Reduced recurrence of atrial fibrillation post ablation. Reduced health care utilization due to less frequent hospitalization… Alan D. Steljes, MD, FACC, FRCPC was trained as an interventional cardiologist. Since fellowship, he has obtained additional certification in nuclear cardiology, echocardiography, CT coronary angiography and finally sleep med icine. In 2010, he opened a two bed sleep lab, recognizing the heart-sleep apnea interaction. The initial 2 beds have been scaled up to 12 beds since associating with the Nevada Heart & Vascular Center. He has since retired from the cardiology practice but continues to oversee the sleep program. He remains passionate about spreading the word about sleep disordered breathing and the heart. He currently shares his time between Las Vegas, NV and Mount Pleasant, SC. Lee A. Surkin, MD, is the Chief Medical Officer of Nexus Dental Systems. A private practitioner in cardiology, sleep medicine, and obesity medicine, he is one of a small group of physicians to be triple board certified in car diology, sleep medicine, and nuclear cardiology. In 2009, he created Carolina Sleep – the only dedicated sleep medicine practice in eastern NC. Dr. Surkin has created a cardiovascular and sleep healthcare model that includes a multi-faceted diagnostic and treatment approach that is enhanced by a network of relationships with physicians, dentists, respiratory therapists, sleep technologists, and public officials who recognize the important role that sleep medicine has in our daily life. In 2012, Dr. Surkin founded the American Academy of Cardiovascular Sleep Medicine which is a not-for-profit academic organization dedicated to educating healthcare providers, supporting research, and increasing public awareness of the convergence between cardiovascular disease and sleep disorders. In 2014, Dr. Surkin created a new multi-specialty practice called Carolina Clinic for Health and Wellness which combines his specialties with primary care, gyne cology, behavioral health and a medical spa. Dr. Surkin is married with three daughters and two dogs and resides in Greenville, NC.
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“Despite its high prevalence in patients with heart disease and the vulnerability of cardiac patients to OSA-related stressors and adverse cardiovascular outcomes, OSA is often underrecognized and undertreated in cardiovascular practice.”
But does treatment of sleep apnea save lives? This, to date, has been much harder to prove. In observational studies that exam ined several modalities of PAP, a significant mortality reduction was observed with PAP, with greater risk reduction observed among patients with CHF.
1. McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea N Engl J Med 2016;375: 919-31.
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The most definitive proof of a survival benefit requires a prospective randomized trial involving thousands of patients. The outcomes of patients on therapy would be compared with outcomes of patients not on therapy, followed over several years. In cardiology, this typically would involve a comparison group on a placebo or sham therapy – not possible with CPAP or oral
Quite possibly, but this hypothesis needs to be tested in future studies. Randomized con trolled trials with longer follow-up and focus on high-risk patients with severe OSA are needed to clarify the clinical benefits.
Future directions for research include innovative and effective options for therapy that are better tolerated and cost-effective. Better identification of which patients with OSA should be treated with the goal of pre venting or mitigating CVD.
appliance.Prospective, randomized controlled tri als have been hampered by a lack of con sensus as to what constitutes an ideal com parator group. Studies have involved small numbers of patients followed for short pe riods of time and have yielded inconsistent results. The largest impediment, especially with CPAP, has been adherence with thera py. In one recent trial, treated patients used their CPAP an average of 3.3 hours a night – not enough to fully correct apnea.1 Not surprisingly, there was no apparent benefit on mortality.Wouldthe results have been better with better adherence to therapy? Or with an al ternative therapy such as an implanted hypo glossal nerve stimulator? Or oral appliance?
– American Heart Association, October 2021
However, the evidence of the heart-sleep connection is so compelling that the Amer ican Heart Association, in October 2021, published their scientific statement on sleep apnea. The paper states that, “Despite its high prevalence in patients with heart dis ease and the vulnerability of cardiac patients to OSA-related stressors and adverse car diovascular outcomes, OSA is often under recognized and undertreated in cardiovascu lar practice.”Thiswas a call to action to cardiologists to recognize sleep apnea within their patient population and to consider therapy. This ap peal was echoed by the American Academy of Sleep Medicine which is encouraging co operation between cardiologists and sleep providers.Cardiologists are encouraged to prescreen their patients with commonly used screening questionnaires such as STOPBANG (Snoring, Tiredness, Observed Apnea, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender). Scores of 3 or greater correlate with a high risk of moderate to severe sleep apnea. High Risk patients are then followed up with home sleep apnea testing or other re mote monitoring technologies. Cardiologists will need to seek out prac titioners with the expertise to treat their sleep apnea patients. This is likely to be a panel of sleep medicine experts including dentists, ENT physicians, and sleep medi cineNowspecialists.thereason we treat patients, is not only so they feel better, but hopefully, also so their overall health is improved/optimized and perhaps their cardiovascular mortality is improved.
Alan D. Steljes, MD, FACC, FRCP
We have added other dental practices as our coverage has spread across the Las Ve gas Valley. Our relationships are mutually beneficial and are founded on respect and trust. We refer patients who have tried and failed on CPAP, or who have declined CPAP. The dentists, in turn, refer patients to us for sleep management. Typically, these are pa tients who have been identified as high risk for sleep apnea or are patients with a posi tive home sleep apnea test (HSAT.) If OSA is mild to moderate, we return the patient to the dentist for OAT. Our only request is that the patient has a follow-up HSAT on the de vice after optimizing therapy. HSAT may be performed either by us or by the dentist. Technology is evolving in dental sleep, and multiple devices are now available. We respect the dentist as the specialist. The den tist can choose whichever modality he/she feels is the best for that patient.
I had several requirements for the new program, which were not available within the community at that time: First, to provide a safe lab for complex patients with cardio vascular disorders. Second, to follow-up on patients post diagnosis to optimize results of therapy. And finally, to offer patients options for Astherapy.much as I appreciate the benefits of CPAP, it was not acceptable to offer CPAP as a one-size-fits-all therapy. Instead, every patient is counseled that there are 3 options for therapy – CPAP, an oral appliance (OAT), or surgery. We discuss the pros and cons of each option, specific to that patient. Often, we recommend CPAP as the first choice and OAT as the backup. Sometimes the other way around. Either way, the patients are always aware that there is a backup option. With your background as a cardi ologist, how did you learn so much about how dentists work in their clinic? Finding a dentist to fit the oral appliance was a challenge. Many dentists were will ing but it became apparent that few had the requisite experience. Insurance was also an obstacle. Most of our patients have Medicare which would cover the device. Most dentists don’t take Medicare. (Can’t blame them!) That’s when Dr. Pam West introduced herself to our practice. She is an experienced dentist with a solid training and extensive clinical experience. She had dedicated the majority of her practice to treating sleep ap nea patients. Just as important, she had the passion for sleep that comes when you real ize how therapy impacts people’s lives. It was exciting to view sleep apnea from her perspective. I gained a better understand ing of the interface of mandible, maxilla, and tongue. How do you see the future of den tist-physician collaboration going as communications improve?
Tell us about yourself.
Istarted my first sleep lab in 2010 in my cardiology office. A sleep lab was definitely unusual for a cardiologist in those days. Sleep medicine was more commonly associated with pulmonology or ENT. Maybe neurology, but never cardiology!
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Educational Aims
3. Recognize epigenetics’ connection to general oral health.
6. Recognize the role of craniosacral fascial therapy in using the patient’s natural genes to correct and straighten the teeth in jaws in conjunction with the use of biomimetic appliances.
2. Realize how the epigenetic code works in the human body.
Child neurologists have much ex posure to many different types of genetic conditions that lead to sleep-disordered breathing. For many years, the tonsils were the prime culprit. However, discoveries show more than simply the tonsils leading to the prob lem – the relationship of upper airway resistance, malocclusion, and the role of epigenetics also must be considered. An aligned body is essential to work ing with malocclusion. Malocclusion and broken teeth cannot be fixed on a body frame that is not in proper align ment. Concepts of craniosacral fascial therapy also are an essential component to treating sleep/breathing issues. All of these factors are a part of the study of epigenetics.
This self-instructional course for dentists aims to discuss the role of epigenetics and craniosacral-fascial therapies on sleep-disordered breathing. Expected Outcomes Dental Sleep Practice subscribers can answer the CE questions online at https://dentalsleeppractice.com/continuing-education/ to earn 2 hours of CE from reading the article. Correctly answering the questions will demonstrate the reader can:
4. Realize epigenetics’ role in periodontal medicine.
5. Identify the role of epigenetics in orthodontics.
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Epigenetics and Sleep Disordered Breathing by Amalia A. Geller, MD
1. Identify some characteristics of the science of epigenetics.
Figure 1: "The music of life" illustration of epigentics
Epigenetics is the study of phenotypic changes that occur via mechanisms that are not related to DNA sequence alteration. Epi genetics means that something is acting up on the Ingenome.2007, the human genome project was completed, and it was after this that the epigenetic code was recognized. Besides the ge netic code, we also have an epigenetic code that essentially tells the genes in our genet ic code when and where they are to be ex pressed. The simplest example of this would be what drives many different tissues to come from one specific cell line. The genetic code contains all the information that humans need to function, but it does not contain the pro gram that determines when and how genes are going to be expressed. The epigenetic code tells where genes are to be activated and de activated during embryogenesis and growth throughout our lives.
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What is Epigenetics?
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How Does the Epigenetic Code Work?
The epigenetic code works through chemi cal modifications and key elements — namely DNA methylation and histone-protein acetyl ation. Epigenetic modification also can be in volved in switching genes on and off by pre venting RNA and messenger RNA formation. These epigenetic modifications can be inherit ed from cell cycle to cell cycle dating back to grandparents, passed on to parents, to the cur rent generation, and passed on to our children.
According to SD Williams, et al., “it is our epigenetic code that allows genetically identi cal cells to express different patterns of genes.”
Factors that can lead to epigenetic modifi cations of our genetic code come from various sources such as the environment and emotion al adaptations to stressful situations — all of which can have an impact on our epigenetic code. An important clinical aspect of this is when certain populations appear to be more susceptible to certain diseases. This leads us into the medical issues of autoimmune dis ease, mental health issues, and cancers. The environment is a very important factor in this because of its capacity to regulate genetic ex pression.Another way to see this concept of epi genetics is in Figure 1 titled “the music of life.” The genetic code can be described essentially as the orchestra. The orchestra has different in struments played by different musicians. Many different types of melodies are produced from this orchestra. But without the conductor to interpret the music and conduct the orchestra, Amalia A. Geller, MD, is board certified in adult and child neurology and a Diplomate of the American Board of Psychiatry and Neurology. She is also board certified in sleep medicine, a Diplomate of the American Academy of Sleep Medicine, and ACGME fellowship trained in sleep medicine. Dr. Geller is currently in private practice at Polaris Neurology and Sleep, PLLC, is a Neuro hospitalist with Platinum, LLC, and is on staff at Summerlin Hospital in Henderson, Nevada. She received her medical degree from University of the East College of Medicine and has been in practice for more than 20 years. Dr. Geller did her adult and pediatric neurology training at the University of California San Diego and her sleep medicine fellowship training at University of Texas South western in Dallas. Her first exposure to the use of oral appliances for sleep disordered breathing was during her training and led to her own personal treatment experiences. Dr. Geller is the Nevada Medical Director for Nexus Sleep Systems.
emotionalsourcescomeourmodificationsepigeneticofgeneticcodefromvarioussuchastheenvironmentandadaptationstostressfulsituations.DSP| Fall 2022 CONTINUINGeducation
Epigenetics’ Role in Periodontal Medicine
In the field of periodontics, a complex sit uation exists with the interaction of the body’s immune system and the inflammatory respons es that lead to periodontitis. There is a genet ic predisposition to this inflammatory state.
Epigenetics involves genes and coding for the pro-inflammatory cytokines that are believed to be associated with periodontitis. A fascinating link has been made between periodontitis, HIV, and AIDS progression. Peri odontitis is believed to be able to reactivate HIV expression through an epigenetic medi ator. Research from the early 1990s indicated that HIV-associated gingivitis and HIV-associ ated periodontitis (HIV-P) were seen only in HIV patients. As discussed earlier, methylation is a very important epigenetic mechanism. An important epigenetic approved therapy in HIV involves DNA methyltransferase inhibi tors. These inhibitors target epimutations (the hypermethylation and epigenetic silencing of tumor suppressor genes/etiologies in human cancers). Essentially chemical modifications of DNA and histone proteins cause epigenetic changes that alter cellular function and host defenses.There is also increasing evidence to sup port the theory that periodontal disease can increase the risk of cardiovascular disease. That chronic inflammation is what leads to atherosclerosis. Dr. Hatice Hasturk of the Har vard-affiliated Forsyth Institute has identified compounds called resolvins that may be able to actually treat chronic inflammation asso ciated with periodontitis and atherosclerosis. Resolvins are molecules derived from ome ga-3 fatty acids that are believed to help sup press inflammation. Resolvin has been formu lated into a topical liquid. When Dr. Hastruk and colleagues exposed rabbits to a cholester ol-rich diet, they developed plaque. These rab bits were then introduced to a bacterium that is known to cause periodontal disease. The rabbits were then treated with Resolvin. They found that not only did Resolvin prevent peri odontal disease, but it lowered inflammation and atherosclerosis. Their hypothesis – control one type of inflammation, and you might be able to control another type of inflammation.
The history of the concept of craniofacial development connects it to epigenetics. The connections between dentistry and epigenetics have primarily been focused in the fields of periodontics and orthodontics. Over 100 years ago, certain Western societies’ diets consisted of high fiber, which required more chewing. Grandparents and great grandparents gener ations were more accustomed to eating cru ciferous vegetables and fruits. Over the years, craniofacial structures changed gradually due to dietary changes where children were offered more opportunities to eat soft foods, soft cereals, macaroni and cheese, etc. Envi ronmental elements such as socio-economic status and early developmental prenatal expo sures to toxins and chemicals definitely impact developmental outcome.
Epigenetics’ Connection to Oral Health
32 and without the sheet music, only noise will be produced. The conductor is the epigene tic machinery instructing the individual genes (musicians). The conductor tells the musicians when and how to play. The epigenetic code is the sheet music.
Pioneers in the field of epigenetics include: 1. Dr. Conrad Waddington (1942) devel oped the term epigenetics years before DNA was described by Watson and Crick in 1953. Waddington’s definition essentially pointed to something that Factors that can lead to
The Role of Epigenetics in Orthodontics
2. Dr. Melvin Moss developed the concept of epigenetic processes (mechanical loading) and the processes that cause these changes.
3. Dr. Theodore Belfor who invented the Homeoblock™ applicance device and POD device.
4. Dr. David Singh developed and invent ed the Vivos DNA appliance.
Another early pioneer in this area is Dr. Melvin Moss who tried to distinguish between epigenetic processes such as mechanical load ing and the processes that caused the changes. He described the macro environment, for ex ample joint loading, down to its involvement with DNA methylation. The force acting upon the jaw induces growth or re-modeling at the level of the condyle. Again, the key elements that the epigenetic code works through are chemical modifications of DNA methylation and histone-protein acetylation.
Dr. Belfor’s device that applies these prin ciples is called the Homeoblock with incorpo rated Unilateral Biteblock® technology, which generates a cyclical strain on the cranial sys tem when the patient swallows and bites on the block. This action causes osteocytes to generate osteoblasts that can generate new bone. The appliances with the Unilateral Bite block® technology make more room for the tongue and can strengthen the muscles that prevent airway collapse.
Another fascinating invention, a lower device also designed with the Unilateral Bite block® technology, is called the Preventive Oral Device (POD)™. The POD™ was FDA approved in 2019 and is designed for those people who suffer from TMD and bruxism. The POD™ allows for dental arches to remain out of contact with each another and allows the tongue to move forward and clear the pathway for breathing.
In epigenetic orthodontics, orthodontists are using the patient’s natural genes to correct Figure 2: Waddington's Epigenetic Landscape. Waddington's epigenetic landscape is a metaphor for how gene regulation modulates development. Imagine a number of marbles rolling down a hill toward a wall. The marbles will compete for the grooves on the slope, and the ridges between the grooves represent the increasing irreversibility of cell type differentiation. Each marble will come to rest at the lowest possible point, representing eventual cell fates, or tissue types. This concept has been more formalized in the context of a systems dynamics state approach to the study of cell-fate, which has opened the door to the key role played by stochastic fluctuation (cellular noise), as well as physical fields, in both cell differentiation and cell proliferation.
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The Moss Functional Matrix Hypothesis led to the concept that genetic control is as sumed to be outside the skeletal system. The orthodontic perspective believes that this is the actual epigenetics’ model and essentially changes that may occur in bone and cartilage are due to signals coming from other tissues. This concept is the basis for the epigenetics’ orthodontics which is also called functional orthodontics.
33DentalSleepPractice.com acts on the genome in order to regulate it (Figure 2).
Dr. Waddington’s definition of epigenetics was focused more on molecular mechanisms, but over time in the orthodontics world in particular, the intra-genomics chemical envi ronment is thought to be the location for epi genetic activity. Orthodontic literature focused more on the physical forces acting on the jaw that lead to remodeling at the condyle. Out side forces that act upon the jaw induce epi genetic changes that affect genetic expression.
The Role of Craniosacral Fascial Therapy
One of many great pioneers in this field of functional orthodontics is Dr. Theodore Bel for, who after 20 years of research developed an orthopedic/orthodontic appliance that in corporates proper breathing and swallowing practices. His approach is in somewhat of a contrast to Dr. Singh‘s DNA device that in volves focus on palatal expansion and widen ing of the upper jaw. According to Dr. Belfor, remodeling and repositioning the upper jaw is the focus, and not palatal expansion. The body provides a physiologic size and shape change known as maxillary morphogenesis which provides symmetry, balance, and proper jaw alignment. There are no genes for asymmetry. A true epigenetic appliance will provide max illary and cranial facial symmetry.
1. Founder of cranial osteopathy: Dr. William G. Sutherland and his student, Dr. Andrew Taylor Still, DO 2. Founder of cranialsacral therapy/identi fying the craniosacral pulse, Dr. John E. Upledger, DO 3. Founder of craniosacral-fascial therapy (Gillespie method), Dr. Barry Gillespie, DMD.
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In Future Articles
The concept of craniosacral fascial thera py is very important as it applies to fixing and correcting the occlusion which hopefully will help resolve sleep-disordered breathing. We must not forget the cranium, the neck, and the entire spine. The body’s balance and align ment is essential to for appropriate breathing and functioning as healthy human beings. The importance of understanding these concepts beginning at life and continuing through chil dren’s developmental stages, will ultimately lead to the prevention of these problems in adulthood.
The C.DSM certificate from ACSDD provides the necessary medical and dental knowledge to confidently approach physicians and seek insurance reimbursement. The certificate is a prerequisite for ACSDD Fellow and Diplomate.
The Academy of Clinical Sleep Disorder Disciplines is the only organization offering a fully online and on-demand certificate in Dental Sleep Medicine. Study the lectures and course materials at your own pace, then when you are ready, take the exam. 12 modules present both the medical and dental science of sleep medicine providing a solid foundation for understanding clinical applications. Most dentists are able to complete the 13 CE program in 4-6 months.
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2. Waddington CH. Canalization of development and the inheritance of acquired characters. Nature. 1942;150:563-565.
The certificate is a prerequisite for ACSDD Fellow and Diplomate
The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider at info@acsdd.org or to ADA CERP at www.ada.org/goto/cerp. This program has been submitted for approval by the ACSDD for a maximum of 13 credits as meeting general dental requirements.
3. Lund G, Zaina S. Atherosclerosis: and epigenetic balancing act that goes wrong. Curr Atheroscler Rep. 2011; 13(3):208-214.
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5. Moss ML. The functional matrix hypothesis revisited. 1.The role of mechanotransduction. Am J Ortho Dentofacial Orthop. 1997;112(1):8-11 6. Moss ML. The functional matrix hypothesis revisited. 3. The genom ic thesis. Am J Ortho Dentofacial Orthop. 1997;112(3):338-342.
Future articles will discuss the relationship of cranial-sacral fascial therapies. Pioneers in this field include:
7. Singh D. DNA Appliance. DNA Appliance. URL: https://dnaappli ance.com. Accessed July 11, 2022.
Also, in our upcoming articles, we will compare the different inventions by pioneers of this field, in particular the concepts and the ories between Dr. Singh‘s DNA device and Dr. Belfor’s device along with other pioneers in this area and their contributions to this exciting field of sleep dentistry.
The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. This program has been submitted for approval by the ACSDD for a maximum of 13 credits as meeting general dental requirements.
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34 and straighten the teeth in jaws with the use of biomimetic appliances. However, what is the role of preparing patients for these devices?
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The prime source for this article was Williams SD, Hughes TE, Adler CJ, Brook AH, Townsend GC. Epigenetics: a new fron tier in dentistry. Aust Dent J. 2014; 59 Suppl. 1.1:23-33.Feinberg AP. Phenotypic plasticity and the epigenetic‘s of human disease. Nature. 2007;447:433-440.
8. Yehuda R, Daskalakis NP, Desmaud F, Makotkine I, Lehrner AL, Koch E, Flory JD, Buxbaum JD. Meaney MJ, Bierer LM. Epigenetic biomarkers as predictors and correlate of symptom improvement following psychotherapy in combat veterans with PTSD. Front Psy chiatry. 2013; 4:118.
4. Lucassen PJ, Naninck E FG, van Goudoever JB, Fitzsimons C, Joels M, Korosi A. Perinatal programming of adult hippocampal struc ture and function: emerging roles of stress, nutrition, and epigene tic‘s. Trends Neurosci. 2013;36(11):621-631.
and
Epigenetics and Sleep Disorded Breathing by Amalia A. Geller, MD Continuing Education Test AGD Code: 750 Date Published: August 15, 2022 Course Expires: August 15, 2025 Legal disclaimer: Course expires 3 years after publication date. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional. CONTINUINGeducation
a. The basis lies in molecular mechanisms. The mechanism lies in physical forces acting on the job that lead to remodeling at the condyle. c. The mechanism involves genetic control outside the skeletal sys tem. both a and b
Each article is equivalent to two CE credits. Available only to paid subscribers. subscriptions do not qualify for the CE credits. Subscribe and receive up to 8 CE credits for only $149 by visiting https://dentalsleeppractice.com/subscribe/. receive credit: Go online to dentalsleeppractice.com/continuing-education/, click on the article, then click on the take quiz button, enter test answers feedback on this article and CE, email us at education@medmarkmedia.com.
__________ a.
b.
6. Epigenetics orthodontics is also referred to as functional orthodontics. a. True b. False
1. The definition of epigenetics is Studying phenotypic changes that occur via mechanisms that are related to DNA sequence alteration. Studying phenotypic changes that occur via mechanisms that are not related to DNA sequence alteration. The study of inflammatory markers related to resolving molecules derive from omega-3 fatty acids. None of the above
d.
9. A therapeutic approach that focuses on correct inclusion by also addressing misalignment in the cranium, neck and spine is called a. Cranial osteopathy b. Cranialsacral facial therapy c. Pneumopedics d. All of the above
b.
35DentalSleepPractice.com
d.
c.
Free
To provide
d.
7. The preventive oral device also known as POD, is designed for which conditions ____________. a. Obstructive sleep apnea b. TMD and bruxism c. Palatal expansion d. All of the above 8. The homeoblock device works by which mechanism of action? a. Palatal expansion b. Expansion of the maxilla, and strengthening the tone of the upper airway to cranial myofascial therapy techniques. c. Generates intermittent pressure on the teeth that allows the pa tient to swallow, this allows bone cells to respond by changing the shape of bone in the cranial facial area. d. both B and C
4. The Moss functional matrix hypothesis describes _______ a. Genetic control that is outside the skeletal system. b. That the macroenvironment (for example) joint loading down to its involvement with DNA methylation is the force that acts on the jaw. c. The action on the job decreases growth and remodeling at the condyle level. a and b
n To
5. What is the most accurate description from the orthodontic perspec tive of the epigenetic model: a. Changes can only come from bone in cartridge. b. The epigenetic model involves changes that may occur in the bone and cartilage due to signals coming from other tissues. c. There is no difference between the Moss functional matrix hy pothesis and the orthodontic epigenetic model. d. None of the above.
2. The epigenetic code works by __________ a. Chemical modifications through DNA methylation and histone protein acetylation. b. DNA methyltransferase inhibitors c. Resolving molecules that decrease chronic inflammation. All of the above 3. Define Dr. Waddngton’s definition of epigenetics ______
10. An important approved therapy that is used in HIV that relates to the concept of the epigenetic model is called ________ a. Tricyclic compounds b. DNA – methyltransferase inhibitors c Sulfa urea compounds All of the above
d.
CE CREDITS
your
d.
For a mandibular advance ment of around 9.5mm (the actual MAD set tings measured according to the methodology developed by Bruno et al. (2020), a force of 11.18 N per splint has been considered.’ Manila Caragiuli, 2021. Whether the MAD is pushing or pulling the lower jaw, the minimum force needed will be of the same intensity. To control this intensity, the force’s application points, orientation, and direction can be carefully selected. Con trolling force intensity reduces undesired side effects such as tooth movement and muscle and TMJ
• In the occlusal plane
• Titration systems in the occlusal plane minimizes the force required to main tain the lower jaw’s protrusion
• Bilateral with no central application point
The Pythagorean Theorem explains why titration systems connected by a diagonal applies more force than necessary on the masticatory system and increases the risk of undesired side effects. If the only force being considered was gravity, at 9.81 newton (Figures 1 and 2):
Centralpain.connector systems apply strong pressure on the incisors (A) especially if there is only a single application point (D).
• Central connecting systems which are located on the incisors creates maxi mum force on fragile teeth
Mandibular advancement devices function by mov ing the lower jaw (mandible) forward. Accordingly, moving any object implies that a force is applied (Newton’s Law). This law applies to any mechanical systems.
• Four application points divide the force on strong teeth This system reduces risk of short term tooth movement (B. Navailles, Ch.Valence, 2016). This brief overview discusses a single mechanical concept. It does not discuss other parameters such as leverage effects on the TMJ, material selection and its impact on forces dis tribution. These and many other factors must be considered by the dental sleep specialist when selecting an appliance.
Table 1: For a mandibular advancement of around 9.5mm at a constant force of 11.18 N forces developed by MAD.3,4 The pressure generated may vary depending on the patient and the protrusion, but the trend remains the same. Classic titration
• Bilateral connectors with no central application point spreads the force on both sides
The Forces Behind Mandibular Advancement Devices (MAD): A Brief Explanation
36 DSP | Fall 2022 PRODUCTspotlight
Sparse literature has investigated the forces developed by a MAD. This paper correlates the force magnitude experimentally measured by Cohen-Levy et al. (2013) using a pressure transducer applied to a MAD with the various device designs.
Fig. 3: Panthera
Bilateral connectors apply less pressure (B-C-D) then central connectors. Bilateral connectors in the occlusal plane apply the least pressure (C). An oblique bilateral connector with four application points (B) applies more pressure than a bilateral connector in the occlusal plane with two application points (C). Why?
To find out more about or D-SAD Classic, visit Referenceswww.pantherasleep.com.availableondentalsleeppractice.com.
FigureFiguresystem21
• Multiple application points divide the forces
The laws of mechanics provide four con clusions regarding titration system:
According to Caragiuli et al., ‘A central connector mechanism discharges the force mainly on the anterior teeth. In contrast, a lateral connector system better distributes the force and affects molars and premolars primar ily, and more uniformly’.3 Taking this into account, Panthera Dental selected the following titration system for the D-SAD Classic MAD (Figure 3).
by Diane Robichaud, Dental technician and member of the R&D team, Panthera Sleep Division
Although patient directed forms and questionnaires paint a pic ture of health or disease, quantifiable numeric data provides a clearer view of patient conditions. We see this in such technol ogies as CBCT, MRI, and the increasingly common non-invasive technologies used in offices across the country. While there is a helpful emotional component in patient directed tools, objec tive measurements have added value to direct better care and outcomes. Let’s set the record straight about what they are, how they are used, and the value they bring.
Objective measurements have been de veloped to become validated, standardized tools for screening and quantifying patient complaints. The concepts have been around since 1894; in 1958, Semarak described the first “Nasal Patency Assessment Device” that enabled simultaneous assessment of na sal respiratory flow and pressure difference between the nasal entrance and choanae. In 1968, Dr. Cottle, whom we all know by the “Cottle Maneuver”, introduced rhinoma nometry to clinical rhinology. To further ex tend the history, Dr. Christian Guilleminault looked at maxillary expansion and rhinome try in 2004. Nasal resistance was part of sev eral of his studies for AHI correlations and proper identification of patients for various therapies, including DOME and CPAP intol erance, as far back as 2012.1-3
Acoustic Rhinometry
Can you trust what the patient tells you? The topic of dis cussion at meetings has moved from sleep disorders to breathing disorders and now to nasal resistance. Subjec tive assessments like patient directed questionnaires have been a validated form of understanding what motivates the patient to seek out healthcare providers from primary care to dentists.
Objective theMeasurements:AirwaySettingRecordStraight by Karen Parker Davidson, DHA, MSA, MEd, MSN, ARPN
38 DSP | Fall 2022 CLINICALfocus
Acoustic Rhinometry was validated as a tool for geometric measurements in 1989 by Hilberg et al., and first came to market in 1993 by Hood Laboratories (K921452), later purchased by Sleep Group Solutions (SGS), followed by GM Instruments, Ltd. (K972140) in 1998.4 To date, these are the only two manufacturers with FDA approved devices that measure the cross-sectional area of the nasal passages to assess static volume
Why Haven’t You Heard about Using Objective Measurements?
These measurement devices, ranging in retail price from $63-$38,000, are used to measure the pressure-flow relationship in nasal breathing, the location of obstruc tions, and the extent obstructions and nasal breathing are disrupted in adults, children, and even small animals pre, mid, and post treatment or therapy. It is a common opinion across all specialties that nasal flow limita tions cause nasal obstructions resulting in a sequela of events to include TMD, postur al problems, an increase in the Hypopnea/ Apnea ratios, and sleep disordered breath ing. Many of these clinical presentations lead to a hypoventilative state and obstruc tive sleep apnea (OSA) if left untreated. Ob jective measurement technologies have been on the market for more than 20 years and published in over two thousand medical and dental journal articles; however, they may be misunderstood in their function, theory, and application. The purpose of this review is to discuss each type of measurement tool, where it is most useful in the clinical work flow, and the effect it can have on blurring the line between medicine and dentistry.
DSP | Fall 2022 CLINICALfocus
Figure 1: A1 Acoustic Rhinometer (GM Instruments) Figure 2: Eccovision Rhinometer (Sleep Group Solutions) Figure 3: NR6 Rhinomanometer (GM Instruments)
40 and anatomical landmarks. While the patient holds their breath, the acoustic pulse sound waves are generated from a speaker or spark source, travels through the nose reflecting from the mucosal surface, picked up by the microphone in the sound tube, back to am plifier, and to the measurement software for interpretation. Two landmarks in the mea surement are minimal crossectional area, MCA, or crossectional area, CSA1, at the in ternal nasal valve (INV) and MCA or CSA2 at the inferior head of the anterior turbinate. The main advantage is that this is a noninvasive and quick test, depending on the brand and company technology, and can be done in an office, OR, or hospital. The disadvantage is the accuracy is dependent on the interface of the nose and equipment by way of the shape of the nosepiece, (round versus anatomical), and positioning of the tube.
Rhinomanometry Rhinomanometry, unlike rhinometry, is a form of manometry that uses pressure and flow sources from a transducer box to ob jectivly measurement nasal function by the intranasal pressure and the rate of airflow during active breathing. Four-phase ante rior and posterior rhinomanometry (GM Instruments, Ltd.), FDA approved in 1990, (K902120) is the only non-invasve, param eter-based technology for measuring nasal function in the sitting and supine postions. In 2010, the Standardization Committee on the Objective Measurement of the Upper Airway published 4-Phase-Rhinomanometry Basics and Practices in the Supplement of Rhinol ogy. In 2015, the Committee updated the standards of practice to declare classic, non 4 phase, rhinomanometry obsolete and con firmed subjective symptoms comparable and compatible to 4-phase rhinomanometry.5 The first measurements of nasal flow limitations were taken in 1894 with the use of a refrig erator plate to measure the amount of vapor in exhaled air, the first rhinomanometer did not become computerized until 1970. Over time, transnasal pressures and the correlation to OSA and disease progression have been studied as many in the medical field find AHI losing relevance as the primary diagnostic metric of OSA.6,7 Pharyngometry Pharyngometry, much like rhinometry, uses sound pulse waves to measure the geo metric area of the nasopharyngeal airway down to the glottis, resulting in static mea surements. Most commonly known as EccoKaren Parker Davidson, DHA, MSA, MEd., MSN, ARPN, for over two decades has held many positions in the medical device industry in the ENT and Sleep markets, in addition to thirty years of clinical experience to include service as a Critical Care Nurse and Flight Nurse in the US Air Force Reserves. Dr. Davidson is adjunct faculty at Liberty University and Central Michigan University, founder of FACT Healthcare Consulting Group, and creator of the patent pending DAFNE Score System to guide and educate healthcare providers the values of objective nasal function and treatment options and improvements based on the readings. She is published in medical journals discussing airway disorders, a coauthor of “The Power of the Tongue In the Beginning, We Were All Tongue Tie” and “Sleep Apnea and Pregnancy: The Female Response to Sleep Breathing Disorders”, a contributing author to “Growing Into Breathing Problems: The Quest for Collaborative Life Time Solutions” and “Health Informatics and Patient Safety in Times of Crisis”, and the author of an upcoming book, “Breathe Through Your Nose, Don’t Pay Through It: The Impact the Healthcare Industry has on Nasal Function and How We Breathe”.
42 vision, it came to market in 2002 by E. Benson Hood Laboratories (K011329) then aquired by SGS soon thereafter. Popular in ENT for voice and laryngeal cases, it has made its way to the dental market as a tool for measuring the airway and positioning the mandible for oral appliance therapy. Although it may be a screening tool for OSA based on the Starling resistor model and volumetric measure ments, it does not correlate to collapsability, which is based on a pressure-flow relationship. Furthermore, clinical obser vations and studies suggest that anatomi cal factors alone do not cause OSA.
1. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761-766. doi:10.1093/sleep/27.4.76
4. Hilberg O, Jackson AC, Swift DL, Pedersen OF. Acoustic rhinometry: evaluation of nasal cavity geometry by acoustic reflection. J Appl Physiol (1985). 1989;66(1):295-303. doi:10.1152/ jappl.1989.66.1.295
5. Vogt K, Wernecke KD, Behrbohm H, Gubisch W, Argale M. Four-phase rhinomanometry: a multicentric retrospective analysis of 36,563 clinical measurements. Eur Arch Otorhinolaryn gol. 2016;273(5):1185-1198. doi:10.1007/s00405-015-3723-5
6. Pevernagie DA, Gnidovec-Strazisar B, Grote L, et al. On the rise and fall of the apnea-hypopnea index: A historical review and critical appraisal. J Sleep Res. 2020;29(4):e13066. doi:10.1111/jsr.13066
2. Iwasaki T, Yoon A, Guilleminault C, Yamasaki Y, Liu SY. How does distraction osteogenesis maxillary expansion (DOME) reduce severity of obstructive sleep apnea? Sleep Breath. 2020;24(1):287-296. doi:10.1007/s11325-019-01948-7
How Do I Integrate These Technologies into My Clinical Practice and Workflow?
Figure
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3. Toh ST, Lin CH, Guilleminault C. Usage of four-phase high-resolution rhinomanometry and measurement of nasal resistance in sleep-disordered breathing. Laryngoscope. 2012;122(10):2343-2349. doi:10.1002/lary.2344
7. Hoel HC, Kvinnesland K, Berg S. Impact of nasal resistance on the distribution of apneas and hypopneas in obstructive sleep apnea. Sleep Med. 2020;71:83-88. doi:10.1016/j. sleep.2020.03.024 4: Pharyngometer (Sleep Group Solutions) 5: Peak Nasal Inspiratory Flow (PNIF) Meter (GM Instruments)
Peak Nasal Inspiratory Flow PNIF, Peak Nasal Inspiratory Flow Meter, is the most cost-effective device for measuring nasal inspiratory function only. The device is provided to the patient to take home to self-assess nasal airflow. The PNIF meter can be utilized to rapidly assess the patency of the nose. It utilizes a variable diameter tube adjusted in liters/ minute alongside a low inertia marker ring, whose position after an inspiratory maneuver shows the greatest flow ac complished. Precise measurements are Plus/Minus 10% of the reading or 10 L/ min flow (whichever is the more prom inent), with repeatability of plus/minus 5%. Product life expectancy with typical utilization is to stay operational for two years and is a great option for patient fol low-up, using telehealth.
By understanding the indication and the ory behind each technology, dentists and medical professionals who specialize in air way can add them as a screening and treat ment assessment tool for therapy identifica tion and improvement at various endpoints. It is equally important to understand that none of them are used to diagnose airway problems or OSA, but correlate to breathing problems that progress to hypoventilation or OSA. For example, breathing during acoustic pulse sound wave measurements can cause a testing error as noncartilaginous tissue will vibrate during active breathing. Positional and postural changes also cause errors in testing, too. Any volumetric change caused by forward head posture, C-spine lesions, shoulder injuries, or spinal injuries, to name a few, will affect a pharygnometry reading by mimicing a smaller airway. The same holds true with rhinomanometry and nasal func tion measurements during breathing. If the test is not measured in the natural state or with the head over the shoulders, what was once a normative mean resitance value can increase with postural changes, mimicing high resistance that may indicate a problem that was not clinically present. Additionally, in testing, recumbent positions affect nasal resistance and airflow limitations – important considerations in snorers and sleep apnea patients.Itisevident based on a number of studies that nasal resistance is an undervalued and overlooked biosignal that affects maxillary growth in children and the mandible posi tion in children and adults. Essentially, nasal resistance data has given the sleep and air way community something to talk about. Each of the these objective measurement devices, proven with validation, specificity, and senstivity studies, has potential value as an assessement tool in trained provider’s hands. Dental practices can develop improved clini cal workflow by quantifying therapy selection and outcomes. Measuring airflow can be an additional reimbursable revenue stream for a mutually beneficial experience between the doctor and patient.
Figure
Success in Sleep Through the Power of Teamwork Your Success is Our Goal Join DreamSleep – a nationwide network of dentists & physicians fighting sleep apnea. Our Whole Patient Program is a comprehensive plan that empowers dental practices with the knowledge, resources, and tools in order to provide patients with the highest standard of care for dental sleep medicine. The Whole Patient Program consists of four principles: Raise public awareness of Obstructive Sleep Apnea, DMSD, TMD, migraine and associated symptoms; train dentists to work with physicians and implement medical treatments; create screening and therapy programs for the industry; and connect patients with providers. Through state of the art, individualized training and implementation processes, we help you seamlessly integrate these medical treatments into your dental practice to increase your patients’ quality of life and add a valuable revenue stream. Call 844.363.7533 today for details. 844.363.7533 | n3sleep.com | dreamsleep.rest Comprehensive education for you and your whole team. Exclusive tools and technology to help you stand out and succeed in sleep. Join our nationwide network and get referrals from our exclusive contracts. Limited Time For a limited time only: in Baltimore for a FREE network with the most obstacles to treatment help you integrate dental providing the education, Education Comprehensive education you and your whole team: •Online, on-demand academic certification •Individualized training programs • In-office clinical training •Team •Physician•Medical•Practice•ScreeningCoachingManagementSystemsBillingCommunication Call *Device pictured for illustration purposes Contract required, additional conditions Education Tools Patients >>
44 DSP | Fall 2022 PRODUCTspotlight
HealthyStart’s Disruptive Software Solution for Pediatric Sleep-Disordered Breathing
As a platform, this solution focuses on processes that must be completed and data that must be collected, which is all that a doctor needs to successfully treat these types of cases. Many doctors have expanded diagnostics in their practice; this platform features capacity to include ceph and CBCT analyses, sleep tests, and communication with collaborative providers such as ENTS, pediatricians, sleep physicians. It really is a one-stop-shop for comprehensive manage ment of patients and their comorbidities.
Telemedicine Functionality
H ealthyStart (HS) has been a leading influencer in the dental space for decades, innovating new diagnostic and therapeutic solutions related to growth and devel opment, sleep, airway and breathing, and oral healthcare.
The HealthyStart System has evolved into an A-to-Z solution for pediatric airway and sleep health. It is built to support doc tors who have never treated these types of cases, educating them on the diagnostic and screening components, as well as the ther apeutic modalities available to the clinician for treatment HealthyStartplanning.launched the first and only comprehensive pediatric sleep-disordered breathing, early intervention orthodontic soft ware platform. The tools included are built to be seamlessly incorporated into generalists’ and specialists’ practice flow, but they have enhanced features to capture the critical data specific to pediatric SDB patients that other wise would be lost in clinical notes and not readily available to visualize improvement over time. It can also standalone as a doctor’s go-to solution for HIPAA compliant patient documentation and management, pending practice preference for organization.
The efficiency, predictability, and stability of HealthyStart’s system of patient screen ing and intra-oral appliance therapy have been validated through decades of clinical research,1 case studies, and testimonials by providers and patient families. Pediatric patients with symptoms of sleep-related breathing disorders, severe malocclusions, and deficient craniofacial development can be successfully treated with the HS appliances without prescription medications, surgeries, prolonged fixed orthodontics, and other inva sive therapeutics that often introduce a litany of undesirable side effects and no guarantee of achieving the target outcome.
HealthyStart’s newest advancement includes proprietary soft ware aimed at optimizing patient outcomes and increasing par ent engagement while streamlining practice management and maximizing chairside efficiency.
by Beth Rosellini, DDS, AIAOMT
Figure 1: HealthyStart’s comprehensive orthodontic software platform features an array of tools to aid practices in treating their Sleep Disordered Breathing patients.
A key component of the new software is telemedicine functionality to facilitate remote management of patients, improving patient compliance and maximizing profitability.
Build Your Own Educational Program to Treat the 9 in 10 Children Exhibiting Symptoms of Sleep Disordered Breathing! Full 4-Week Digital Series (Or Live) 18 CE Credits (16 CEs for Live) 1 Free Habit Corrector 30-min Blueprint Meeting Sample Display Stand ($75 value ea.) Name/Location on HS Website Free Full Case (Exp. in 6 months)** Free 30-min Private Mentorship ($145 value ea.) Live Course for Doctor + 3 Staff ($300 for Each Additional Staff) 5% off 6-month or 10% off 12-month FreeMentorshipHabitCorrector With Each Paid Case Submitted Within First 3 Months Basic$2,800 Standard$3,400 Deluxe$4,000 11 22 Package Features 30/60-min Mentorship Session $150/$250* Full Case $650* Add-Ons / Customizations Save $1,795! Save $2,090! Lecture ONLY $2,000*Max A, Class III, Habit Corrector $100 ea.* Live Course $1500 Sample Display Stand + Appliances $75 regular price: $125 ea.regular price: $750 for additional associates with package purchase Stand and appliances shipped after Blueprint Meeting Open-Bite OverbiteOverjet / Thumb Sucking Crowding *Add-ons / customizations marked with asterisk are only available at time of course purchase - NO EXCEPTIONS **The expiration date on free case(s) is not a hard date and can be changed if needed. Please discuss with our Support Team if you need to alter the date. Turn to page 44 to learn more about HealthyStart's Customized Educational Program to treat children with SDB and straighten teeth without braces. 844-KID-HEALTHY www.thehealthystart.comcontact@thehealthystart.com
Metadata Analysis Enhances All Outcomes
Ongoing Case Support
The HS software allows comprehensive and individualized feedback to providers on all cases, from start to completion. This fea ture is intended to support newer providers who have less experience, but also to build confidence of more experienced providers so they are inclined to take on more com plex cases. There is no limit to the number of questions that can be asked through the duration of a case, and feedback is tailored to specific patient needs and the doctor’s skill set and clinical preferences.
tion Age has ushered in an era in which con versations related to diagnosis and treatment planning go far beyond in-office patient edu cation and informed consent. Patient families are constantly googling questions, streaming related content, and communicating directly with each other. It is a double-edged sword, in that fortunately it is an indicator that fam ilies are proactive in helping their children while at the same time exposing an increased potential for sharing inaccurate information or accurate information that is not applicable to a certain HealthyStartindividual.hasleveraged this trend to maximize global results. With 40,000 follow ers on various public social media accounts and hundreds of private doctor forums, the HS team participates in conversations with parents and providers alike to share evi dence, best practices, expectations, etc. Even better, because those in the groups share a common philosophy that prioritizes preven tive health, many of the parents of children in HS and clinical team members who use the system jump in and provide additional support, feedback, and camaraderie.
1. https://dentalsleeppractice.com/healthystart-nearly-60-years-of-innovations-new-technology-and-now-plans-for-the-future/
Digital Education Platform
Figure 3: A HealthyStart patient wearing the first appliance in the HealthyStart System, the patient before and after treatment
Growing Online Community
Whether doctors like it or not, the Informa
DSP | Fall 2022 PRODUCTspotlight
Beyond increased engagement, providers have access to ongoing monitoring of symp toms and can confirm the case is progressing as predicted or, alternatively, can escalate concern to avoid a delayed response. All of this works so providers can focus on the high impact needs of their patients while physically in the office, but otherwise can allow patients to do the work at home with the HS tools.
FigureHabit-Corrector.2:AHealthyStart
46
The HealthyStart (HS) Parent App adds tremendous value to patient families in treat ment by prompting parents to monitor more closely a child’s progression via completion of the Sleep-Disordered Breathing Question naire and uploading clinical photos from home every week, instead of only capturing this data on a monthly or quarterly basis in the dental office. The child benefits from the parents being more actively engaged in their at-home therapy. Documenting symptoms and taking photos create tangible metrics to monitor so that the provider is not limited to an oftentimes short, subjective report at the following in-office visit.
The Digital Education Platform is a unique learning environment that combines digital and live courses incorporating “hands on” treatment with weekly Friday Forums to provide practical case, practice, and compli ance tips.
While continuing to lead this industry, HealthyStart recognizes the importance of ongoing evaluations of clinical outcomes and patient and doctor experiences. Anon ymous metadata crowdsourced through participating practices is being deployed to verify alternative hypotheses and to continue to iterate improvements for enhanced clini cian and patient functionality. It is those of us who are harnessing the momentum of the data science who will continue to exceed patients’ expectations and deliver the best clinical solutions of tomorrow.
Beth Rosellini, DDS, AIAOMT, is a biological dentist and clin ical researcher with special interest in chronic inflammatory conditions, airway and sleep health, and alternative/non-phar maceutical therapies. She has completed her accreditation with the International Academy of Oral Medicine and Toxicology and has been selected as a speaker and educator in this space. She’s served as the principal investigator on studies funded by the National Institutes of Health, and she’s currently managing 2 ongoing clinical studies that are using the HealthyStart® System to evaluate clinical outcomes in more complex pediatric Down syndrome cases, as well as in children who suffer from chronic seizures.
Meeting With the Global Leader of Pediatric Dental Sleep Medicine:
48 DSP | Fall 2022 EDUCATIONspotlight S
Dr. Audrey Yoon
In some instances, craniofacial deficient development and malocclusions may negatively affect the onset of sleep disorders. So, it’s great that there is a doctor who has put a lot of effort into treating kids who have problems with proper sleep. Please meet Dr. Audrey Yoon, a dual-trained orthodontist and pediatric dentist specializing in sleep medicine.
Audrey Yoon, DDS, MS, is a dual trained orthodontist and pediatric dentist. She is also a diplomate of American Board of Dental Sleep Medicine and diplomate of American Board of Orthodontics. She is an adjunct assistant professor at Stanford University Sleep Medicine Center, an adjunct assistant professor in Orthodontics at University of Pacific and also a co-director of Pediatric Dental Sleep Mini-residency program at Tufts University. Dr. Yoon has worked on a pioneering technique, performing maxillary distraction os teogenesis for the treatment of OSA and has co-authored chapters in several leading textbooks. Currently her active areas of research include craniofacial growth modification, customized distraction techniques, surgery-first ap proach of maxillomandibular advancement surgery technique, and the ge nomic study to identify genetic anatomical factors relating to OSA.
A commentary from Dr. Audrey Yoon regarding her recent publications: “We, den tists and orthodontists, have the ability to change the trajectory of growth when inter ventions are implemented at the right time, targeting the right structure. I developed the strategies used for targeted therapy at dis tinct developmental stages to maximize the growth potential and improve the growth pattern more favorable. It is time to approach pediatric OSA from a phenotypic focus.”
leep disorders are very common and significant problems which are often undiagnosed and untreated. Have you ever wondered what the most vulnerable but unrecognized population category of sleep disordered breathing? It’s children.
In the case of a child experiencing sleeping disorder from a very early age, they may naturally develop many comorbidities. For example, they might get cognitive developmental delay, cardiovascular diseases, various mental disorders, craniofacial deformations, and/or many other pathologies.
ter guideline is the first of its kind to be used by medical practitioners of all specialties on an interdisciplinary team for helping many patients develop a natural healthy sleep.
She teaches this growth modification pro tocol in the curriculum of the Tufts University Pediatric Dental Sleep Mini-residency. This program is the first university-based pediatric dental sleep mini-residency program using an evidence-based hands-on workshop to educate global leaders in this field.
Dr. Audrey Yoon has mastered and provided a full scope of non-surgical and surgical orthodontics techniques for airways management including air way growth modification, oral appliances and clear aligner therapy for sleep apnea. She uses pediatric palatal expansion, surgical orthodontic treatment of MMA (Maxillomandibular Advancement), customized MARPE (Minis crew-Assisted Rapid Palatal Expansion), DOME (Distraction Osteogenesis Maxillary Expansion), and many others protocols to develop customized treatment plans for each individual depending on the diagnoses. Within the past decade, Dr. Audrey Yoon has pioneered a growth mod ification protocol for those children who face various challenges of sleep disorders breathing. Following her guidelines, dentists and orthodontists can implement some modifications during the growth of craniofacial struc ture to achieve significant changes in the patient’s growth patterns and help diminish or eliminate their sleeping problems. Currently, this structural mas
Dr. Yoon has also established the World Dentofacial Sleep Society (WDSS) this year and currently serves as a founding co-pres ident. WDSS is an international non-profit organization for dentists to raise the aware ness of the global public health problem of sleep disorders from early childhood to adult. It aims to promote education for the screening, diagnosis, and multidisciplinary treatment modalities and to advance research between professional organizations in the field of sleep. We are looking forward to further inno vative work from her to advance the field of sleep medicine.
ModuleMEDICINEI:Live-StreamedOnline Friday, December 9, 2022 Friday, February 24, 2023 Friday, March 31, 2023 Module II: On Campus *Date Change* Friday - Sunday, June 9-11, 2023 Mini-Residency Registration open! Space is limited. Savethedates!DentalSleepMedicineMini-ResidencyModuleI:Live-Streamed October 13-15, 2022 Module II: On Campus January 19-21, 2023 Module III: On Campus April 20-22, 2023 TMD & Orofacial Pain Mini-Residency Module 1: Live-Streamed - September 10, 2022 Module II: On Campus - November 17-19, 2022 Module III: Live-Streamed - February 4, 2023 Module IV: On Campus - March 2-4, 2023 Module V: Live-Streamed - April 1, 2023 Module VI: On Campus - May 25-27, 2023 2022-2023 Further questions, please contact ordentalce@tufts.edu617-636-6629 dental.tufts.edu/CEPEDIATRICThis course is designed to bring awareness to the importance of early intervention in treating pediatric SDB. This first-of-its-kind program will help dentists understand the basics of normal sleep maturation, respiratory physiology, and craniofacial development throughout childhood.
that Dr. Zelk and I train dental offices through the AIR Institute, and have shared this system with many offices throughout the country.
Joseph Zelk, DNP, FNP, BC, CBSM, DBSM, D.ABDSM, is dou ble board certified in Behavioral Sleep Medicine. Dr. Zelk is currently licensed in Oregon and Washington providing sleep specialist services to dental sleep medicine offices in both states. He has nearly 20 years of experience treating patients with PAP therapies and oral appliance therapy. He has contrib uted to patented oral appliance technologies; is creator and early adopter of combination therapies to improve patient adherence to PAP therapies; and coined the use of Hybrid Positive Airway Pressure (HPAP) therapies. He is currently lecturing nationally on sleep disorders and consulting on new FDA clearance projects for novel OSA treatments.
Less Time Between Screening & Treatment with a Trusted Partner
Building trust between a dentist and a sleep physician means sharing reliable data. We chose a high-quality true Type II sleep test ing device (Zmachine Synergy) and its shared inter-office portal so we could have confidence our patients were not being shortchanged.
Has your dental sleep practice ever been slowed down by sleep clinics taking so long to get your patients studied, interpreted, and sent back for treatment? It sure frustrated me until I found a way around this problem by bringing a sleep clinic into my general dental practice, Hillsboro Dental Excellence, outside of Portland, Oregon. By partnering with Dr. Joseph Zelk, a board-certified sleep specialist that is licensed in Oregon and Washington, I made the process easy. Dr. Zelk owned a sleep practice in Portland and had an active base of over 15,000 patients, so he needed me, too. I was drawn to bring Dr. Zelk into my practice because he is a champion of alternative therapies to CPAP, like man dibular advancement devices, Nightlase, and other therapies that can be done only by dentists. We both have a passion for helping patients get the best treat ment options available for their specific needs. Working with Dr. Zelk, I can efficiently and affordably screen, test, diagnose, and obtain letters of medical necessity for alternatives to CPAP, often within one week. Since integrating a sleep specialist service into my practice, I have been able to screen and diag nose 6 patients per week on average. This allows me to keep the excitement going with the patient and not watch them fall off like other patients who depend on the traditional sleep referral process. In many communities, it can take months just to get a sleep test! Our process and work flow is so efficient
50 DSP | Fall 2022 PRODUCTspotlight
Between the CBCT, comprehensive photo graph series, intraoral scans, and a Type II sleep test device, we are able to gather enough data to make not only a sleep breathing diagnosis, but to have a good understanding of which treatment modalities may work for the patients who do not wish to use CPAP. The Zmachine portal allows for the screening, sleep records and images to be shared among the dental office, the sleep specialist, and other collabo rators (e.g., ENT, oral surgeon, myofunctional therapist) to provide our patients with truly collaborative, multidisciplinary care.
Zmachine Synergy
by Drs. Geoffrey Skinner and Joseph Zelk
Dr. Geoffrey Skinner is a key opinion leader and board mem ber of the American Academy of Clear Aligners, a Diplomate of the American Board of Dental Sleep Medicine, a Winner of the Invisalign Reingage Doctor of the Year, and the creator of six top-selling and top-rated dental apps used by over 150,000 dentists worldwide. Dr Skinner is a diamond Invisalign provid er and key opinion leader for Candid Pro and Fotona. Dr. Skinner practices with Dr. Joe Zelk on the west side of Portland, Oregon.
The Zmachine Synergy is a nine-channel Type II home sleep test (HST). I chose the Zmachine because it is easy to use by the patient and provides more clinical data than other devices while also being very affordable for the dentist. I did not need to sacrifice data for cost. The single-channel three-lead EEG provides a true AHI by recording the actual sleep time. Due to its affordability, I also use the Zmachine for titration. The combination of working closely with a local sleep physician and the many benefits that the Zmachine Synergy provides allows Dr. Zelk and I to screen and treat patients more efficiently and affordably. More people are breathing better during sleep – that’s what it’s all about.
Pre-Filter Gas MediaPhaseFilter HEPA Filter Directional Airflow design ensures contaminants are removed at the source and replaced by fresh, clean air. Clean toreturnedairhallway Aerosols collected at source Eliminate Airborne Threats Air Quality Guard is a Clean Air System Designed for the Unique Challenges of Dental Practices Air quality is CRITICAL to your practice. Contaminants are everywhere: Pathogens, Pollutants, Viruses, Bacteria & Fungi all threaten our air quality and quality of care. Benefits of Air Quality Guard: • Arm and ceiling intakes capture aerosols at the source and move them away from occupants • Contaminated air is filtered through a 3 layer system, removing greater than 99.99% of all contaminants • Reduces the spread of COVID-19 and reduces sick leave • Negative pressure airflow cycle ensures that contaminants are captured before they can circulate • Quietly and efficiently filters & replaces up to 100% of air with pure, clean air • Power ful enough to replace all the air in the room every 7 minutes* *Based on recommended system design principles. Customization may increase or decrease this value. Learn More and Request a Consultation Today! (800) 210-9768 | support@airqualityguard.com | www.airqualityguard.com
52 DSP | Fall 2022 PRODUCTspotlight
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How do you give the tongue more room during sleep? Slow Wave Engineering dis covered through rapid prototyping using 3D printing that the “secret sauce” is to provide at least 8mm of vertical opening and at least 30mm of horizontal or lateral room. Any thing less won’t cause the tongue to posture forward during sleep. 8mm of vertical opening leaves lips closed and still encourages optimal nasalButbreathing.thetongue is not the only problem for people who suffer from OSA. Environmental conditions and sleep position itself make up the other 20% of the problem. People who drink alcohol before bed, take certain med ications, or get exposed to chemicals during the day, are going to have issues with nat ural sleep patterns. Learning to avoid what bothers you and having the body learn to eradicate the sleep positions that contribute to OSA are critical to great sleep. Slow Wave is the only company that not only encourages daily sleep testing but actively enables it by supplying a Wellue O2Ring™ with every appliance prescribed. By turning on the active feedback of the ring, it will gently vibrate when oxygen levels drop below a preset value (we recommend 89%). This stimulates the wearer to change sleeping positions to stop the vibration. After one to several nights of wearing, this position change becomes automatic without arousals. Biofeedback trains the body to stay or only move into sleep positions that do not trigger apnea events. Oximetry biofeedback, combined with wearing the Slow Wave DS8, has provided up to 90%+ efficacy rates in patients who follow the routine. It also pro vides Slow Wave with a great database of what environmental factors affect patient sleep. More on that in the next article.
C urrent treatments for Obstructive Sleep Apnea (OSA) mostly focus on the tongue. Rightfully so, for tongue position is critical to determine whether someone gets quality sleep or has disruptive breathing during sleep. Some devices try to bypass it (CPAP; BIPAP); most oral appliances try to pull it forward along with the mandible, and hypoglossal nerve stimulation nudges the tongue forward to clear the airway.
Most of these devices don’t give the tongue anywhere to go. The result is pain, substandard efficacy, and ultimately, non-compliance. The multi-patented Slow Wave DS8 takes a totally different approach to OSA by focusing primarily on giving the tongue someplace to go. Doing so naturally stimulates the tongue to move into a forward position. Why is this important? In 2020, a study published in Nature and Science of Sleep demonstrated that “OSA patients, intolerant to CPAP have a strong positive correlation between a high tongue position based on the Friedman Tongue Position (FTP) grade and presence of retropalatal Complete Concentric Collapse (CCC).”
Slow Wave is the only company that supplies a Wellue O2Ring™ with every appliance prescribed
The Problem is 80% Tongue & 20% Environmental! You Need to Address Both
1. Zhao C, Viana A, Ma Y, Capasso R. High Tongue Position is a Risk Factor for Upper Airway Concentric Collapse in Obstructive Sleep Apnea: Observation Through Sleep Endoscopy. Nat Sci Sleep. 2020 Oct 19;12:767-774. doi: 10.2147/NSS.S273129. PMID: 33117012; PMCID: PMC7585274. The Slow Wave DS8 allows 8mm of vertical opening and at least 30mm of horizontal or lateral room for the tongue
Slow Wave, Inc. 1002 Marble Heights Dr. Marble Falls, TX 78654 Phone: (830) 220-5700 www.SlowWave.net The Slow Wave DS8 multi-patented design solves this by providing at least 8mm of vertical space and 30+mm of horizontal space for each patient physiology. Proper space stimulates the tongue to move forward into its natural position² during sleep • Total patient comfort • No morning repositioner needed • More profitable for the dentist Call us or check out www.slowwave.net to join our growing community of dentist partners! 1. Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes; https://doi.org/10.1177%2F0194599818762383 2. Nat Sci Sleep. 2020 Oct 19;12:767-774. doi: 10.2147/NSS.S273129. eCollection 2020 www.SlowWave.net The Slow Wave DS8 reduction90%AveragingOSA Why does hypoglossal nerve stimulation show better efficacy results than traditional oral appliances?¹ It solves the root issue in OSA by stimulating the tongue to move forward during sleep. But where is the tongue to go?
Please join us at the Greater New York Dental Meeting Sleep Apnea Symposium November 27-30, 2022 to learn from top educators in sleep dentistry. The next few pages will introduce you to the speakers and sponsors of this valuable symposium.
Steve Carstensen, DDS, has treated sleep apnea and snoring in Bellevue, WA since 1998. He’s the Consultant to the ADA for sleep related breathing disorders and heads the ADA’s Children’s Airway Initiative. He trained at UCLA’s Mini-Residency in Dental Sleep Medicine and is a Diplomate of the American Board of Dental Sleep Medicine. He lectures internationally, directs sleep education at Air way Technologies and the Pankey Institute, and is a guest lecturer at Spear Education and Louisiana State Dental School, in addition to advising several other sleep-re lated manufacturers. In 2014, he helped found Dental Sleep Practice magazine and currently serves as Chief Dental Edi tor. In 2019, Quintessence published A Clinician’s Handbook for Dental Sleep Medicine, written with a co-author. At the GNYDM, I will be talking on ‘The Dentist’s Role in Sleep Related Breathing Disorders.’ We have an increasingly important ability to impact community health by making airway considerations an everyday part of our practices. We must reach beyond traditional dental areas of emphasis, like dental and periodontal health, to consider how our preven tive focus can help our patients reduce their risk of complex health conditions like cardiovascular disease while improv ing quality of life. It is rewarding to embrace the professional challenges involved with medical discussions with patients and other health care providers. This talk will prepare the dentist to identify, refer for diagnosis, and properly manage sleep related breathing disorders in their day-to-day dental practice. I will talk about which patients need treatment right away, who must be sent through the diagnostic system, and why there are different types of treatment available. Dentists can make the biggest impact on health by emphasizing nasal breathing. Learners will experience exercises they can pro vide their patients right away to change bad mouth breathing habits into healthy nose breathing. We will talk about those different treatments and identify steps any dentist can take to move their patients from unaware to sleeping quietly and breathing well every night. In the hands-on workshop, dentists will be able to match patients with the custom mandibular advance ment device most likely to be successful for them. Each dentist will create a custom morning realignment device for themselves to learn how they can assure patients their bite won’t shift while they sleep. Having a semi-custom pro fessional interim device to provide patients for immediate treatment is a critical part of practice, so each dentist will make one on themselves.
I got into treating dental sleep medicine through the efforts of my mentor, Dr. Keith Thornton, inven tor of the TAP device and Pankey Faculty. I met Keith in 1989 at Pankey and he encouraged my involvement in the new field from the start. A patient came to my dental practice seeking repair of his sleep appliance – after hearing Greg’s story and learning how beneficial his dentist had been for him, I began learning what I needed to provide such service to other patients. My father was diagnosed, after much cajol ing, with severe OSA and felt so much better on his CPAP that I knew I wanted more dentists to have the good feelings of helping their patients improve their health. My teaching became more and more about what dentists can do to help people breathe, and in 2015, I sold my dental practice to start up a new practice with a like-minded partner where all we treat is sleep related breathing disorders. We work with health care providers like sleep physicians, primary care and cardiologists, otorhinolaryngologists, and speech and language professionals to find the right way to help people. Many people think snoring is benign and mostly a social problem for the bed partner. When it occurs in adults, it is often the sign of an underperforming respiratory system. The scariest part, however, is when snoring occurs in children, or their airway is compromised because of mouth breath ing. Snoring in adults has many health implications; snoring/ mouth breathing in children sets them on a pathway where their health can never fully recover for their entire lives. The biggest opportunity for the public and health care profession als is to recognize compromised respiration as early in life as possible and correct it before bad things happen. Setting kids up to breathe easily for life is dentistry’s highest obligation.
GNYDM
GNYDM Sleep Symposium Speaker
Steve Carstensen, DDS, FAGD, FACD, FICD, D.ABDSM
You will hear expert advice about side effect management, setting expectations for patient experiences, and a thorough discussion of the various types of devices available. Dentists will leave the workshop prepared to immediately begin helping people breathe better.
Register at www.gnydm.com/sleep-apnea-conference 54 DSP | Fall 2022 SPECIALsection
Panthera Dental – Panthera Sleep Panthera Sleep division designs and manufactures cut ting-edge custom-made medical devices for sleep-re lated breathing disorders such as snoring, obstructive sleep apnea and bruxism. All Panthera Sleep products are produced using proprietary design software, industrial 3D printing processes and medical grade polyamide type 12, a biocompatible, highly durable and versatile nylon.
What is Panthera Doing to Drive the Industry Forward? Panthera Dental is committed to design and manufacture custom-made dental restorations, sleep breathing disorder solutions and implantology products using proprietary CAD/ CAM processes, smart manufacturing, and superior quality materials. Panthera’s highly skilled and passionate team is dedicated to provide the highest quality outcomes and to deliver state-of-the-art solutions to dental, medical, and sleep professionals who strive to improve patients’ quality of life Pantheraworldwide.Dental is one of North America’s most techno logically advanced centers. Panthera’s new state-of-the-art Industry 4.0 compliant facility is dedicated to the automated manufacturing of dental prosthetic products and dental sleep appliances. The Company has built a robust industrial and digital smart manufacturing business following Industry 4.0 principles allowing Panthera to produce with the highest quality and the fastest lead time in the industry and provide real-time production workflow information to customers.
SPECIALsection 55DentalSleepPractice.com
GNYDM Sleep Symposium Sponsor
Did You Know? The Panthera D-SAD Classic oral appliance is now eli gible for Medicare/PDAC reimbursement using the E0486 HCPCS code. Contact us if you need support. Contact Panthera Learn more about Panthera by visiting their website at www.pantherasleep.com or following them online instagram.com/panthera_dental/.https://www.facebook.com/PantheraDental/,https://www.linkedin.com/company/panthera-dental-inc,atorhttps://www. at www.gnydm.com/sleep-apnea-conference
Register
GNYDM
workshop. While we were attending, I heard the words”Dental” and “Sleep” used in a sen tence for the first time. I got a sleep test and found out I had obstructive sleep apnea. I con tinued to do research on this topic and made my first oral sleep appliance in the lab three weeks later. To my astonishment, it worked and changed my life. I was 50 pounds over weight, pre-diabetic, had high blood pressure, and a walking heart attack ready to happen. I lost the weight, got off the medications, and got my health back, plus my sleep apnea was under control. That is when I realized that if it could change my life, it could change others’ lives also.
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How Does Your Practice Approach Sleep Medicine?
A little over 25 years ago, I was working as a dental assis tant and the dentist asked me to go with him to a dental
What is the Most Profound Statistic or Misconception as it Relates to Sleep that You Want the Public to Know?
Register at www.gnydm.com/sleep-apnea-conference DSP | Fall 2022 SPECIALsection
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Stan Jones, CDA, DLT
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Great question! I talk with dentists monthly that struggle with proper appliance selection for their patients, and they don’t understand what a custom oral sleep appliance looks like. I coach dentists and their teams to narrow down the appliance selection process, take the proper measurements, and analyze the right variables to provide a custom fitting and performing appliance for their patients.
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The DreamSleep approach to Dental Sleep Medicine is to keep it simple, streamlined, and productive for the patient and the dentist. The dentists that we have partnered with are providing a proven therapy for their patients and improving the health of the communities they serve.
Stan Jones brings more than 25 years of experience with coaching dentists and their teams in Dental Sleep Medicine. He was at the forefront of Dental Sleep Med icine at its early beginnings and has watched it evolve into what it has become today. He has extensive knowledge and on-hands expe rience in the implementation and practical application of Dental Sleep Medicine in a dental practice. He has studied the mechan ics of oral sleep appliances and understands that every appliance application needs to be custom to that patient. He is a certified dental assistant and a dental lab tech for over 30 years, and a member of the N3Sleep Consulting Division. He is the lead trainer and coach for the DreamSleep System for Dental Sleep Medicine. Stan looks forward to meeting you and working together to streamline and optimize your sleep practice. His lecture “Success in the Dental Sleep Practice” will address the following: Division of labor within your team The whole team training approach Medical Billing approach Understanding how teamwork will accelerate your sleep program How to best delegate the work responsibility among your team members Understand which medical billing solution is best for your sleep practice
56 GNYDM
GNYDM Sleep Symposium Speaker
How Did You Get into Sleep/This Industry?
GNYDM Sleep Symposium Sponsor Nexus Dental Systems
To learn more about Nexus Dental Systems, visit https:// nexusdentalsystems.com/ or follow it at https://www.face book.com/NexusDentalSystems or https://www.linkedin. com/company/nexusdentalsystems.
For too long, dental sleep medicine has been a frag mented patchwork of solutions; difficult to navigate and stitch together. We have seen many dentists give up on sleep medicine because they could not overcome several common hurdles, the most frequent complaint being problems with medical insurance billing. While medical billing is a huge obstacle, it does not exist in a vacuum. The truth is that lack of training, disjointed electronic medical record systems, and fractured insurance payer systems have all made it difficult for patients to receive care. For a condition that affects mil lions, that is unacceptable. An estimated 67 million Americans, about 1 in 5, have AHI >5, and they need our help. Their health is suffering, and their condition will get worse without treatment. In 2017, the ADA tasked every dentist with screening for Obstructive Sleep Apnea and providing treatment when prescribed by a physician. We are here to help you deliver on that mission.
What Sparked Nexus’ Passion for This Industry?
What is Nexus Doing to Drive the Industry Forward?
Nexus Dental Systems is a group of innovative companies joining forces to save more lives. Ours is a vision of a com prehensive solution that simplifies the delivery of life-sav ing treatment to millions of patients with OSA. We have united several key solutions for medically necessary dental treatments into one fully integrated system: credentialing (ACSDD), whole team training (N3Sleep), patient outreach and education (DreamSleep), and an innovative medical bill ing solution that is integrated into the whole process (Nexus Bill). Each of these solutions addresses a core challenge dentists face when treating sleep. Together we are reshaping the future of dental sleep medicine by removing barriers and expanding access to care.
EDUCATION TRAINING SOFTWARE TECHNOLOGY SPECIALsection
57DentalSleepPractice.com GNYDM
Register at www.gnydm.com/sleep-apnea-conference
Nexus Dental Systems is the only company in the mar ket with a true end-to-end solution. Our conglomer ate has the B2B expertise that fulfills the needs of a dental practice to: Identify, Screen, Treat, and Monitor Sleep Treatment Compliance for Oral Appliance Therapy. Our mis sion is to raise public awareness of sleep apnea, train dentists to implement dental sleep medicine, create sleep apnea pro grams for the industry, and connect patients with providers by creating sustainable and resilient systems for providers and the public.
How Did You Get into Sleep/This Industry?
Kristie Gatto, MA, CCC-SLP, COM®
As a clinician that focuses on the neuro muscular education and re-education of the muscles of the head and neck, sleep became a natural progression of intervention as more collaboration has been seen amongst pro fessionals in recent years. Patients exhibited difficulties that were associated with sleep and swallowing. When interventions were provided to address the head and neck mus culature, a correlation of better sleep began to be reported.
What is the Most Profound Statistic or Misconception as it Relates to Sleep that You Want the Public to Know?
Intervention does not happen overnight, nor does it con sist of a few exercises and things are “fixed”. Therapeutic intervention should be tailored to the individual and custom ized to meet that individual’s needs. Sleep leads to body’s ability to optimize function, repair the body, grow the body with the release of hormones and so much more. Without appropriate sleep, one will suffer. Many times, the individ ual with the sleep issues do not realize there is a problem because that is their normal. Correcting the issues give them (back) the life they should be living.
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GNYDM Sleep Symposium Speaker
K ristie Gatto, MA, CCC-SLP, COM® received her bachelor’s and master’s degrees from the University of Hous ton in Houston, Texas. She has worked as a speech language pathologist in the public and private school systems, skilled nursing, rehabilitation and children’s hospitals, and in private practice. In 2004, Ms. Gatto became the co-owner of a private practice in North west Houston and began her journey in treat ing children with pediatric feeding disorders. After years of searching for answers in tradi tional feeding approaches, she underwent training in the field of Orofacial Myology and became the first certified orofacial myologist in the city of Houston in 2011. Ms. Gatto is currently the owner of The Speech and Language Connec tion, which has two offices in the greater Houston area and employs multiple speech-language pathologists with various specialties.Forroughly twenty years, she has focused her clinical skills on treating patients with issues in feeding, dysphagia, deglutition, oral sensory aversion, orofacial myology, and swallowing- related disorders, as well as articulation, phono logical processing, and associated concerns related to sleep related breathing disorders.
How Does Your Practice Approach Sleep Medicine?
Professionals that provide oromyofunctional therapy and intervention work with dentists and sleep professionals to strengthen the oropharyngeal muscle complex for swallow ing, sleep, articulation, and overall enhanced muscle func tioning. We work with our patients to increase strength and tone within the orofacial complex and collaborate with den tal sleep professionals to provide an optimum airway during neuromuscular re-education.
Register at www.gnydm.com/sleep-apnea-conference DSP | Fall 2022 SPECIALsection
Kristie Gatto is a current Board of Directors member of the Oral Motor Institute and on the editorial review board for Dental Sleep Practice magazine. She is a member of the American Speech-Language-Hearing Association and a past president of the International Association of Orofacial Myology. Additionally, she has served as a Board of Directors member for the American Academy of Private Practitioners in Speech Pathology and Audiology and a member of the Community Advisory Board at the University of Houston. She is an instructor for the International Association of Oro facialHerMyology.symposium
topic will be Oromyofunctional Therapy and Breathing.
GNYDM Sleep Symposium Speaker
• to recognize warning signs of more involved medical issues, avoiding the ‘it’s just snoring’ trap • to present accurate, safe medical information to reas sure patients about their condition and therapy
K ettenbach is an internationally positioned and well established company which for more than 75 years has attracted attention in the dental sector thanks to its inventions and product innovations. The foundations for effi cient processes and successful treatment in dental practices have been established in the segments of dental impressions and restoration. Simply intelligent. Market-leading products such as Panasil® and Futar®, supplemented by the in-house development of innovative materials such as Identium®, have long simplified the dayto-day work of dentists. Product innovations in the area of restorations have also been added: for temporary and per manent restorations the Visalys® product line is synonymous with quality at the highest level. We are never satisfied until our customers are satisfied withAtus.Kettenbach we are dedicated to accomplishing the extraordinary. We have only one goal in mind: to develop excellent products for our customers. And this philosophy endures, as is demonstrated by the most recent generation of the owner family. Kettenbach is and will continue to be a family-run company. We think it is important to have continuity to ensure that we can consistently fulfill the high expectations of our customers. Our company depends on the individual members of our staff as well as the knowl edge and effectiveness of our carefully selected management team. Our business divisions are united by strong motivation to develop products of outstanding quality for our customers.
Register at www.gnydm.com/sleep-apnea-conference SPECIALsection
His lecture “The Medical Side of a Medi cal/Dental Problem: Sleep Apnea” will address how patients with sleep apnea can have real medical problems. While a medical history can uncover those issues, follow-up depends on understanding complex interactions between diagnoses, medications, and risk. Patients these days seek whole answers and are not satisfied with health care providers who don’t commu nicate. This program helps you discuss cases with your patients and avoid being known as ‘just the device provider.’ Attendees will learn about how physicians approach collaborative care and how each of us is doing what we do best, but working together, gives the patient their best chance of optimum health. Learn:
GNYDM Sleep Symposium Sponsor Kettenbach Dental Jonathan Lown, MD, is a highly-regarded physician board certified in the areas of Sleep, Internal Medicine, and Lipidology and is a Diplomate of Sleep and Internal Medicine (ABIM). He is the Clinical Director of Delta Sleep Center of Long Island, and Co-founder of Delta Sleep International, established to disseminate knowledge about Sleep, worldwide. In addition, Dr. Lown is Assistant Professor of Medicine, Stony Brook University Medical School.
Jonathan Lown, MD
Dr. Lown is passionate about treating patients with sleep difficulties including Obstructive Sleep Apnea and was diagnosed with Obstructive Sleep Apnea himself in 2000, and has been a compliant CPAP user for over 21 years. He has also partnered with Sleep Dentists, to improve awareness and treatment alternatives for OSA and is an active member of both the AASM (American Acad emy of Sleep Medicine) and AADSM (American Academy of Dental Sleep Medicine), and is a member of the AADSM education committee.
• the different roles the dentist and physician play in managing sleep-related breathing problems
59DentalSleepPractice.com GNYDM
There are some requirements for doing this right. Marketing with a separate sleep brand requires:
This is an advanced strategy, but if you want a killer, competitive advantage over other general dentists in your area, it’s hard to beat when done well. If you create a new practice: another practice name, phone number, and address, you can build a web site and marketing campaign that looks like you “specialize” in sleep treatment. You are probably promoting sleep along side implants, ortho, and other general den tistry procedures. It’s a full menu of options that you could argue gives patients a onestop-shop for dental care. But when a patient has a medical problem and they are consid ering alternative treatment options, you will win the patient over by setting yourself apart as the go-to expert with an easy-to-under stand process. If patients come to your home page and all of the content is about their problems related to OSA, they know that you get it and you are that expert. Google loves these websites for the same reason. They see a focused presence, and your marketing team will be able to optimize your home page for ‘sleep apnea [City name]’ rath er than relegating that phrase to a secondary page at best. That’s a massive win for SEO and Google ranking potential. Your sleep web site’s focused content and patient experience tell Google that they’d be fools not to consid er you for the top spot if people are looking for sleep apnea treatment in your area. Your internal pages will be focused on symptoms and treatment options. Your blog posts will be about SLEEP ONLY and not a bunch of other dental keywords. Everything in your site will make you look like THE SLEEP EXPERT in your area.
The best dental sleep website tells the story of the struggle past patients have been on and how those patients achieved an amazing out come. You and your office helped the patient through the journey and the patient emerged victorious! The struggle and a better life on the other side are all the patient really cares about.
Iam often asked, “How can I get more dental sleep patients from my marketing?” The dentists who ask this are highly trained in treating OSA, but they struggle when it comes to marketing dental sleep treatment. They don’t understand what makes the phone ring. For the best sleep dentists, the dentists who really rock, if they follow these dental sleep marketing tips, they’ll get more patients scheduling appointments.
You have patients who need YOU and what you have to offer. Focus your sleep mar keting on them and their needs.
Consider a Sleep Brand
Not
Dental website design companies often get this wrong. They are focused on build ing websites that the dentist likes or that is just like the site of another dentist who their clients idolize. That approach is most often doomed to fail. You are not your patient. That amazing dentist is not you and isn’t practic ing in your market.
Focus Your Sleep Marketing on Patient Needs Your patient only cares about you and your office as far as you can help them live a more comfortable life doing what they love. They don’t care about your bona fides or which appliance you use. Your patient’s im mediate concern is, “Do you understand my problem, and can you help?” If your website doesn’t make that clear from the get-go, then all the pay-per-click and SEO in the world doesn’t help.
Sleep Marketing Tips for the Faint of Heart Fashbaugh
by Jonathan
60 DSP | Fall 2022 PRACTICEmanagement
A separate business address. You can cheat a little bit by having a different suite number at your building but you must have a separate address from your primary dentistry brand. If you don’t, it’s unlikely to work and could even hurt your main practice’s results. You’ll have even more success if your office is in the heart of your city.
• A separate phone number. You don’t want your address and phone number to match your main office because it will confuse Google about your on line business listings. Your new brand will have its own listings because you’ll need…
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Marketing a separate sleep brand requires:
Jonathan Fashbaugh is the president of Pro Impressions Marketing. He founded the company after seeing a need for more reliable, transparent marketing for dental offices. Pro Impressions’s first client was a sleep dentist and has re mained active in helping sleep dentists attract more patients with a full suite of marketing services.
PRACTICEmanagement
• Separate social media profiles. Your sleep practice will need its own so cial media profiles for the same rea son that you need a separate website. Highlight the sleep-only focus. Get your patients at your current practice to like or follow the new practice pro files and let them know that you’ll enter them to win a drawing if they do so. Let them know that you are launching this new practice to help people suffering from snoring, fitful nights of sleep, morning headaches, and the life-threatening damage that OSA causes. Ask them to share the new page and posts you create with friends and loved ones who may not understand that their symptoms could be due to sleep apnea. People are less likely to share a website, but bitesized social media posts with a cause for apnea awareness are appealing.
Patients shouldn’t continue suffering from OSA while their symptoms go unnoticed or under-treated by the medical community. That’s the message you should broadcast: don’t wait! Don’t suffer more than you have to. Take action!
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• Separate social media profiles.
All of this may be hard at first. You are starting a new marketing campaign from scratch. It will feel redundant until you start seeing new patients at the new office. Then you’ll realize that you’re double-dipping in an increasingly competitive and lucrative market. You’ll still get sleep patients at your main office, but thanks to this advanced sleep marketing, you’ll push competitor websites off the first Google page, too. Launching a separate practice for sleep treatment also gives you an exit strategy. Af ter you’ve built up a second practice, you can consider selling your general and cosmetic practice while still having an established and thriving practice in the area. Some dentists try to do sleep-only after the fact. They’ll probably tell you that they wish they had started it all much earlier.
• A separate business address. A separate phone number. A separate marketing campaign. A separate website.
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• Separate ads and a separate ad bud get. Your sleep website and social media profiles can go unnoticed for a long time if you don’t promote them. If you split off some of the budget from your main office, both websites will only have partial funding behind their campaigns. Invest the added bud get to get the added patients. It only makes sense.
Engage Prospective Patients with Action-Oriented Sleep Marketing
• Separate ads and a separate ad budget.
A separate marketing campaign. Your sleep practice will not succeed on the merits of your other website. It needs its own profiles on the internet and so cial media. It needs its own ads that point to its own content that lives on…
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• A separate website. Every dental brand needs a website, and your new sleep office will be no different. Mul tiple Google listings pointing to your old website will look like the new one is duplicative of the old one and will either confuse Google, hurting your main office’s results, or get deleted as a duplicate. Google believes that ev ery small business should have one website and only one website. Your sleep website should take advantage of the opportunity to showcase its focus on sleep apnea treatment with original text about what patients go through and how you help. Don’t bor row content from your other website. Write all-new dental sleep content.
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Hire Sleep Marketing Experts
If people can use your website to help answer questions, they go be yond reading and start engaging with it. This sets your website apart.
Get more new sleep patients by:
It is critical that sending the re sults to your office is optional. If you force the contact, your form goes back to being a marketing element rather than an online screening tool. The option to invite contact makes this assessment a powerful indirect call to action.
• Having a click-to-call button on your website for mobile devices
• Having your phone number in large text at the top of your website
62 Include assessment forms on your web site that stop short of diagnosing patients online but start the screening processn (see example at left). An online Epworth or Berlin question naire changes your website into a useful extension of your practice rather than just an information source about your practice.
• Adding links to schedule a consulta tion throughout every page of your website – not just at the top and bot tom of the page.
People search Google for answers to their sleep questions. Not all will make suitable pa tients for you. Still, look for trends and get into the mindset of people who have been suffer ing from sleep apnea. You can capture their interest and minimize the amount of money you must invest in generating a new sleep pa tient from your marketing.
Online interest wanes over weekends and peaks on Tuesday and Wednesday. Don’t waste your money on advertising on week ends. The interest is down and you don’t have people ready to answer the phone at your office anyway. Weight your visibility for midweek awareness. People will feel like you’re reading their groggy minds as they try to figure out why they just can’t get the rest they need.
Be careful in the kind of content that you put in your blog and on social media. There’s a fine line between attracting people in search of a dentist and people in search of at-home, DIY sleep treatment. Your Google Ads and social media strategy need to be led by someone who understands that not every click is worth targeting. Targeting CPAP searches is a doubleedged sword. They are more costly to gener ate a lead, but you will know that you almost certainly are speaking to someone who al ready had a diagnosis. When you have good visibility on Google, you probably already get calls asking if you offer CPAP equipment. This isn’t likely your website’s fault as much as Google’s. Google has two goals: list local providers for services and to sell stuff online. Unfortunately, sleep is an area where both service providers and equipment are fighting for the same patient eyeballs. Phone skills training is necessary to either quickly direct the flow of the conversation to compliance and comfort with OAT or to get the person off the phone so that your team is ready for the next opportunity.
In terms of marketing, we are not a fit for all practices, but we offer a marketing anal ysis report on our website that is free to use. You can get your custom report almost in stantly at www.proimpressionsgroup.com. We also offer marketing consults that are free of charge. You can schedule your meeting on our website.
My company, Pro Impressions Marketing, has been marketing sleep dentists since our company launched in 2010. We’ve been part of the community ever since, attending sem inars with our dentists, sponsoring events of fered by companies and organizations such as Myotronics and ICCMO. We only work with dentists and are passionate about helping pa tients find relief from their symptoms, which makes us incredibly good at what we do.
Of course, traditional calls to action are critical too. It’s unbelievable how often mar keting companies launch websites where the phone number is hard to find and contact forms are buried at the bottom of the website (or don’t exist at all).
Sleep Marketing Tips and Trends
• Including a basic Contact Us page.
If you’re not comfortable about offering just sleep apnea and snoring treatment, we’d encourage you to consider adding an em phasis there alongside TMJ treatment. Most of our offices that add more sleep patients also offer TMJ treatment and do very well. If you need help streamlining the diagnosis and insurance billing for sleep treatment, we have partners that can help.
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