Dental Sleep Practice Spring 2022 by MedMark, LLC

New Medical Section

The Importance of Communication by Scott Williams, MD

Non-CPAP Treatments for Obstructive Sleep Apnea by Jyotsna Sahni, MD

Panthera Dental

POISED

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INTRODUCTION

It’s Never the Same the Second Time

t feels good to be back as an Editor for Dental Sleep Practice. In fact, it’s better than before. Think about times in your life when you’ve had a chance to return to a place that was familiar, only to discover new, exciting details that give you even more energy and curiosity about what there is to learn. While these times may not yet afford us the opportunities to visit a favorite vacation spot or gather with our friends at meetings, as we begin to step back into the world, we’ll see things never spotted before. Such as it is with Dental Sleep Practice magazine. As I return as Chief Dental Editor, I am very happy that DSP has embraced medical colleagues to provide the education and perspective dentists need to be the best partners in our patient’s health strategies. Treating sleep related breathing disorders has never been purely medical or dental, because from the earliest years oral appliances were prescribed after diagnosis. For far too long physicians and dentists have seen themselves as separate, rather than two highly trained professions each with their distinct role to play. Any Venn diagram will have a large area of overlap. Physicians can learn from dentists, too. By increasing the scope of the magazine, DSP will bring us together with greater appreciation for how we can all contribute to the best outcomes. This fits the science. Increasing awareness of the need to pay attention to measurements beyond the AHI means the major advantage PAP devices have over oral devices, lowering the number of compromised breathing

events, is not the only endpoint. Continuing research shows physiologic effects differ between individuals in ways none of the founders of sleep medicine could have anticipated. Changing treatment goals means different therapies – myofunctional therapy, pharmacology, physical therapy, and other modalities add to Steve Carstensen, DDS our ability to personalize care. Diplomate, American Board of Whether you are adding a medical Dental Sleep Medicine service to a dental practice or learning to work with a speech and language pathologist for myofunctional therapy, improving communication skills is critical to success. DSP adds Com- Changing treatment munication Corner – each issue will goals means different give you and your team tips for how therapies – myofunctional to get the message across. Take a moment to look at the therapy, pharmacology, Editorial Board. A diverse group of physical therapy, and other medical professionals, each with amazing skills and talents, have vol- modalities add to our unteered to guide Dr. Surkin and me ability to personalize care. as we serve as Chief Editors. Each of them is a lifelong learner, same as you, Lee Surkin, and me. Our journey continues, together. Welcome to the new Dental Sleep Practice magazine – with you, I look forward to discovering what’s next to be learned.

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing the online quiz after reading the article “Mastering the Myo Merge: The Importance and Essentials in Implementation in the Dental Office” by Karese Laguerre, RDH, which starts on page 30.

DentalSleepPractice.com

CONTENTS

Panthera Dental: Poised for Dentistry 4.0 by Steve Carstensen, DDS, FAGD, FACD, FICD, D.ABDSM Modern manufacturing to address the rising need.

Our New Medical Section

MEDICAL

Look for this green border on

Cover Story

Medical Intro

Renew in ’22 by Lee A. Surkin, MD, FACC, FCCP, FASNC, FAASM

Medical Insight

The Importance of Communication by Scott Williams, MD Read about an update on the AADSM’s task force on establishing guidelines for the MAD titration process from a sleep physician who is directly involved.

Gabriel Robichaud, Panthera CEO and Co-founder; Béatrice Robichaud, Panthera VP Marketing & Customer Experience and Co-founder; and Alfred, a fully autonomous mobile robot.

Medical Insight

Continuing Education

Mastering the Myo Merge: The Importance and Essentials in Implementation in the Dental Office by Karese Laguerre, RDH You need this service – here’s how to make it work.

Non-CPAP Treatments for Obstructive Sleep Apnea

2 CE CREDITS

2 DSP | Spring 2022

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CONTENTS

Publisher’s Perspective

Don’t Just Survive – Thrive! by Lisa Moler, Founder/CEO, MedMark Media

14 Communications Corner

An Invitation to Influence by Mary Osborne, RDH What matters is how behavior changes.

22 Board Member

Lieutenant Colonel Scott Williams, MD Meet our new medical editorial board member Dr. Williams.

28 Board Member

Jyotsna Sahni, MD Meet our new medical editorial board member Dr. Sahni.

42 Product Spotlight

ProSomnus® EVO™: Crossing the Chasm in DSM Implementation by Mark T. Murphy, DDS, D.ABDSM Continuously looking for innovative ways to add value.

43 Practical Tips To Breathe, or Not to Breathe by Lisa Stillman, RDH, BS; Julie Seager, RDH, BSDH; and Rhoda Kublickis, RDH, BASDH, MHS There’s more to xylitol than sweetening your coffee.

46 Expert View

Wait, We Have Four Sets of Tonsils? Where Are They, and What Do They Do? by Tom Colquitt, DDS How your patient reacts to the environment matters.

by William M. Hang, DDS, MSD Dentists have a few precious years to make a difference.

39 Product Spotlight Every Breath Counts by Beth Rosellini, DDS, AIAOMT Getting started early has lifelong benefits.

40 Pediatrics

Which One is the Best? by Lauren Ballinger, DDS It’s not about the device.

4 DSP | Spring 2022

Publisher | Lisa Moler lmoler@medmarkmedia.com Chief Dental Editor Steve Carstensen, DDS, D.ABDSM stevec@medmarkmedia.com 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) Laura Sheppard, CDT, TE DeWitt Wilkerson, DMD Scott Williams, MD (Psychiatry, Sleep) Gy Yatros, DMD

National Account Manager Adrienne Good | agood@medmarkmedia.com

36 Clinical Focus

Can We Really Prevent OSA in Children?

Spring 2022

Sales Assistant & Client Services Melissa Minnick | melissa@medmarkmedia.com

50 In Memoriam

Todd D. Morgan, DMD We’ve all lost a friend.

54 Product Spotlight Choosing the Right OSA Device by Alex Buddemeyer, CDT Simplifying your choices for better implementation.

56 Sleep Humor

...The Lighter Side of Sleep Apnea

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.

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PUBLISHER’Sperspective

Don’t Just Survive – Thrive!

hen preparing my first message of 2022, I was looking for inspiration. I found a quote by author Richelle E. Goodrich, which said, “Revitalized, I find the strength to battle new tomorrows.” She added, “This year, I survived. Next year, I will thrive!” Revitalization is a key to continuing to grow and prosper in the coming years. It means to give new life or vitality. Here at MedMark, revitalization is exactly what we concentrate on every day – for our readers and our authors, and ultimately for patients.

The focus of DSP is very close to my heart, whether it is revitalizing patients’ lives or adding new vitality to a dental practice through sleep medicine. Having battled a life-threatening sleep disorder myself, I know how important it is for patients to be able to find a diagnosis and treatment. We are honored to be a part of the future of dental sleep medicine. The American Board of Sleep Medicine (ABSM) website documents that about 7,500 board-certified sleep specialists serve approximately 325 million people in the United States. An estimated 22 million Americans have sleep apnea, but 80% of moderate and severe obstructive sleep apnea patients are undiagnosed. You can help change that statistic with information from our publication and digital opportunities to help grow dental sleep practices nationwide. In this issue, we welcome back Dr. Steve Carstensen as Chief Dental Editor. In “Panthera Dental Poised for Dentistry 4.0,” he delves into the extraordinary Robichaud family and visionary manufacturing 4.0 processes that allow dentists to be artist-scientists. In the CE, “Mastering the Myo Merge,” Karese Laguerre, RDH, discusses creating a collaborative airway team and adding myofunctional therapy to your practice. An exciting development is a new section that cultivates a multidisciplinary approach to OSA. The section will feature articles written by the new medical editorial board, comprised of leaders in sleep medicine from varied subspecialties and led by our own Chief Medical Editor, Dr. Lee A. Surkin. In this issue, we welcome articles by Drs. Jyotsna Sahni and Scott Williams.

While we all are laser-focused on succeeding and expanding our options this year, we also should remember the importance of practicing empathy and kindness. Stories of these past 2 years of the COVID19 pandemic taught us all that everybody has a personal and professional story that has deeply impacted their lives. Some share these challenges with the world, and some prefer to keep it personal, but in the light of what we have all gone through, part of the revitalization of 2022 will be to recognize that we need each other’s support to move forward. There are many ways to practice kindness in the dental world. Be a mentor to another dentist who has questions on technique or materials that work for you. Motivate a colleague who is just starting out or is restarting. Use your social media to be an inspiration. Call peers and suggest they read an interesting article that will help move their practice forward. Tell a few people in your personal life that you are proud of them. Revitalization means so much, especially this year, and MedMark is proud to be a catalyst for positive change. For our readers, our articles and webinars can help you gain or change perspective and move in new directions. For manufacturers and innovators, our marketing services can bring you the attention you deserve and the recognition you seek. Our motto this year is “Renew in 2022!” With our combined experience and insights, we can stride into the future together. For this issue, we put a new spin on the quote at the beginning of this perspective. “Last year, I survived. This year, I will thrive!”

Lisa Moler Founder/CEO, MedMark Media

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COVERstory

Panthera Dental

POISED

for Dentistry 4.0

by Steve Carstensen, DDS, FAGD, FACD, FICD, D.ABDSM

entistry, even sleep breathing dentistry, is an artist’s medium. Sculpting teeth and making bespoke devices, whether in the mouth, lab bench, or CAD program, is the expression of the artistic skills of the creators. Individual creativity is what we all treasure in the visual, performing, and creative arts. Dentistry is healthcare – and, in our field, millions of people breathe poorly and need our help. Can they all be served by the artists? Manufacturing is entering a new phase – in history, there have been four major shifts. The first change was external power replacing human work, the second, mechanical assembly lines and the third, the entry of computers to the creative process. Phase 4.0 is when the machines, using AI, connect with each other to maximize productivity and efficiency. Additive manufacturing, or 3D printing, allows nuanced details such as complex dental anatomy to be fully considered. Human designers individualize care while robotic manufacturing provides the ability to scale to meet population health needs. Artistry meets innovation meets manufacturing. The first automobiles were built by hand by their inventors. Demand soon resulted in builders coming together to put the machines together, by hand, one at a time. It wasn’t until Henry Ford created the moving assem-

8 DSP | Spring 2022

bly line that enough cars could be produced to meet the needs of the population. Today’s F150 is put together with up-to-date versions of that same assembly line – lots of people plus one robot to place the windshield glass. Tesla reinvented the assembly line, using 160 robots linked to purpose-built software. Onsite engineers and computer programmers can change anything nearly immediately. Ford uses Phase 2 manufacturing with enhancements; Tesla, and now Panthera Dental, are working in Phase 4 industries. Back to dental devices to maintain an open airway – begun by entrepreneur dentists in their own offices, soon embraced by dental restorative laboratories. More recently, we’ve seen the third industrial phase introduced. Manufacturers are using CAD design, 3D printing, and CAM – computer milling

COVERstory machines to create custom devices out of raw materials. Humans apply design talents and send instructions to the machines, one by one. Increasing efficiency requires more humans, more skills, and more machines. A faster assembly line. Can this thinking provide the answer to millions of patients who need a dental device? We are witnessing a CPAP recall, the rise of consumer sleep technology and the lowering of barriers to diagnosis and medical decision making around sleep related breathing disorders. A tsunami of demand for dentist-driven oral appliance therapy is at hand. Is the industry ready to meet a sudden need for tens, hundreds, of thousands of oral appliances? Panthera Dental’s Robichaud family leaders are visionaries. Spinning up the traditional assembly process to be ready to make more devices was too small. After all, it was this family who developed the world’s first CAD-CAM oral appliance, implant bar, and maxillofacial prosthesis. They wrote the very first software

DentalSleepPractice.com

COVERstory

A tsunami of demand for OAT is at hand.

10 DSP | Spring 2022

that made 3D printed nylon devices possible. A version of that program is still in use today in France. After their previous company BioCAD was acquired by Nobel BioCare, who is not present in the sleep appliance space, the family formed Panthera Dental, and built from the ground up a suite of new generation software dedicated to implants, prosthetic and sleep. Today the company is run with many of the same early team, including the software engineer who wrote the first ever sleep CAD-CAM code and the lab artist who originally made sleep appliances by hand. Today’s 3D print engine is the result of decades of experience and is entirely contained in the same network that runs Panthera. Bug fixes, upgrades, and innovations are done daily by the engineers working only steps away from the production floor. Not a production floor like you might think of. When Tesla bought an old car factory, they installed skylights and painted the floor with white enamel to emphasize light and cleanliness. Two years ago, Panthera’s third production facility opened to incorporate every innovation to enhance outcome

detail, the importance of work-life balance in the team, and 4.0 manufacturing. When milling an implant bar from a puck of titanium, or using a world-class 3D printer to create titanium maxillofacial custom implants and prosthesis, tolerances are in the single-digit microns. Keeping those promised fit standards was part of building design – the floors are three times the thickness code requires, just to make sure traffic vibrations don’t disturb the milling robots and lose precision. Besides the metal structures, Panthera makes more than the DSAD Classic and DSAD X3 mandibular advancement devices – they are soon to be joined by some innovative oral orthotic designs being tested. Meeting patient needs via dentist-customer ideas. Manufacturing 4.0 also requires efficient use of expensive resources. Dental devices are printed using laser-sintered Polyamide 12 – a standard medical-grade nylon material, in batches of dozens at a time – but there’s no waiting to ‘fill the machine’ if that would hold up delivery to the patient breathing badly. Panthera’s software uses artificial intelligence to track every case from order to delivery date,

COVERstory

Choose to be ready for this bright future.

12 DSP | Spring 2022

placing it in front of the expert designer, sending the code to the right printer, and guiding the QC department for which order comes next. Even shipping is directed to reduce delivery times. Machines are interconnected and signal the humans responsible at each step to create efficiencies. Any need to move faster can be driven by the AI – not a faster production line, but simply upscaled versions of what happens every day at Panthera. Work trays are distributed around the facility not by people struggling to open doors with armloads of cases, but by Alfred, a fully autonomous mobile robot. He glides on his electronic rounds, avoiding people and obstacles, like your Roomba with shelves. Efficient, and fun! More machines can easily be brought online, more designers trained because everything is in-house. The AI even helps plan for production peaks and valleys – no team member is going to face an unmanageable workload, unwanted overtime, and an unexpected interference with their home life. The culture of Panthera grows from Robichaud family values. Current leadership, co-founder siblings Gabriel and Beatrice Robichaud, along with their aunt Diane, understand the value of coworkers feeling supported. Instead of hiring out a customer service group, or even placing the people answering the phone offsite somewhere, when a dentist calls in, the person taking the call is a short walk to the production floor, the designer, the software engineer, accounting, and the CEO’s office. Every team member has free reign to bring an issue up wherever it might need to go. Large displays show real-time production queue, quality measures, customer location and other company data, connected, yes, to the

same software network. The new building’s brightest, most window-filled space is the team lunchroom – long community tables for maintaining connectedness. A (very) big screen TV provides entertainment – during a Stanley Cup match people came back to the office to cheer their team on together. Does that happen at your dental clinic? Imagine the shared commitment to best practices when everyone on the team feels connected. It’s not just the machines sharing a network in 4.0 manufacturing. There are many reasons to pick where the order for the MAD ends up, but increasingly, shared values are becoming important factors for dentist’s choices. Supporting a company that is committed to a smaller environmental impact, a happier, values-driven culture, and a future focus provides the dentist more than a ‘bottom line’ justification for choosing one device over another. In the dental office, efficiency means an excellent fit and long service life – good value for the patient. Precision and correctness of fit, not synonymous terms, are hallmarks of the careful process at Panthera. Each device is custom designed, efficiently, by the software developed by Panthera engineers. The amount of retention, the fit around each tooth, even the placement of the components are all customized under the trained eye of the CAD artist. The nimble software can meet the needs of most patients and their dentists. Additive manufacturing can be adapted to more details of the oral anatomy with less waste than milling or hand-building devices. Panthera has a process for every level of expertise and equipment choice, from stone models to highly sophisticated intraoral scans. One of their early adopters is a dentist who now heads up R&D, putting innovation into real practice with over 2,500 nylon devices delivered. Working with the armed forces of both Canada and the US has further refined what can be done when everyone on the team shares commitment to highest quality, cutting edge innovation, and maximizing 4.0 manufacturing. Dentists as artist-scientists. Together with supplier-artists using 4.0 manufacturing, we are the ones who will finally help large numbers of people make every breath, every night, their best. Panthera Dental has made the choice to be ready for this bright future. Choose wisely, and you can be, too.

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COMMUNICATIONScorner

An Invitation to Influence by Mary Osborne, RDH

ou come back from a sleep course armed with new information, research, and experiences. The first patient you see in your practice exhibits signs of airway issues you simply cannot not see! Enthusiastically, you show her what you see, explain the implication, and encourage her to have a sleep study.

Start

“Umm. I’m okay.” “Not right now.” “No thank you.” Wait, what? Weren’t we taught that if you give people good information, they will make the right choices? What went wrong here? The truth is it is probably not the first time you gave a patient good information that they chose not to act on. Perio disease. Replacing a missing tooth. Home care recommendations. We have seen this before. All of our study, our thoroughness, our clarity of communication does not always result in acceptance. What’s missing? Some indicaby asking questions tion from the patient that they want and listening more your advice. An invitation to beintentionally. come a trusted advisor regarding their overall health. Have you ever been given advice you did not ask for? You may be able to hear it, but it is not the same as when you have asked for advice. We have a responsibility to inform our patients, but they may not be ready to hear all of what we know. How can we help our patients open up to hearing our recommendations? It’s a process. The late Dr Bob Barkley said your dental degree gives you the right to practice dentistry, but “you have to earn the right to influence your patients.” The key to earning that right is trust.

14 DSP | Spring 2022

Trust

Patients must trust our competence, but our clinical training can lead us to believe that information alone builds trust. Information is important, but it is equally important that patients trust our motives. They must feel confident that our recommendations are in their best interest. We must know them well enough to make recommendations for them. Another aspect of trust that is too often neglected is our patients’ ability to trust themselves, a confidence in their own knowledge and ability to make decisions about their health. Without that confidence, they may choose not to make a choice. They often choose to do nothing. How can we learn enough about our patients to help them find the motivation to improve their health? Start by asking questions and listening more intentionally to information they are already providing. You may be missing opportunities in systems you already have in place in your practice.

Opportunities

Medical history: If we want to be seen as partners in health the first form a patient fills out should give them an opportunity to focus on health, not just disease. Reviewing a patient’s health history form is standard practice, but it can be more than just a review of health problems. It can be an opportunity to ask them about what they do to maintain

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COMMUNICATIONScorner health. We can ask them about how they came to include exercise or supplements or healthy diet patterns. If we listen carefully, we can hear patterns about how they make decisions about their health. We can look for opportunities to acknowledge and support their choices. A few well-placed questions can also help us understand something about a patient’s ability to incorporate significant change into their lives. They may report they have quit smoking, or lost weight, or incorporated regular exercise into their lives. Showing an interest in how they accomplished the change reinforces their success. “What prompted you to lose all that weight?” is a question that helps us understand what motivates them. Asking “How did you quit smoking?” offers insights into strategies that have been successful for them in the past. Questions like these can provide useful insights about how you can help your patients through the process of integrating sleep appliances into their lives. Clinical Exam: A thorough clinical exam demonstrates our attention to detail and our knowledge. When we ask the patient questions during an exam, we also invite the patient’s expertise into the relationship and engage them in the process. “What do you remember about how you came to lose that tooth?” (or have that root canal, or that crown.) That conversation during an exam

Mary Osborne, RDH, has worked in dentistry for over forty years. She brings to her work the experience of day to day, hands on clinical dentistry as well as a wide range of knowledge gained in working with dental practices around the world. Mary’s education and experience as a dental hygienist and patient facilitator help her to understand both the rewards and challenges of practicing dentistry. Her love of learning, and deep belief in personal and professional growth through authentic communication have made her a respected and admired advisor to dentists and their teams for many years. Mary is known internationally as a writer and speaker on patient care and communication. Her writing has been acclaimed in respected print and online publications. She is widely known at dental meetings in the U.S., Canada, and Europe as a knowledgeable and dynamic speaker. Her passion for dentistry inspires individuals and groups to bring the best of themselves to their work, and to fully embrace the difference they make in the lives of those they serve.

16 DSP | Spring 2022

also allows us to support decisions made to restore a tooth, or replace it. Show patients conditions you notice and ask them questions about what you find before giving treatment information. “Have you noticed this scalloped pattern on the sides of your tongue?” You might ask how long they have been aware of that pattern on their tongue. When patients provide us with information, they are more likely to be interested in findings we point out to them and information we offer. Review of Findings: Going over conditions we observe provides an opportunity to ask the patients thoughts about what we have discovered together. Patients can share their confusion, concern, or pre-conceived ideas. “I know we’ve given you a lot of information today, Mr. Jones. I’m wondering, what thoughts do you have about what we have found?” They may be surprised, confused, disappointed, skeptical. Listen carefully, attentively, to understand more deeply who they are and what is important to them. Avoid the temptation to suggest treatment too quickly, to offer a solution to a problem they do not yet own. Allow time for them to digest the new learning. You might give more information or ask further questions. “Do you tend to wake up in the morning with a dry mouth?” “Has anyone ever told you that you snore?” When these questions emerge through a dialogue about what they are thinking or feeling, they will be more meaningful to the patient. If they have little or no awareness of conditions you identify you can encourage them to pay attention between now and the next time you see them. See if they notice mouth breathing, or dry mouth, or disturbances in their sleep.

Mutual Trust

Nobel prize recipient Dr. Albert Schweitzer said, “Patients carry their own doctor inside. They come to us not knowing that truth. We are at our best when we give the physician who resides within each patient a chance to go to work.” When we invite the “physician who resides within each patient” to come forward in our conversations we encourage patients to trust themselves. When we listen generously to the doctor inside, we encourage patients to trust us. We can “earn the right to influence.”

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MEDICAL

MEDICALintro

Renew in ’22

t is an honor and privilege to be the first medical editor in chief of Dental Sleep Practice. When the opportunity was presented to me, it was not a difficult decision to make given my strong interest in continuing to promote and cultivate an interdisciplinary approach to managing Obstructive Sleep Apnea. Without hesitation, my answer was a resounding “YES, of course.”

I quickly came to realize the team’s incredible skill and competency to produce an outstanding edition every quarter. Their drive to achieve excellence is indicative of a dedicated and Lee A. Surkin, MD, FACC, FCCP, FASNC, FAASM passionate pursuit to deliver valuable resources to the dental sleep community. This drive even persisted through the incredibly challenging dark days of the 2020 Covid shutdown when DSP adapted and continued “business as usual” while adhering to all of the required health and safety measures without any lapses in quality or content. This year’s mantra is “Renew in ‘22,” which may seem like a simple objective but is really quite complex and bold. The Cambridge Dictionary defines the word renew as, “to begin something again or with increased strength.”

We are embarking on a new, interdisciplinary approach to reporting high-impact news and information relating to the sleep industry as a whole.

In 2022, my editorial partnership with Dr. Steve Carstensen grants DSP the opportunity to renew by expanding our perspectives as a community while continuing our focus on dental sleep medicine. We are embarking on a new, interdisciplinary approach to reporting high-impact news and information relating to the sleep industry as a whole. Through these changes, DSP will

18 DSP | Spring 2022

reach more providers and become an even more meaningful resource thereby increasing its strength. DSP will feature articles written by the new medical editorial board, comprised of leaders in sleep medicine from varied subspecialties. Contributions will provide a fresh perspective for readers that are educational, informative and cutting edge. So one might ask why DSP is doing this? Well, we all know that there are increasing challenges to patient care, changing landscapes in reimbursement models, and ever increasing competition. It is incumbent on sleep dentists and sleep physicians to lock arms to deliver the best possible care to our patients. The only way to do this is to collaborate, evolve, and stay current with skills and education to tap into as many resources as are feasible to make it all work. I am looking forward to working with the DSP team to build on its solid foundation and provide an even more comprehensive platform from which the sleep dentist and sleep physician can forge a stronger partnership to benefit and enhance patient care. My father-in-law commonly referred to a fairly well known quote by Confucius, “The green reed which bends in the wind is stronger than the mighty oak which breaks in a storm.” Needless to say, we are all experiencing quite a storm during these unprecedented times and must stay laser focused being green reeds for both patient care and self-care.

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MEDICAL

MEDICALinsight

The Importance of Communication by Scott Williams, MD

leep medicine is a highly collaborative and multi-disciplinary field. There are few medical specialties that allow Internists, Psychiatrists, Family Physicians, Otolaryngologists, Pulmonologists, Pediatricians, Neurologists and Dentists all to work together to solve specific patient complaints. We are also very proud to have highly skilled Sleep Technologists, Respiratory Therapists, Durable Medical Equipment experts, and a vast array of support personnel to assist. With that collaboration comes challenges, though, and the quality of the care is inextricably linked to the ability of the sleep clinic to communicate the plan of care to the entire care team. One of the most significant topics at the physician-dentist interface is the determination of how well a mandibular advancement device (MAD) is working, and when it is appropriate to order a MAD titration polysomnogram. In recent weeks, I have been fortunate to work with the American Academy of Dental Sleep Medicine (AADSM) on their Referral Efficacy Task Force. In this endeavor, we are creating some easy to use products for Dental Sleep Medicine (DSM) specialists to determine when the patient is ready to be

20 DSP | Spring 2022

sent back to the physician for confirmation of treatment efficacy and quantify patient improvement. These documents are intended to be shared with the referring sleep physician’s office, and should provide some standardization across the country. In addition, this task force is developing guidelines for the AADSM to guide dentists when to refer the patient back to the sleep physician. The AADSM Board of Directors will approve and make these materials available to members within the next few months. The first step in the workflow is to determine whether the patient has returned for follow-up DSM visits. The AADSM wants to make it clear, especially to patients, that this step should not be rushed. The patient should use a MAD for a couple of months* before evaluating the overall efficacy. This timeline is important for physicians to convey to patients who might be looking for a “quick fix.” It is critical for the sleep physician to discuss the relative timelines and milestones of MAD and CPAP prior to placing a DME order or referring to DSM experts. MAD therapy is very labor intensive up front, but once successful-

ly delivered and adjusted, a MAD is much easier to maintain than CPAP. These differences must be communicated to patients at every appointment to ensure expectation management and optimize adherence. The second step is for the DSM specialist to determine patient’s adherence. Whereas the minimum CPAP adherence is typically >4 hours per night at least 70% of nights, the AADSM defines MAD adherence as requiring use 80% of nights at least 5 nights per week. There are commercially available adherence monitoring devices, but often we rely on patient self-report. The dentist will provide initial troubleshooting if adherence is sub-optimal, but this is an area where close communication is critical in case there are other aspects of care that the medical provider can treat. Once adherence is established, the dentist will assess overall subjective response to treatment as a third step. The AADSM is creating a Verification of Treatment Efficacy form, and can be used to provide feedback to the medical clinic. If the patient is reporting problems with treatment, the dentist will provide initial troubleshooting. This is another step where close coordination is important because patients early in the treatment are at risk for discontinuing therapy if they perceive it not to be value added. A quick phone call between the medical and dental clinics will go a long way to improving outcomes for these patients.

A quick phone call between the medical and dental clinics will go a long way to improving outcomes for these patients. Finally, the fourth step is to refer the patient back for a titration study. Many patients are lost to follow-up at this point, even if they feel well, because they may not want another PSG. Once again, close coordination between medical and dental professionals can ensure that a consistent message reaches the patient. It is common for a patient to be partially treated and when the MAD titration study is performed, even greater improvements in subjective and objective response are realized. In order for the PSG to be as useful as possible, it is recommended that the dental clinic meet with the sleep technologist to review the types of devices that they prescribe, and to make sure the overnight staff are comfortable adjusting it. An instructional paper is acceptable, but when possible an in-service allows for interactive teaching and is preferred. While the above may seem simple, they will no doubt result in markedly improved responses to therapy.

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MEDICALinsight

*The suggested timeframe is currently under review with the AADSM.

Lieutenant Colonel Scott Williams, MD, is the director for Military Psychiatry and Neuroscience at the Walter Reed Army Institute of Research. LTC Williams was born in Bournemouth, England and was raised in Princeton, New Jersey. He graduated and was commissioned into the U.S. Army from The University of North Carolina at Chapel Hill in 2000. LTC Williams received his medical doctorate from the Uniformed Services University of the Health Sciences in 2004. He completed a dual residency in Internal Medicine and Psychiatry at the Walter Reed Army Medical Center in 2009. He completed fellowship training in Sleep Disorders Medicine at the Walter Reed National Military Medical Center in 2012. Upon graduation from fellowship, Dr. Williams assumed duties as Chief of Sleep Medicine at Womack Army Medical Center. While there he served on the AASM Education Committee and obtained an academic appointment as assistant professor of medicine at USUHS, later rising to the rank of associate professor of Medicine (primary) and Psychiatry (secondary). He increased his involvement with the AASM after returning to WRNMMC to take charge of the Sleep Disorders Center. He is now the chair of the Sleep Technologist and Respiratory Therapist Education Committee and is part of the gold standard panel for the Inter-Scorer Reliability program.

DentalSleepPractice.com

MEDICAL

BOARDmember

Lieutenant Colonel Scott Williams, MD Tell us about yourself.

irstly, I wanted to thank DSP for inviting me to be part of the editorial board. I am an active duty Lieutenant Colonel in the United States Army and am currently serving as the director for Military Psychiatry and Neuroscience at the Walter Reed Army Institute of Research (WRAIR). Originally trained in Internal Medicine and Psychiatry, I went on to complete a sleep disorders fellowship at the Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland. I have served in a variety of leadership roles in the Army, ranging from the Chief of Sleep Medicine at both WRNMMC and Womack Army Medical Center to Director of Medicine at the Fort Belvoir Community Hospital. I enjoy teaching both junior physicians and our support staff about the fascinating advances in sleep medicine, and previously chaired the American Academy of Sleep Medicine’s Education committee. I also have an interest in advocacy efforts and work with the Sleep Research Society to ensure that the voices of patients, clinicians, and researchers are heard. Our current research work at WRAIR focuses on the impact of sleep deprivation in the military, and ways to optimize performance even when it is not possible to get a full night’s sleep. With your background in internal medicine, how did you learn so much about how dentists work in their clinic? Throughout my time in sleep medicine, I have worked closely with Dental Sleep Medicine professionals and have treated hundreds of active duty servicemembers with mandibular advancement devices, because they are so effective and easily portable for those sleeping in austere conditions. I am passionate about advancing the cooperative relationship between medical and dental providers and am active in the American Academy of Dental Sleep Medicine as well as the AASM. I currently serve as the physician liaison to the American Board of Dental Sleep Medicine (so you can blame me for any of the difficult board exam questions!).

22 DSP | Spring 2022

How do you see the future of dentistphysician collaboration going as communications improve? Having given multiple talks at both professional societies’ annual meetings and having worked on numerous task forces, I see a bright future for the dentist-physician relationship so long as individuals are willing to continually communicate and share best practices with each other. Increased multi-disciplinary research is also extremely important, because it improves the quality of care in both the dental and medical settings. As with any healthcare specialty, there are many challenges, but by combining efforts, I see this as the best chance to improve patient outcomes and decrease morbidity. I can be reached at scottwilliams1978@ yahoo.com.

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MEDICAL

MEDICALinsight

Non-CPAP Treatments for Obstructive Sleep Apnea by Jyotsna Sahni, MD

hile PAP therapy has been considered the gold standard for the treatment of obstructive sleep apnea for many years, there are new treatment options available. Oral appliance therapy has been shown to be effective and preferable to CPAP in many patients and continues to gain popularity and recognition. In addition, many other effective treatments are emerging. Positional Therapy

Since sleep apnea tends to be worse in the supine position where the patient’s tongue may fall backward due to gravity and occlude the airway. Simply shifting to the side may offer benefit for patients with positional sleep apnea. While it is simple to ask a patient to stay off their back during sleep, this may not be a practical suggestion without a tool to aid them. Low tech mechanical devices that simply alert a patient to turn over is an option. This can be as simple as wearing a fanny pack around the waist stuffed with socks or sewing a tennis ball into the back of their night shirt. The lump which they feel every time they turn to their back serves as a signal to turn over onto their sides. There are “anti-snore backpacks” and some devices specifically designed for positional sleep apnea. These devices are easily available online, do not require a prescription, and are generally inexpensive. A more sophisticated option to treat positional sleep apnea involves a light plastic

24 DSP | Spring 2022

collar worn around the neck during sleep. A small rectangular box is positioned against the nape of neck which contains a position sensor. The position sensor vibrates, like a cell phone, when the patient turns on their back. There are incremental increases of vibrational intensity that occur as the patient continues to maintain supine position. The device starts at a low level with a very gentle vibration and, based on the algorithm of the device, it will eventually reach a more intense level, if the patient has not turned over sooner. The device is charged through a USB port and a download can be obtained to look at its efficacy. This report shows how often the patient attempted to turn onto their back (“supine attempts“) and how often it was successful in thwarting those attempts. It also looks at percentage of the night that the patient spent snoring and overall duration of use during the night. Unlike the low-tech mechanical devices which can be unwieldy, this device only requires the neck collar to be worn. The rest of the body is free from encumbrances. Therefore, it is less intrusive and may be more acceptable to the patient. This device is significantly more expensive than the low-tech options and does require a prescription.

Treatment of Nasal Obstruction

Nasal congestion and allergies are very common and lead to worse snoring and obstruction. Avoidance of known allergens, nasal flushing, nasal steroids, oral antihis-

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tamines, or leukotriene receptor inhibitors (e.g. Montelukast) are conservative treatment options to help with nasal congestion and obstruction. Since many patients with nasal allergies also suffer from asthma, reducing nasal allergies may reduce asthma exacerbations which tend to worsen during the night and can lead to awakenings and hypoxia. While unlikely to be curative for sleep apnea alone, these measures may improve sleep apnea and allow other treatment options to work better, for example, notably oral appliance therapy for sleep apnea. When nasal congestion is more significant, ENT surgical procedures may be curative of sleep apnea. One such example is nasal turbinate reduction which may be accomplished with freezing or lasers and procedures to support an incompetent nasal valve. Nasal dilators can prevent an incompetent nasal valve from collapsing during sleep and making it harder to breathe out of the nose. A common type of nasal dilator is an adhesive strip that is placed on the external

nostrils at night and can reduce snoring and increase airflow through the nostrils. Unfortunately, the adhesive itself can be irritating to the skin. It is a single use product and can get expensive. Another example is a plastic or metal nasal dilator. For example, one such device is a small strip of plastic in the shape of a horseshoe that is placed inside the nostrils. Reusable and generally comfortable, it too, prevents the nasal valve from collapsing, reduces snoring, and increases airflow through the nostrils. There are a large number of nasal dilators on the market, fairly inexpensive, sold over the counter, and a variety of shapes and sizes, some of which may be more comfortable for one patient’s anatomy over another. A new and innovative treatment for both nasal obstruction and sleep apnea is an airway stent (Alaxo Airway Stents, Alaxo USA, Inc.). Available in three depths, this device addresses nasal turbinate hypertrophy which can lead to congestion, snoring, and worsening of sleep apnea.

MEDICAL

MEDICALinsight

Dr. Sahni has been in medical practice for 22 years. The first 11 years of her career she was an internist at Canyon Ranch Health resort. Since then, she has practiced sleep medicine exclusively. She opened her own practice, Swan Sleep Medicine, four years ago. When asked why she chose sleep medicine, she often jokes that she could not commit to a single organ. Fortunately, sleep medicine is a combination of pulmonology, cardiology, neurology, and psychiatry. Never boring, sleep medicine requires a multi-disciplinary approach to diagnosis and treatment. To that end, she has been certified in holistic medicine, nutrition, and Ayuvedic medicine as well as Sleep medicine. In general, sleep medicine is a happy field of medicine. When people are sleeping well, they feel more rested, of course, but also have better mood, sharper memories, lower heart risk, and stronger immunity. Dr. Sahni asks that you forgive the pun, but when sleep is improved, it’s like night and day! She evaluates patients in her office as well as administers home sleep tests to look for sleep apnea and insomnia studies to look at brain waves while sleeping. She treats a wide variety of adult sleep disorders. She is taking new patients.

DentalSleepPractice.com

MEDICAL

MEDICALinsight Weight Loss Weight loss may be curative in mild cases of sleep apnea. By reducing extra tissue in the cheeks, palate, tongue, neck, and upper chest, it will frequently improve, although may not fully resolve more severe cases of obstructive sleep apnea.

Surgery

Reduction or Elimination of Certain Medications Certain medications may worsen sleep apnea. For example, narcotics which suppress respiratory drive can lead to increased obstructive sleep apnea, central sleep apnea, and hypoxia. Muscle relaxants or drugs that have muscle relaxing effects such as Diazepam, a benzodiazepine, can worsen obstructive sleep apnea and hypoxia. Only the smallest, most effective dose of these drugs should be administered, and safer alternative drugs should be used preferentially.

There are a variety of surgeries that may benefit sleep apnea including bariatric surgery, ENT surgery, and hypoglossal nerve stimulation.

Devices that Exercise the Tongue A small hand held device, recently was approved by the FDA for snoring and mild sleep apnea, provides neuromuscular electrical stimulation to the tongue and upper airway muscles. The goal is to strengthen the muscles to prevent significant loss of tone during sleep. The device is used daily for 20 minutes for 6 weeks initially, then just twice weekly after. It has been shown to reduce snoring and the severity of sleep apnea. It does require a prescription.

Negative Pressure Device Unlike the oral appliance that brings the mandible and tongue forward to make more room in the airway, there is a device that directly targets the tongue. A small E-battery powered device essentially utilizes gentle vacuum suction positions the tongue forward in the mouth to prevent obstruction of the airway. This oral negative pressure device is worn during sleep and requires a prescription.

26 DSP | Spring 2022

There are a variety of surgeries that may benefit sleep apnea. Frequently underutilized, bariatric surgery can be curative in less severe cases of sleep apnea, but may greatly decrease severity of sleep apnea in other patients. Gastric sleeve and gastric bypass are the most commonly performed surgeries. Tonsillectomy and adenoidectomy is curative in approximately 80% of children with obstructive sleep apnea and is rarely performed in isolation in adults, because it is generally not effective. Uvulopalatopharngoplasty (UP3) is ENT surgery that greatly alters the anatomy of the oral cavity by removing excess tissue to open it up. Mandibular advancement surgery is major surgery that involves bringing the maxilla and mandible forward to create more space in the airway. Deviated septum repair can improve nasal breathing and therefore be adjunct therapy for the treatment of sleep apnea. Hypoglossal nerve stimulation is a promising treatment modality for moderate to severe obstructive sleep apnea. It involves an outpatient procedure with two incisions. The first is where a battery is implanted in the upper right chest pocket. It is similar to a pacemaker battery and lasts approximately 11 years. The second incision is performed to place a wire in the vicinity of the hypoglossal nerve, the motor nerve of the tongue. When used during sleep, the device senses inspiration and delivers an electrical stimulus to the hypoglossal nerve which moves the tongue forward thereby enlarging the airway. One month after surgery, the patient is “activated.” The patient is given a remote control which is turned on at bedtime. Over the course of approximately three months, the patient calibrates the intensity of nerve stimulation to control sleep apnea. A final in-lab polysomnogram is performed to ascertain that the patient is optimally treated.

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MEDICAL

BOARDmember

Jyotsna Sahni, MD Tell us about yourself.

graduate of Haverford College and the University of Pittsburgh, I have been in medical practice for 22 years. The first 11 years of my career I was an internist at Canyon Ranch Health resort. Since then, I have practiced Sleep Medicine exclusively. I opened my own practice, Swan Sleep Medicine, five years ago in sunny Tucson, Arizona. When asked why I chose Sleep Medicine, I often joke that I could not commit to a single organ. Fortunately, Sleep Medicine is a combination of pulmonology, cardiology, neurology, and psychiatry. Never boring, Sleep Medicine requires a multidisciplinary approach to diagnosis and treatment. To that end, I’ve been certified in holistic medicine, nutrition, and Ayuvedic medicine as well as Sleep Medicine. I’ve also had extra training in cognitive behavioral therapy of insomnia (CBT – I). In general, Sleep Medicine is a happy field of medicine. When people are sleeping well, they feel more rested, of course, but also have better mood, sharper memories, lower heart risk, and stronger immunity. I ask that you forgive the pun, but when sleep is improved, it’s like night and day! I evaluate patients in my office with a comprehensive history and physical and administer home sleep tests to look for sleep apnea as well as insomnia studies to look at brain waves while sleeping. I am taking new patients. Since the pandemic, I have become a huge fan of the Food Network, falling in love with Chef entrepreneur Bobby Flay, and perfected queso fundito with roasted poblano chili sauce. I also enjoy spending time with friends and family in intimate groups outdoors, watching kitty videos on Facebook, and fantasy fiction on Netflix.

With your background in internal medicine, how did you learn so much about how dentists work in their clinic? While my internal medicine background has absolutely nothing to do with dentists,

28 DSP | Spring 2022

the majority of cases I treat are obstructive sleep apnea. With oral appliance therapy gaining recognition, OSA patients benefit when sleep physicians and dentists work together. I believe quality care requires a multidisciplinary approach.

How do you see the future of dentistphysician collaboration going as communications improve? While I treat a wide variety of adult sleep disorders, the bulk of any Sleep Medicine practice is obstructive sleep apnea. As dentist-physician collaboration improves, I predict that patient care will be greatly improved, too! Now that oral appliance therapy is much more widely available and recognized as an effective and convenient treatment option, patients won’t be routinely prescribed CPAP but will have truly individualized care.

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CONTINUINGeducation

Mastering the Myo Merge The Importance and Essentials in Implementation in the Dental Office by Karese Laguerre, RDH

leep and airway focused dentistry have been estimated to be a $6 billion global industry and has seen rapid growth since COVID-19.While airway is comprised of much more than just sleep, this is outstanding news for the profession. Piqued interest and awareness mean that there are new options for growth in one’s professional life and in practices of collaborative care amongst professionals.

Educational Aims This self-instructional course for dentists aims to show that sleep and airway dentistry have become the latest way to increase dental practice differentiation and achieve through collaborative care patient overall wellness. Unfortunately, being a hot topic and featured more prominently at dental conferences does little for the reality of practice integration. Delve into a deeper understanding of the benefits of incorporating orofacial myofunctional therapy into the dental practice and how to navigate integration.

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. Upon completion of this course, participants will be able to: 1. Identify key members of a collaborative care team with airway focus; 2. Understand the steps required to establish and maintain a healthy collaborative relationship; 3. List the processes involved in establishing orofacial myofunctional therapy inside and out of the dental office; 4. Explain the role of orofacial myofunctional therapy in the dental practice.

30 DSP | Spring 2022

The soft tissues of the cranium have the all-important job of supporting facial growth and impacting the trajectory of dental arch development.1 The function of these muscles is often overlooked unless a patient presents with orofacial pain or discomfort. Yet, they have a direct impact on the services one provides and the oral appliances prescribed. At the convergence of frustration and discovery lies an underutilized service that can be incorporated into the sleep dentistry practice to meet the needs of both the patient and the provider. Orofacial myofunctional therapy is an individualized program of exercise and re-training for muscles of the orofacial complex. Strengthening these muscles reduces the collapsibility of the upper respiratory tract that allows the obstruction that leads to an apnea. This century old field of specialty has been studied and shown to improve CPAP and oral appliance tolerance, decrease obstructive sleep apnea symptoms and in some rare instances eliminate the need for the CPAP. A 2018 comprehensive review of 11 separate studies concluded: “OMT [orofacial myofunctional therapy] is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure.”2 The addition of this specialty in the dental office requires much planning and several essential considerations to ensure a consistent patient experience, effective treatment coordination, and successful collaboration.

CONTINUINGeducation Team Considerations

Incorporating orofacial myofunctional therapy into the dental office is not just treating the teeth as a structure, rather the individual person with teeth. It’s the piece that connects the ability to address what can be done about identified oral problems with specified questions about why deficits have occurred. However, it takes more than just myofunctional therapy or sleep dentistry, it takes strong team collaboration as well. The dental office is made up of a team of players, ranging from the front desk managing the schedule to the dentist performing treatment with the assistant. In airway dentistry it is no different – the influence of the team is critical to one’s success. Whether one is referring out for orofacial myofunctional therapy or establishing an in-office adjunctive service, collaboration is the key to success. Many patients with orofacial myofunctional disorders will need other care. Some may even need to see a specialist for diagnosis and treatment before they are able to start other treatments. Myofunctional therapy is not effective when there are structural deficits, such as insignificant palatal width for the tongue to rest, physical obstructions to nasal breathing present, or the presence of significant sleep apnea. In dental screenings, some of these are readily notable, for others a referral is necessary. Having a trusted network of professionals whose values are aligned to provide patients with quality service is essential. Treating airway centered disorders can be expensive and most often is out of pocket. Patient trust in their providers facilitates greater acceptance to a prescribed program or suggested treatment plan. The following are providers you should seek out in your area: Orofacial Myofunctional Therapist/Orofacial Myologist – Helps to resolve functional issues and compensatory patterns in orofacial musculature. Always best to have a professional that provides this treatment modality for most cases with appliance therapy, sleep breathing disorders, and tethered oral tissues Speech Language Pathologist – Can help with patients with oromyofunctional disorders, as well as speech, speech sounds, and feeding disorders. RDHs and SLPs have specialized training in oral anatomy, health, and function, and with training, can include myofunctional therapy in their practice. OMT is only included in licensure definitions in three

states for SLP (PA, CT, NJ) and none for RDH, however. Occupational or Physical Therapist – Can also be trained in oromyofunctional intervention. An occupational therapist can help with sensory disruptions and sensory integration; whereas, the physical therapist can help with postural alignment, breathing, and temporomandibular dysfunction disorders. Sleep Physician – May be a pulmonologist, neurologist, or other physician with a specialty in sleep medicine. As per the ADA recommendations any patients screened that have a high risk for sleep disordered breathing should be referred to a sleep physician. Having a trusted Manual Therapist (a.k.a. Bodywork Professional) – Physical manipulation of the network of facial system and strains that may present professionals is within are under the scope and capabilities of a body worker. This all-encompassing ti- essential tle can refer to an osteopathic physician, chiropractor, craniosacral therapist, physical therapist, or massage therapist. Osteopathic physicians are trained to use gentle pressure and stretching to manipulate soft tissue to treat or prevent illness or injury. Otolaryngologist (ENT) – Are critical in providing medical clearance and intervention for the patency of the airway. When a patient exhibits at risk or in need of diagnosis and treatment of upper respiratory blockages, airway disorders, and physiological anomalies, a referral to an ENT is necessary. Lactation Consultant – Can be a LC, CLC, or an IBCLC to treat the breastfeeding dyad (mother and baby) to facilitate proper latch, position, milk supply, and global feeding intervention as it relates to breastfeeding. While this is not an exhaustive list of team members, they are essential collaborators in the care your patients will need to address the

Karese Laguerre, RDH, is a registered dental hygienist, myofunctional therapist, author and key opinion leader in sleep and myofunctional therapy. She founded The Myo Spot, a practice focused on amplifying oral wellness to whole body wellness, through which she has helped hundreds of patients, children and adults alike, discover how great life can be functioning on full. Passionate about education and self-help, she published Accomplished: How to Sleep Better, Eliminate Burnout and Execute Goals. When not working with clients globally she spends time with her husband and four kids.

DentalSleepPractice.com

CONTINUINGeducation multi-faceted manifestations of sleep and airway disorders.

Out of Office Team Building, Networking, and Referral

There are 5 steps in successful team building and development covered here: forming, storming, norming, performing, and adjourning. Each step comprises one piece of the welloiled machine a collaborative relationship needs to flourish and grow. 1. Forming Forming is the most critical step for implementation. As mentioned previously, a strong team of multi-disciplinary providers is required to address the many manifestations of airway centered disorders. Attaining this complete team within a single office is a challenging task, therefore working relationships with professionals in your region are required. The referral orofacial myofunctional therapist may be a dental hygienist or speech-language pathologist who practices as an independent practitioner. There are other healthcare professionals who can obtain training and certify in orofacial myology, such as RNs, PTs, and OTs. However, the gold standard of care remains with the RDH and SLP who have specialized knowledge of oral anatomy, function, and physiology of the oral phases of the swallow. Seeking out independent practitioners may consist of completing an online search for therapists in the area or searching the directories of professional associations. The International Association of Orofacial Myology (IAOM), Academy of Orofacial Myofunctional Therapy (AOMT), International Association of Airway Hygienists (IAAH), Breathe Institute Ambassadors (TBI) and American Academy of Physiological Medicine and Dentistry (AAPMD) all have robust directories one can search. A Google search or social media search using the terms “myofunctional therapist near me” may also provide a listing of nearby professionals. Contacting a new prospective collaborator is no different than meeting a new friend. Get to know them personally and lead with a face-to-face public social meeting, such as a breakfast gathering at a local coffee shop. This enables an interpersonal relationship to best meet the needs of the patients. Get to know how these professionals started their interest

32 DSP | Spring 2022

in dental sleep medicine, became airway focused, and incorporated orofacial function. Establish the types of patients to focus therapy on, how a typical program is developed and carried out, how much growth is hoped for one to achieve, and the expected length of time of the program. Full disclosure should be provided by both entities. These questions will guide interactions with outside professionals, manage expectations, and form a foundation of effective communication for collaborative patient care. 2. Storming The second stage is how this team weathers the uncomfortable presence of unavoidable conflict. Conflict is the nourishment one’s team needs to grow. Most conflicts in professional relationships are based on misunderstandings. Face to face communication is preferable to handle conflict with all providers, regardless of if they are in or out of the dental office. E-mail and texts may lead to misunderstandings as intended messages get lost in translation. Compromise and split difference in resolution may be the solution to meeting the needs of the patient. 3. Norming Our third stage is one’s ability to maintain the relationship. This is crucial for optimal ongoing patient care in collaboration. One must establish the team relationships either within the office or externally and be prepared to educate other professionals about one’s expertise. Some questions may be familiar, but some may not. Orofacial myofunctional therapy is a specialty about compensatory orofacial muscle patterns and the associated neuromuscular re-education of the dysfunctional muscle movements for appropriate functional swallowing. Like any outside professional, be it a periodontist, sleep specialist or oromyofunctional interventionalist, additional education presents a grounded knowledge of their specialization. Myofunctional therapy can be shrouded in mystery as neuromuscular repatterning is considered a highly specialized skill that is rarely introduced in educational settings during traditional trainings (dental, hygiene, speech, or others). It is also imperative to understand that refining the collaboration process is continual. With the introduction of newer research, techniques, education, and integrations into the

CONTINUINGeducation practice, changes will be expected as the information related to dental sleep and orofacial myofunctional therapy intervention is surging. Staying current with these changes with all members of the team is integral during the norming stage. When approaching team members about changes to routines or techniques, a 3 T’s approach is preferred. This begins with translating respect, then transferring the issue from a problem to a solution and implementing trust for all parties to make informed decisions. For example: Dr. Nicole is having an issue conveying myofunctional therapy to her patients. This has been frustrating for her, and she would like better wording or understanding from the therapist, Joanne. Using the 3 T’s Dr. Nicole calls Joanne and states, “Hi Joanne. I want you to know that I am very happy to have the referral relationship we have. The work I’ve observed with my patients has improved the overall orthodontic outcome and promoted retention. I would like to handout or summary defining myofunctional therapy to share with patients. This would help to reduce chair time explaining while increasing patient understanding and promote increased follow through. I would like your guidance on the matter as I trust you know best how to explain it in the most effective way possible.” The therapist now feels valued and trusted as the specialty provider and is more likely to address it promptly. By offering a solution, it presents Joanne the choice to either agree or propose an alternative. This exchange becomes mutually beneficial and overall meets the needs of the patients at large. 4. Performing, Stage four brings us to the bottom line. This should be a relaxing stage where one steps back and appreciates the well-oiled machine. A mutually respectful, didactic referral relationship continues to enhance learning from both parties. There are five important improvements that can be observed. They are improvement in the office differentiation, overall patient satisfaction, promotion of patient loyalty, increased patient load, and potential sales of related services. As one works through cycle of team building and maintenance one should find improvement in several areas. Occasionally one may have a relationship that does not serve the office well and may be detrimental in certain areas. In those cases, it is important

to consider and properly implement the final stage, adjourning. 5. Adjourning Collaboration starts, and also ends. As much as all parties would desire to enjoy long term referral relationships, when they cease to serve the founding purpose, a choice point arises. Sometimes, a decision is necessary to part ways. One must remember that how this separation occurs, matters. Referral relationships end for any number of reasons. A provider may move or leave a practice, priorities change, performance declines, or chronic conflict in the working relationship are some examples. Don’t ghost the other provider – always contact them to explore what has changed. Express the 3 T’s and make a final attempt to resolve any issues. When the relationship cannot be salvaged, complete any open cases and wish them OMT is a well. Every failed endeavor is an opportuinclusion nity to learn and pivot going forward.

In Office Implementation

beneficial in any dental practice.

Many providers seek out the situation where a staff member potentially takes on the role of orofacial myofunctional therapist. The thought is that the service becomes more convenient for patients and the dentist. This, however, can be the trickiest of situations, as who you pick matters and training does not mean competence. The ideal dental hygienist must be eager to learn and equally invested in making this transition. That investment may be financial or a vested interest in advancing their career. There is considerable information to learn, education to obtain to establish a solid understanding of the information in the field. Whether or not the dentist decides to invest in a staff member’s education, it is always encouraged that the dentist and hygienist pursue ample education to be effective providers to the patients. Prior to transitions or education, formulate a contract. Confirm that person reflects qualities and characteristics reflective of your practice. Speaking, personality, and salesmanship are crucial as a brand is being built. One must have the ability to effectively communicate the message, the understanding, and overall basic need for appropriate intervention. Many professionals have made mistakes regarding educational funding of others, only to have the individual become trained and seek new DentalSleepPractice.com

CONTINUINGeducation opportunities outside of the office for which they were trained. Avoid this undue stress, and ensure all terms are decided prior to any education or money put out by the dentist or the professional office. A contract should include a mutually beneficial set of terms regarding compensation, expenses, length of service, continuing education, and expectations. This agreement begins the relationship on a positive note without hesitation. Compensation is a delicate topic and can be managed in one of two ways in the dental practice. Most frequently the therapist is provided either an hourly rate or a commission based on fees collected for the services rendered. Hourly wages can be aligned with office rates for services typically provided by the professional. When this option is considered, the dental office would provide treatment space, accounting, supplies, and scheduling. These are overhead charges that save the therapist from having to pay for rent, purchase their own supplies, and spend time doing administrative tasks. This is a more typical compensation schedule for providing the therapeutic service. Another option would be the negotiation of specialty wages. This would entail a negotiated rate and the professional would be responsible for acquiring business resources. In this instance the therapist would be charged for the space in the form of rent. It has also been observed that when hourly compensation or a percentage is negotiated, a growth period should be expected and is slower. When considering this type of fee arrangement, one must consider the potential loss while a schedule is being developed. Percentage wages are beneficial initially and incentivizes growth, so this option is an acceptable alternative. The industry average is to have 30-40% of collections as a compensation reserved for the therapist. Initial training courses can cost anywhere from $2,300 to $3,500 and will vary from exclusively online to in person. One must be mindful that a single introductory course usually does not suffice, and multiple trainings should be expected. It is also a fair expectation for the professional office to have to pay for additional advance training within the first year. Introductory training options can be with the International Association of Orofacial Myology (IAOM), Academy of Orofacial Myofunctional Therapy (AOMT), Graduate School for Behavioral Sciences, Neo-Health Services, MyoMentor, Airway Health Solutions, or Dental Sleep Toolbox. One must do their due dil-

34 DSP | Spring 2022

igence and review the programs available to verify if they will meet the needs of the office and what one is seeking. Also, be mindful that not all programs offer the same content, structure, timeframe, or expectation. State legislation is unclear and most dental practice acts pertain strictly to clinical dental hygiene services without mention of orofacial myofunctional therapy. Maryland, Iowa, Nebraska, New Jersey, and Texas have current and/or pending state board rulings that myofunctional therapy is not part of the dental practice and must occur separately. What this means for the dental practice is that orofacial myofunctional services should reflect a distinction from clinical dental hygiene. The myofunctional therapy business can be within one’s office and may in many ways resemble the practice, but it is NOT the dental practice and should be presented as such. Depending upon the negotiated pay structure, billing practices will evolve. It is strongly suggested that a separate business entity is created with an EIN, payroll, billing, accounting, tax filing, and so forth. This will enable the business to evolve with changes in legislation. Seek appropriate guidance for the actual payment process – W-2, 1099, separate company, etc. Be prepared to give the new therapist time to develop all the separate and appropriate forms for registration, patient onboarding, evaluation, treatment planning, referrals, and progress reports. There will also need to be implementation workflows and staff acclimation and training on new patient management software for scheduling, billing, and tele-therapy when applicable.

Conclusion

Orofacial myofunctional therapy is a beneficial inclusion in any airway focused dental practice. Patients will enjoy the convenience of having multiple services available in one location and it differentiates the practice as one that amplifies oral wellness to overall wellness. There are multiple challenges and rewards to establishing this practice in the dental office successfully, but when has anything worth doing been easy? 1.

Benkert KK. The effectiveness of orofacial myofunctional therapy in improving dental occlusion. Int J Orofacial Myology. 1997;23:35-46 De Felicio, Claudia, et al. “Obstructive Sleep Apnea: Focus on Myofunctional Therapy.” Nature and Science of Sleep, Volume 10, 6 Sept. 2018, pp. 271–286., https://doi.org/10.2147/nss. s141132.

CONTINUINGeducation

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Mastering the Myo Merge: The Importance and Essentials in Implementation in the Dental Office by Karese Laguerre, RDH 1. Orofacial myofunctional therapy is NOT effective when all of the following conditions are present, EXCEPT _________. a. Significant sleep apnea b. Orthodontic appliances c. Physical obstruction to nasal breathing d. Insignificant palatal width for tongue rest 2. Establishing or forming a new collaborative relationship should be treated like meeting a new friend. a. True b. False 3. Which of the following professionals are essential on a collaborative care team ___________. a. Orofacial myofunctional therapist b. Otolaryngologist c. Manual therapist d. Only A&B e. All of the Above 4. There are 4 steps in successful team building and development. a. True b. False 5. During the process of maintaining the collaborative relationship, the 3 T’s approach is recommended. This consists of all EXCEPT _______________. a. Transposing trust b. Transferring a problem into a solution c. Translating respect d. Implementing trust

6. A mutually respectful, didactic referral relationship continues to enhance learning from both parties. a. True b. False 7. In a successful collaborative relationship there is no need to foreplan a possible end to the relationship. a. True b. False 8. Transitioning a dental hygienist to the in-office orofacial myofunctional therapist means the team must ___________. a. Carve out time in her schedule designated OMT b. Create a dual-compensation payroll format c. Have detailed, thoughtful discussions around a complex change in expectations d. Add new services to the office website 9. A single introductory course in orofacial myofunctional therapy should suffice for quality patient care and outcomes. a. True b. False 10. An employment contract should consist of terms regarding ______________. a. Compensation b. Expenses c. Length of service d. Continuing education e. Expectations f. Only A, B, & E g. All the Above DentalSleepPractice.com

CLINICALfocus

Can We Really Prevent OSA in Children? Would making two simple changes to our strategy increase our chances of success? by William M. Hang, DDS, MSD

id you know very young children with reduced oxygen saturation during sleep can be afflicted with irreversible brain damage?1 If you’re surprised, you are not alone. Currently, lateral expansion and tonsil and adenoid removal are becoming more popular, but more can and should be done. After decades in the sleep arena, I have concluded that by making two changes to our treatment strategy, we can significantly increase our chances of success. Focus on the A-P Plane of Space

First, we need to look at how the human skeleton has evolved. In two independent studies, research conducted by anthropologists Dr. Daniel Lieberman2 at Harvard and Dr. Robert Corruccini3 at Southern Illinois University, explain that the mid-faces of all people living in all industrialized countries are recessed relative to our ancestors. With both jaws more recessed, the soft palate and

2A.

Figure 1

36 DSP | Spring 2022

2B.

the tongue are also recessed which compromises the airway. As one pre-eminent sleep physician, Dr. John Remmers, explains, “...a structural narrowing of the pharynx plays a critical role in most, if not all, cases of OSA”.4 It is very easy to expand the maxilla laterally, but I believe we need to focus our energy on the A-P plane of space. Figure 1 shows a 16-year-old boy with an inter-molar width of 45.5 mm. He was treated by another practitioner with an expansion device to achieve this very broad width which is probably 10 mm wider than most children this age. Although successful in lateral expansion, the appliance used does little or nothing to develop the face forward. This patient’s profile is significantly recessed – and he snores! This case only reinforces my mantra, “You cannot expand your way out of an anteroposterior problem”. Can we develop the jaws further forward? Would that forward development improve

2C.

Figure 2A-2C: Facial meltdown waiting for four permanent upper incisor teeth to erupt! A. 5y 5m; B. 8y 4m; C. 10y 11m

CLINICALfocus the airway? There is evidence in the literature that the answer to both those questions is “Yes”.5,6 Lateral expansion of the maxilla is part of the process used in the treatment described in these articles, but the A-P part of the treatment is the other strategy employed which goes beyond current trends.

Treat Children in the Primary Dentition

The second strategy is to treat children in the primary dentition. A recent Journal of Clinical Orthodontics survey of the profession indicated that orthodontists rarely treat before the first molars erupt at age 6.7 The adverse effects of reduced oxygen in a child’s brain won’t wait until age 6 to occur. Therefore, I can’t justify waiting to treat until we have permanent teeth in the mouth. Figure 2 shows a child I first evaluated at 5 years 5 months of age with all primary teeth present. He was a slow dental developer and didn’t have all four upper incisors in place until he was almost 11 years of age. These pictures show that not only did his face not develop forward, it recessed more than a centimeter during that 5-year period. We began treatment when the upper four incisors were present. What I discovered was that too much unfavorable vertical vs. favorable horizontal growth had already occurred to get a more desired result. Even the best-cooperating patient and most experienced doctor could not overcome this growth deficit to get the desired amount of forward growth. Figure 3 compares his profile at age 18 years 5 months of age with that of his father at age 35 years 9 months of age. Although our efforts did get some forward growth, our waiting caused us to start from a worse position with his lower face back more than a centimeter! His father suffers from OSA just like millions of others with faces similarly recessed. Prior to age 40, the father had problems associated with his OSA which resulted in having stents placed in his coronary arteries. The questions which concern me most are: With the boy’s profile recessed almost as much as his father’s,

do you suppose he is at greater risk to develop similar problems? What if we had begun treatment for him prior to the eruption of any permanent teeth and had stopped the unfavorable vertical growth earlier? This one patient was a game changer for me. I decided I had no choice but to treat when we first recognized the problem even if it was in the primary dentition. I could not, in good conscience, continue to do what I came to think of as “supervised neglect”. Waiting until four upper incisors were in the mouth, with predictable long-term impact so severe, I began to treat earlier. Treating in the primary dentition is pretty scary for most orthodontists who are not prepared behaviorally to deal with kids this age. Pediatric dentists generally have the training to work with children under 6. Several pediatric dentists are recognizing this and understand that they are on the front lines of the airway pandemic that is affecting our population. The following two patients were among some of the first I treated in the primary dentition. The two biggest factors in the success of these cases were beginning treatment early and the mother’s desire to have the best for her children. Figure 4 shows the first patient at 4 year 10 months who had a gummy smile because her upper anterior teeth were already 13 mm back from an ideal position. We began treatment and advanced these teeth about 13 mm. Her permanent incisors eventually followed the primary teeth into good positions.

4B.

4C.

3A.

3B. Figure 3A-3B: What are the chances he will be like his dad with OSA? A. 18y 5m; B. 35y 9m

4A.

4D.

Figure 4A-4D: Treatment began at 4y 10m. A. & B. Pre-treatment; C. & D. Post Orthotropics®

Bill Hang, DDS, MSD, has been in private practice since 1975 and is currently practicing in Agoura Hills, California. Having been traditionally trained, he extracted teeth for crowding and often retracted the teeth. For the last 40 years, however, he has been a pioneer in non-retractive treatments to improve the airway in patients of all ages and recently founded OrthO2Health.

DentalSleepPractice.com

CLINICALfocus

5A.

5B. Figure 5A-5B: Treatment began at 3y 10m. A. Pre-treatment; B. Post Orthotropics®

The gumminess of the smile was eliminated, and her lower face was guided forward. Figure 5 shows her sister with upper incisor teeth 12 mm too far back at 3 years 10 months of age. We advanced the upper anterior teeth about 12 mm and guided the mandible forward. Her profile improved even more than her sister’s. Their mother is thrilled with both the esthetic and functional improvements we achieved. We are now performing the same treatment for the younger brother. The ADA has made a big step forward thanks to Dr. Steve Carstensen’s work. In 2017 he helped the ADA issue a proclamation calling for dentists to screen for all forms of sleep disordered breathing in children.8 Unfortunately, not near enough progress is being made to implement a long-term strategy. From my experience, making two simple changes – focusing on the anteroposterior plane of space and treating in the primary dentition – increases our odds of success dramatically.

We are all on this journey together in uncharted territory. I do not have all the answers, but I hope to create an awareness of some of these problems, teach what I have learned over the years, and inspire others to develop even more effective treatments because “You can’t expand your way out of an anteroposterior problem.” 1.

2. 3.

4. 5.

7. 8.

Harper RM, Kumar R, Ogren JA, Macey PM. Sleep-disordered breathing: effects on brain structure and function. Respir Physiol Neurobiol. 2013 Sep15;188 (3):383-91. Liberman DE. The Evolution of the Human Head 2011; The Belknap Press of Harvard University Press Corruccini, RS. How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes. Lewiston, NY: The Edwin Mellen Press;1999. Remmers J. Personal communication. AACP 2002. Singh GD, Edina LE, Hang WM. Soft tissue facial changes using biobloc appliances: geometric morphometrics. Int J of Orthod. 2009;20:29-34. Singh GD, Garcia-Motta AV, Hang WM. Evaluation of the posterior airway space following biobloc therapy: geometric morphometrics. J of Craniomandibular Practice. 2007; 25:84-89. Keim RB, Vogels DS, Vogels PB. 2020 JCO study of orthodontic diagnosis and treatment procedures. JCO. 2020; LIV:731-745. ADA House of Delegates; The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders. 2017

9 IN 10 CHILDREN EXHIBIT SYMPTOMS OF SLEEP DISORDERED BREATHING Scan the QR code to become a HealthyStart Provider today to treat the over 40 million children affected!

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38 DSP | Spring 2022

contact@thehealthystart.com

PRODUCTspotlight

Every Breath Counts Benefits of Same-Day Delivery of HealthyStart®’s Preformed Intraoral Appliance to Address Pediatric Sleep Disordered Breathing by Beth Rosellini, DDS, AIAOMT

ral healthcare providers are uniquely positioned in their communities to educate patient families on Sleep Disordered Breathing. Dental teams screen for signs and symptoms, and initiate low-risk, high-reward therapeutics to reduce and resolve corresponding poor oral habits and chronic conditions. As supported by publications by the ADA and the International Pediatric Otolaryngology Group, a cross-disciplinary approach to children’s breathing problems optimizes clinical outcomes. More specifically, dental providers have:

A HealthyStart patient wearing the first appliance of their system, the Habit Corrector.

1. The capacity and opportunity to educate patient families on this condition via the recommended 2x/year wellness hygiene visits. They simply spend more time with kids and caregivers than their physician counterparts. 2. The knowledge to screen patients for root causes of Sleep Disordered Breathing with expertise in hard and soft tissue developmental patterns that can impact this condition. Tongue posture and function, inter-arch relationship, and shape of the arches all affect children’s breathing.

Beth Rosellini, DDS, AIAOMT, is a biological dentist and clinical researcher with special interest in chronic inflammatory conditions, airway and sleep health, and alternative/non-pharmaceutical 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.

2-year progress with the HealthyStart System from age 7 (left) to age 9 (right). Photos courtesy of Anthony Marino, DDS, MS.

3. Therapeutic tools to begin to reduce the symptoms, and, in some instances, completely resolve the concerns, preventing the need for any other therapeutic intervention. Patients treated with intraoral appliance therapy, specifically with the HealthyStart® Habit Corrector, have demonstrated major improvement in many clinical conditions associated with their poor sleep, health, and breathing. The device incorporates internal therapy that benefits every pediatric patient. Because it is founded on passive wear of the device at night, it removes most barriers to compliance. Adding services to treat the pediatric population is a natural progression for an adult practice. Most adult patients, especially if they have breathing problems of their own, can understand the benefit of intervening early to prevent the exacerbation of this condition and all the comorbidities that come with it. Their personal experience often enhances their motivation to support the child through the recommended plan. DentalSleepPractice.com

PEDIATRICS

Which One is the Best? by Lauren Ballinger, DDS

am frequently asked by colleagues interested in incorporating early airway focused treatment into their practice, “should I use Myobrace, Healthy Start, or some other myofunctional orthodontic “system?” Nothing makes me happier or more excited for the future of our profession than knowing there are others wanting to learn how to treat littles with preventative dental sleep medicine. Rather than giving my personal recommendation on a specific system, I believe the best answer is found by asking yourself more questions. Do you understand WHY myofunctional orthodontic systems (oral trainers and appliances) work? Do you know what the goals of treatment are for these systems? Which patients are good candidates for this treatment approach? Answering these questions requires use of your own brain, rather than relying on a branded message. If you are willing to lean-in to the details, then I think any of these systems can be an excellent match for select patients. After you’ve mastered the system details, there are patient-centered questions. What are their concerns and fears? Their dental and health goals? In pediatrics, it’s important

40 DSP | Spring 2022

to bring the child into the conversation in an age-appropriate way. They are the ones treating themselves, after all. Getting them curious and excited goes a long way in gaining their trust, acceptance, and compliance. Having an understanding of anatomy and physiology, craniofacial growth and development, how behaviors and compensations come into play and what internal (body) and external (mind, environment) barriers your growing patient may face, are crucial to informing your treatment choices. Human variation requires more than one system, one appliance, one lab, or one treatment approach. The better you understand your patients, the more apparent it will become which “tool(s)” may be the most effective. I am partial to Myobrace because that is what I am familiar with and have been using for almost 7 years; I am a certified provider. I like that Myobrace has a strong myofunctional educational platform that works in conjunction with their oral appliances and trainers. If you understand the science behind myofunctional therapy and how the appliances/trainers function as adjuncts, then it really doesn’t matter what system you use. You can think through these cases yourself, choose cases wisely and know how to trouble-shoot. On the other hand, I believe some of the other systems, such as Heathy Start, offer more direct guidance with case selection and treatment. This has benefits, especially for those new to these treatment options. Understanding WHY these systems help our patients is more important than which system you use. Simply stated, these systems work on habits and muscles, not the teeth. They are functional appliances that can lead to better health, and as a “side benefit” also make the teeth straighter. These systems work via normalizing oral muscle function by way of re-patterning and correcting para-functional/ dysfunctional orofacial muscle habits and establishing nasal breathing day and night. The younger we initiate treatment, the better we can help children untangle

PEDIATRICS their poor habits and “grow-out” of the suboptimal growth patterns that put them at risk for sleep breathing disorders, including sleep apnea. Tooth and bite relationships begin to correct when the underlying causes of malocclusion and poor craniofacial growth are treated, e.g., incorrect muscle function, poor oral rest posture, and nasal disuse. These goals are universal, patient improvement is not; progress requires time and support. If nasal breathing is not achieved in the first months of treatment, you should figure out why. Is it a compliance issue? Is it a structural issue? Do they need a referral to an ENT or allergist? Any of these systems can produce aligned teeth, well developed faces, and healthier airways. Nasal breathing reduces inflammation in the nasal and posterior airways and improves blood gas balance. Your patient learns to keep their lips gently together at rest with the tongue in a supportive position in the palate, facilitating development of the maxillary arch. The facial muscles no longer need to assist with swallowing, reducing forces that cause downward and backward growth of the jaws, narrowing of the posterior airway, and stress to the TMJ. Breathing is healthier and more efficient, restful sleep is more likely to be achieved, an overactive sympathetic nervous system begins to relax, pain patterns are reduced AND skeletal growth and dental development begin to normalize. The body returns to homeostasis. These appliances/trainers can also provide light forces that, in conjunction with improved muscle function, create some maxillary expansion and uprighting of mandibular teeth. As impressive as the results can be, it is vital to understand the limitations of these systems. They are 100% reliant on patient compliance. Your job is to screen your patients, identify their goals for treatment, and offer a tool to help them. During therapy, our role is to monitor results and offer changes in course if the original treatment plan is not producing the desired outcome. For example, while it is true that establishing nasal breathing can lead to reduced inflammation of the adenoids and/or tonsils, it is also true that they can be so obstructive that they ARE the barrier. In other words, can your patient breathe through their nose effectively and efficiently enough to be able

to break through and find success in a myofunctional orthodontic program? Or are they stuck? We want our patients to be successful and not get frustrated and give up. Sometimes, requiring a child to breathe through the nose, lips closed, with a rather large appliance in their mouth, is just too much to ask. Sometimes, it works like a charm. Recognizing the nuances and being able to think through WHY this treatment approach may be working well, or not so well, will produce clinical wisdom, improving your confidence. I cannot overstate the importance of remembering that every day a child is not breathing, sleeping, and growing well, is a day that they cannot get back. We must not waste precious time attempting to pound a square peg through a round hole. Change course if you need to. Adding a myofunctional component may be the key to making other therapies more successful. Our young and growing patients who breathe through their nose both day and night, with harmony in their orofacial muscle function and proper oral rest posture, will grow-up healthier AND have better looking faces with straighter teeth. No matter which myofunctional orthodontic system(s) you use, as long as you understand WHY they work, choose your cases wisely, know what the potential barriers to treatment may be, when to refer for collaborative care, and that there is no such thing as a one size fits all approach, then you can make a huge difference in a child’s life. AND have fun doing it.

Understanding WHY they help is more important than WHICH system to use.

Dr. Lauren Ballinger is a board-certified pediatric dentist and a specialist in orofacial myology. She practices pediatric airway focused dentistry in Western Massachusetts and is the founder of Good to Grow: Pediatric Dental Wellness, Airway, Grow and Sleep Solutions and The Nurture Frenectomy Center. Dr. Lauren founded The Endeavor Group: a global assembly of passionate health professionals, promoting awareness of, and solutions for optimal breathing and airway health for children under age 6. She is also the pediatric dental chapter leader for the AAPMD. Dr. Ballinger is a featured faculty member in The Pankey Institute’s Dental Sleep Medicine program, focusing on preventive dental sleep medicine for the pediatric dental population. She is forever grateful to her own children, Jack and Libby, who ignited her passion and motivated her pursuit of knowledge.

DentalSleepPractice.com

PRODUCTspotlight

ProSomnus® EVO™: Crossing the Chasm in DSM Implementation by Mark T. Murphy, DDS, D.ABDSM

rossing the Chasm is a term related to the technology adoption lifecycle. The ‘chasm’ exists between the early adopters and early majority. When cell phones crossed the chasm, it was because the features, advantages and benefits enjoyed by early users were clearly appreciated by the rest of us. Using artificial intelligence, robotic manufacturing, and an innovative medical grade material, ProSomnus EVO is an Easy, Safe and Effective DSM device. Early adopters made EVO their ‘go-to’ right away and now the early majority are, too. With EVO, device selection is easier, there are fewer side effects, and the efficacy is better than legacy devices, according to data submitted by ProSomnus doctors. Let’s have a look at how EVO helps you Cross the Chasm! Make it Easy

The ProSomnus portal offers transparency to cases, invoicing and payment options. It prevents ordering mishaps and shows every device design feature. The customer care and operations teams are trained to work with a full range of bite registration techniques – you choose what’s easy. Send your best impressions or scans. ProSomnus accepts every kind of STL file – they were the first with a completely digital pathway to manufacture these medical devices. The precise fit ProSomnus is known for is even better with the MG6™ material of EVO. First time easy delivery and great fit without adjustments is standard. Doctors report scheduling shorter delivery appointments. Less time and stress – that’s easy.

Must be Safe

The smaller milled platforms provide more tongue space. This results in the need for less ‘dose,’ or advancement. Our doctors report less tooth

Mark T. Murphy, DDS, D.ABDSM, is an American Board of Dental Sleep Medicine Diplomate and has practiced in the Rochester, MI area for 40 years. He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, serves on the DSM faculty at University of Detroit Mercy School of Dentistry and is a regular presenter on Dental Sleep Medicine at the Pankey Institute. He has served on the Board of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center, and the Dental Advisor. He lectures internationally on Leadership, Strategic Planning and Dental Sleep Medicine.

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movement, easier recapture of the MIP bite, and fewer adverse side effects. Milled PMMA and MG6™ both outperform others in device hygiene and staining. Other partially milled devices have hand-assembled advancement mechanisms or add soft liners that compromise precision and cleanability. Biogunk and stain have long affected physicians’ and patients’ views on OAT. Better devices, with fewer side effects that are easier to keep clean – that’s safe!

More Effective

Results matter. Better efficacy and excellent compliance delight patients, physicians, and payers. Recent studies show the true cost of CPAP is 2-3x that of OAT over 3 years. Physicians want therapeutic results; payers want lower costs; and patients want comfortable devices. ProSomnus is investing in clinical and RCT to establish OAT as a frontline therapy and demonstrate to the FDA a clearance for severe OSA, so more people can be treated – that’s effective! Watch for more innovation from ProSomnus – our team is working to provide answers for all your office system needs, so you can continue your dental and your sleep practice with confidence and profitability.

PRACTICALtips

To Breathe, or Not to Breathe That is the Question – Xlear is the Answer

by Lisa Stillman, RDH, BS; Julie Seager, RDH, BSDH; and Rhoda Kublickis, RDH, BASDH, MHS

ylitol – you may know it as a natural sweetener, but did you also know it has wellness properties which enable it to be used for prevention and treatment of certain systemic conditions and biofilm-related illnesses? Every airway-aware clinician has an opportunity to improve not only nasal breathing but have a serious impact on their health using xylitol. Xylitol’s Mechanism of Action (MOA) in the upper airways is as follows: • Blocks adhesion of pathogens to mucosal tissues (bacterial, fungal, viral) • Hypertonic: Opens airway by reducing swollen tissues • Facilitates cilia movement which enhances the natural mucociliary cleaning cycle and produces nasal nitric oxide (NO) • Hydration/moisturizing Research has found that xylitol blocks adhesion of bacteria to epithelial cells thus allowing the body to wash them away.1 Irrigating the sinuses with a saline-xylitol solution has also been shown to improve chronic rhinosinusitis symptoms associated with the nose, ears, facial pain, quality of sleep, and daytime productivity versus a saline-only irrigation.2 In a 2015 presentation, Dr. Nsouli shared his findings of a study which showed that a nasal spray with xylitol increased peak airflow 35% more than saline alone and measurably increased participants’ quality of life.3 In a similar study, Drs. Olmos and Baba’s findings showed that three minutes after spraying participants’ noses with Xlear Sinus Spray, participants experienced a 20% improvement in airflow volume. “The health benefits of nasal volume and flow improve sleep breathing disorders and respiratory disease. Increases in nasal breathing results in uprighting head posture resulting in a reduction of chronic facial pain, headaches and jaw locking.”4 Prior to the pandemic, it was well established that saline spray with xylitol was highly effective on bacterial and fungal pathogens

in the nose. Effectiveness on viral pathogens has, naturally, claimed the attention of medicine. Xlear has been proactively working with researchers conducting in vitro and in vivo studies. Researchers found the nose has the highest viral load of SARS-CoV-2 in the body when infected with the virus.5 By adding anti-viral or virucidal agents, like xylitol and grapefruit seed extract, to a saline nasal wash, the scientists found lower viral loads – making the combination beneficial against SARS-CoV-2.6 A case series of three patients with active Covid infections showed that use of Xlear Nasal Spray resulted in a reduction of symptoms related to the viral infection and received a negative test twice as fast as participants who did not use the nasal spray.7 Researcher Antony Cheudjeu found that xylitol blocks receptor sites of the SARS-CoV-2 virus which inhibits it from attaching to the cell wall of its host.8 Researchers also performed laboratory studies at Utah State University (2020) and University of Geneva (2020) which showed Xlear Nasal Spray destroyed 99.99% of the SARS-CoV-2 virus.9 In a different study, researchers used electron microscopy to photograph the interaction between xylitol, grapefruit seed extract (GSE), and the SARS-CoV-2 virus. They concluded, “Combination therapy with GSE and xylitol may prevent spread of viral respiratory infections not just for SAR-CoV-2 but also for future H1N1 or other viral epidemics. GSE significantly reduces the viral load while xylitol prevents the virus attachment to the core protein on the cell wall.”10 Dental offices assisting patients to improve their airway health have long suggested nasal rinses to increase nose breathing. Suggesting a combination of saline, xylitol and grapefruit seed extract such as Xlear adds antiviral effects. Patients seeking natural products to address health concerns can be assured the lack of artificial chemicals and medications will provide them relief from nasal stuffiness, decreased exposure to the virus, and the convenience of DentalSleepPractice.com

PRACTICALtips a simple spray. Reducing barriers to effective therapy benefits every outcome clinicians hope for.

About Xlear

Xlear Inc. is the leading manufacturer of natural nasal care products containing xylitol. The company started in the year 2000 and is based in American Fork, Utah. Xlear, Inc. is committed to providing natural, health-enhancing products based on the safety, effectiveness, and science of xylitol. They offer drug-free sinus and oral care products, and a line of natural xylitol sweeteners. 1.

Kontiokari, T., Uhari, M., & Koskela, M. (1998). Antiadhesive effects of xylitol on otopathogenic bacteria. The Journal of Antimicrobial Chemotherapy, 41(5), 563–565. 2. Weissman, J. D., et al. (2011). Xylitol nasal irrigation in the management of chronic rhinosinusitis: a pilot study. The Laryngoscope, 121(11), 2468–2472. 3. Nsouli, T. M.; et al., (2015) ORAL ABSTRACT #46. 4. Olmos, S., Baba, J., (2019.). Improved Nasal Volume Utilizing Hyperosmotic Saline Xylitol Mixture (Effective Alternative or Adjunct to Decongestants and Antihistamines). EC Pulmonology and Respiratory Medicine 8.5, 444-452. 5. Zou, L., et al., (2020). SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. The New England Journal of Medicine, 382(12), 1177–1179. 6. Farrell NF, et al. (2020). Benefits and Safety of Nasal Saline Irrigations in a Pandemic—Washing COVID-19 Away. JAMA Otolaryngol Head Neck Surg., 146(9):787–788. 7. Go, C. C., et al., (2020). Potential Role of Xylitol Plus Grapefruit Seed Extract Nasal Spray Solution in COVID-19: Case Series. Cureus, 12(11), e11315 8. Cheudjeu, A. (2020). Correlation of D-xylose with severity and morbidity-related factors of COVID-19 and possible therapeutic use of D-xylose and antibiotics for COVID-19. Life Sciences, 260, 118335. 9. Ferrer, G., et al., (2020). A Nasal Spray Solution of Grapefruit Seed Extract plus Xylitol Displays Virucidal Activity Against SARS-Cov-2 In Vitro. BioRxiv. 10. Cannon, M. L., et alk., (2020). In Vitro Analysis of the Anti-viral Potential of nasal spray constituents against SARSCoV-2. BioRxiv.

Xlear Nasal Spray and Kid’s Xlear Ingredients: Water, Xylitol, Sodium Chloride, Grapefruit Seed Extract (GSE)* MOA: Hydrates nasal tissues, hypertonic properties which reduce tissue swelling to open the airway, reduces the ability for pathogens to stick together, cell divide and invade the tissues. Blocks adhesion of pathogens to mucosal membranes. Washes away allergens and pathogens. Protocol: Use prophylactically morning and night. Use every four hours when symptomatic of allergies or infection. Safe for all ages. Safe for use during pregnancy. No drug interactions. Xlear Rescue Ingredients: Water, Xylitol, Glycerin, Sodium Chloride, Sodium Bicarbonate, Oregano, Tea Tree, Eucalyptus, Parsley, Pau D’ Arco, Grapefruit Seed Extract (GSE)* MOA: Essential oils alleviate congestion, open airway. Protocol: Use as needed when exposed to pathogens.

Xlear Max Ingredients: Water, Xylitol, Capsicum, Aloe Vera, Sodium Chloride, Grapefruit Seed Extract (GSE)* MOA: Xlear Max quickly alleviates sinus pressure, capsicum acts as a natural vasoconstrictor. Protocol: Use for severe sinus pressure, sinus headache, allergies and congestion as needed. Xlear 12-Hour Decongestant (medicated) Ingredients: Oxymetazoline HCL (hydrochloride), Benzalkonium Chloride, Purified Water, Xylitol MOA: Oxymetazoline HCL (hydrochloride) is a medicated vasoconstrictor which shrinks swollen tissues immediately. Xylitol alleviates dryness and mitigates rebound effect. Protocol: For temporary use only. Provides instant relief from severe congestion due to colds, hay fever, or sinusitis. Use as needed every 12-24hrs. Follow instructions on packaging.

* Is grapefruit seed extract (GSE) safe to use with medications? Furanocoumarins interact with a variety of medications. From grapefruit juice and pulp, 45,000 - 139,000 ppb of the chemical is common; from GSE, 62 -345 ppb. There isn’t data available for medication interactions at this level, so customers should consult their physician prior to use of any products containing GSE. – Jason Neal, Quality Manager, Xlear

Lisa Stillman, RDH, BS, knows from personal experience how this natural sweetener, xylitol, can help those in need. She is a cliniXlear nasal care products cal dental hygienist, national speaker, published author, and was awarded the RDH Magazine/Sunstar Award for her work with the mental health population. Lisa is a Regional Education Manager for Xlear/Spry, who is the leading manufacturer of the xylitol dental defense system. She can be contacted at Lisa.Stillman@Xlear.com. Julie Seager, RDH, BSDH, is an informed and engaging speaker and published author with more than 25 years in the dental industry. She blends real-world experience and evidence-based clinical information so her audiences can put to good use what they learn in her courses. Julie is sponsored and employed by Xlear, Inc. as the Western Regional Education Manager, representing both Spry and Xlear Xylitol products. She lives in Sacramento, California where she also uses her “passion for prevention” to help encourage her dental hygiene patients toward achieving improved oral and systemic health. Julie can be contacted at Julie.Seager@Xlear.com. Rhoda Kublickis, RDH, BASDH, MHS, was born in the Philippines. Twenty-nine years after receiving her Associates in hygiene school, she received her Masters of Health Science at Nova Southeastern University. Prevention is her passion. She has educated thousands across the country on the oral systemic link as the Regional Education Manager for Xlear/Spry. Rhoda can be contacted at Rhoda.Kublickis@Xlear.com.

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#12

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EXPERT view

Wait, We Have Four Sets of Tonsils? Where Are They, and What Do They Do? by Tom Colquitt, DDS

ere’s a fact I’ll bet, unless you are a parent of young kids, you haven’t thought much about as a dentist. Lots of kids, even after they have their adenoids removed, continue to have Recurrent Otitis Media (ROM), ineffectively treated with antibiotics and tubes inserted through the tympanic membrane, exposing the middle ear to the outside world. After draining off a pool of pus, the piercing becomes a source of more infection. Often these kids now have problems with their Tubal Tonsils, which hypertrophy and remain infected along with the middle ear.

Figure 1

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Everything needed to sustain life comes to us through our nose and mouth. All these structures need to have the correct “Place in Space in the Face” and the airway behind it (thanks to Sandra Kahn for that term). Each has specific functions with shared plumbing, which requires exquisite cooperation between the air conditioning structures and the food processing structures. This functional symbiosis is run by the tongue. The tongue is the conductor of the business of living and needs to construct its own Linguatorium (my term) in which to run the show, beginning at or before birth. There is a ring of tonsillar tissue (Waldeyer’s Ring) surrounding the air-gathering pharyngeal structures at the back of the throat. These are essential bits of lymphatic tissue necessary for a properly functioning immune system. The driver is functional nasodiaphragmatic breathing (NDB) and a proper swallow after efficient mastication. All of which is led by coordinated tongue movement within the Linguatorium which it helped create and maintain.

There are bilateral sets of four tonsils surrounding the airway (Figure 1). We can see some of them. Some we can’t. They, along with the nose, are our bodies’ Maginot Line against would-be pathogenic invaders. In 1939, Germany went right around the Maginot Line to invade and occupy France. Airborne pathogens can do the same thing if we have structural, functional, and behavioral breathing problems that permit this to happen. And it happens so much as to be pandemic.

From Top to Bottom

Pharyngeal Tonsils, or Adenoids. First lymphatic responder in nasal breathing to pathogens and particulates missed by the cilia of the nasal epithelium and the antimicrobial effects of Nitrous Oxide (NO) secreted in the paranasal sinuses. NO is secreted at 200 times the level needed for killing inhaled pathogens, according to Dr. Emet Schneiderman of Texas A&M College of Dentistry. As such, the nose is our natural first responder, and we as homo sapiens are hardwired for naso-diaphragmatic breathing. The released NO also potentiates the activity of the cilia in the airway epithelium to expel inhaled noxious particulate matter. In addition to killing microbes, nasal inhalation warms, moisturizes and filters incoming air before it can reach the Adenoids and other tonsils. Nasal breathing to and from the diaphragm utilizes all the lung volume, whereas shallow mouth breathing uses the intercostal muscles and only the top third of the lungs. The diaphragm is the pump for the immune system. You can see that the Pharyngeal Tonsils (Adenoids) are part of the back of the throat. Since they have no capsule like the Palatine Tonsils, it is virtually impossible to completely remove them surgically without damaging this part of the pharyngeal wall. Let’s continue our tonsillar tour.

EXPERTview

Figure 2

Figure 3: Palatine Tonsils. Left - Acute Tonsillitis. Right - “Kissing“ Tonsils

Next Drainage Stop: The Tubal Tonsils They are located at the pharyngeal opening of the Eustachian Tubes (Figure 2) to keep bad stuff from crawling up the ET and causing a middle ear infection. Tongue movement and proper swallow mechanics opens the ET, equalizing pressure, unless overgrown tubal tonsils squeeze it closed. Last Drainage Stops: The Palatine and Lingual Tonsils The Palatine Tonsils are the big Figure 4: Middle ear infection (Otitis Media) boys we can see. Can’t see the Lingual Tonsils as they are embedded in the dorsum of the tongue. Figure 3 shows something very wrong with the Palatine Tonsils. Picture of the Kissing Tonsils shows something very wrong with the airway and is the reason the Pediatric guidelines for childhood Obstructive Sleep Apnea recommend Tonsillectomy as the FIRST line of defense. This despite these lymphatic structures being essential for a lifetime of immune system function.

In 1970, after graduating from Baylor College of Dentistry, Tom Colquitt, DDS, began practicing in Shreveport, LA where he still maintains a private practice. His practice has expanded beyond Dentistry and “Dental Sleep Medicine” into reinventing a new multidisciplinary medical model focused on detecting and correcting dysfunctional breathing in patients of all ages. Dr. Colquitt has been addressing and studying nocturnal sleeping/bruxism issues since the 1970s and treating nocturnal breathing issues with oral appliances since the 1990s. Additionally, he has been an adjunct professor in the Sleep Fellowship Program at LSUHSC medical school in Shreveport, LA since 2007. He is a former trustee of the Baylor College of Dentistry and a fellow in the American College of Dentists. Dr. Colquitt is past president of Baylor Century Club, Northwest Louisiana Dental Association, Ark-La-Tex Dental Congress, Southwest Academy of Restorative Dentistry, American Academy of Restorative Dentistry, and International Academy of Gnathology American Section.

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This despite multiple studies showing the airflow improvement is only temporary unless the child learns proper breathing behavior. This despite multiple studies showing kids who had T&A surgery frequently grow up to be sicker adults than those who didn’t. Ear infections are the most common reason for pediatric visits in this country, with 30 million doctor visits per year. Half of all pediatric antibiotics prescribed are for Otitis Media. The annual cost of treatment estimated at more than Two Billion Dollars. This is a pandemic plagued by ineffective symptomatic treatment that does not address the CAUSE. The middle ear is connected to the upper respiratory tract by a tiny channel known as the Eustachian Tube (ET). Germs growing in the nose or sinus can climb up the ET and enter the middle ear to start growing (Figure 4). This is more common in children than adults because these tubes are shorter and straighter than in adults. Why do these structures get infected so often in so many modern humans? What could contribute to this being such a hugely prevalent and expensive public health issue? The reason for overprescribed antibiotics and tissue mutilation? Could it be related to dysfunctional breathing involving problems with structure, function, and behavior, beginning at or before birth? Could it have something to do with a cascade of events caused by improper development of the Cranio Facial Respiratory Complex? You may be like me, having forgotten about Tubal Tonsils. We had no way to connect middle ear infections to mouth breathing, much less breastfeeding and early childhood nutrition. You may be curious what dentists can do about this problem. I’d love to tell you, but I’m out of space in this essay. Stay tuned…

SLEEP... IT’S WHAT WE DO

@apexdentalsleeplab

INmemoriam

In Memoriam

Todd D. Morgan, DMD March 4, 1958 – September 28, 2021

Todd was an exemplary friend and mentor to many of us in dental sleep medicine. His loss is deeply felt across our profession. In honor of our friend, I’m printing an essay he wrote about getting started in the field. Accompanying Todd’s words are tributes from some of his long-time friends in the industry.

Christina Marie LaJoie

My 33-year career at Great Lakes Dental Technologies afforded me many connections with amazing mentors and colleagues and many lasting friendships. I started in 1991, when only 3 appliances were available and based only on diminishing or eliminating snoring. I think of the first Alan Lowe/ Schmidt Nowara series of courses we presented, back in 1995. As the mailers were received by the prospective attendees, there were many questions about the content of the course and why they should attend. Dr. Todd Morgan was one of them, and I could feel his passion unlike any other. When we met, I felt like I already knew him. Even then I could sense his future contributions to the field of sleep for Dentists and Sleep Physicians, and ultimately the care he gave to his patients. We were all getting our pearls gathered with designs, materials, and records and how to manage relationships with sleep docs/laboratories. Dr. Todd was so eager to volunteer his time with his suggestions and clinical trials. He continued his research and encouragement for dentists to become more aware of sleep disordered breathing. He came up with a design change to the Sleep Herbst that many dentists adopted. It was new in my work ethic to be able to respect him as a Doctor and have that blend into a friendship. I was privileged to witness this amazing man from the very beginning and he never gave up! I was fortunate to call him, his wife Barbi, and their children my

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INmemoriam

West Coast friends. We made a point to have dinners once or twice a year, and twice I was a guest in their home. I miss him every day and stay in contact with Barbi. I will keep his visions alive through them and his many contributions to our Sleep Community

Pat Mc Bride, PhD, CCSH, Clinical Sleep Specialty

It isn’t often that someone comes into your life and sparks a previously unlit ember, lighting an entirely new pathway. Todd Morgan did that for me in 2006. I mean, how can you not listen when a guy whips out a bunch of illustrations of animal phenotypes, compares it to human anatomy, then tells you that the price for human speech, community and culture all started when the voice box dropped – unfortunately compromising our very ability to breathe. Wow, just wow. Back then in a culture where medicine wanted nothing to do with dentists, Todd paved the way for others with dignity, grace, grit, and a take-no-prisoners attitude. Todd got things done, adapted technology across the business and medical spectrums early – no one had ever heard of cardiopulmonary coupling back then, or medical/dental software. Plenty of derision, scoffs, and dismissive attitudes abounded, yet Todd kicked open many of the doors we all walk through today. Thank you,

Ultimately, Kindness and Laughter Count.

my friend. My most profound memory from the last few years was sitting after a course in Columbus, Ohio. Somehow the topic of our humanity towards each other came up, and Todd said something I shall never forget: “We do what we do to make a difference, take care of our families and educate our kids, but most of all, we do what we do to make the world a better, healthier place for others. We all bring our own quirkiness, spirit and sometimes our innermost demons to the table in order to make a difference. Ultimately, kindness and laughter count.” That advice and the generosity of spirit with which it was given will be my forever-treasured memory of Todd as he lives on in our hearts and minds.

John Remmers, MD

Todd Morgan was broadly interested in the field. He contributed innovative treatment, paleontology, and ongoing science to the treatment of obstructive sleep apnea. I can think of no higher praise than to recognize that Todd was continually curious about a lot of subjects.

DentalSleepPractice.com

INmemoriam

The Rewards of Dental Sleep Medicine by Todd D. Morgan, DMD

remember my first case using an oral appliance clearly, because it was my father. I knew that my dad snored – because we could hear it down the hall in our bedrooms! How my mother coped with that I’ll never know, but my brothers all thought it was funny. Little did I know what OSA was slowly doing to my father’s health, until I began my practice in Dentistry and hung out my shingle in the community of Encinitas. Starting a practice from scratch is not done much anymore, I don’ think, and so I had lots of time to read and comb through industry magazines while waiting for new patients to stroll in.

When I came upon a small article about a dentist in Albuquerque named Thomas Meade my eyes grew wider as I read about his invention and work with something called the Snore Guard®. I immediately thought of my dad but still could not appreciate the ramifications of OSA – there was no mention of it in the whole article and it had barely been discovered! I was so excited I drove from San Diego to see Tom and observe him. Tom was very gracious and shared his experience with me. Tom – Thank you, and RIP. I took Tom’s words to heart and started experimenting by gluing two night guards together. Now I was ready to fly to Dallas, with a supply of trays, alginate and stone in my suitcase. I thought my dad would be excited to try this fix for his obnoxious nighttime habit. Well, good luck with that. My dad was not the most friendly guy and kinda grumpy sometimes. It took a ton of convincing, but he finally agreed – after all, I was a doctor now… BTW – don’t mix stone in your mom’s kitchen sink! A trip home and another back to Dallas and I was ready to deliver! This time I brought my lab hand piece, acrylic and tools for the “delivery appointment.” I didn’t expect to have to convince him a second time to give it a go, but finally the stage was set. He reluctantly agreed and it was off to sleep, with me in the adjacent room, waiting for the symphony to begin…

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After about an hour, as I recall, I had heard nothing. I went down the hall to peek and pushed the door open. My dad was sound asleep and quiet! Problem was my mom was sitting up in bed. She saw me and I came over to her side to ask what was wrong. I’ll never forget her response: “I can’t sleep, it’s too quiet.” Really?? I was completely sold by my first case. And not so much by stopping a champion snorer in their tracks, but by the transformation my father underwent. He became a nice guy and more engaged with life (my mom said that it was a fair trade in her mind). I’m sure now that my dad had OSA, at least all the signs. That positive experience, and finding the right mentors launched my passion for further discovery and what has been a very rewarding adventure into Sleep Medicine and Oral Appliance Therapy. The help we can offer our patients, beyond their teeth, just became colossal. Thank you, Dad. Our reach into our patients’ health is more than I would have believed. And, for those that begin this work, get ready to make a lot of folks very happy – two or three at a time! Because it’s no joke, you are treating your patient plus their loved ones, friends and extended family. I’ve experienced incredible reward for doing this important work. I never anticipated finding it happening over and over again.

PRODUCTspotlight

Choosing the Right OSA Device “Which Sleep Device Should I Prescribe to My Patient?” by Alex Buddemeyer, CDT

ith over 200 different types of oral sleep devices used to treat obstructive sleep apnea in today’s market, it can be overwhelming for many practices to decide which to use. To give a simple answer, prescribing a sleep device can be determined by three main factors; is this a Medicare patient, do they have bruxism, and how many teeth do they have? Once you have the answer to these questions, determining the proper sleep device is easy.

Milled DynaFlex Adjustable Herbst®

DynaFlex® helps by keeping things simple for your practice by offering four of the most commonly used oral devices to treat your sleep patients: The DynaFlex Dorsal, The DynaFlex Adjustable Herbst, TAP® Devices, and EMA. The DynaFlex Dorsal® design addresses concern many patients have with hinged devices. Due to its 2-piece design, It allows the patient to comfortably yawn, take a drink of water, and not feel locked in like some of the other hinged devices. The DynaFlex Adjustable Herbst® device is one of only four designs that is PDAC approved for Medicare reimbursement. This device uses metal arms that attach the upper to the lower

Alex Buddemeyer is a Certified Dental Technician (CDT) and manager of the state-of-the-art Sleep Device Laboratory at DynaFlex. With a degree in Dental Technology and more than 11 years of experience in dental sleep medicine, Alex is able to advise the best way to handle even the most unique cases, as well as ensure your patients are receiving the highest quality sleep devices available on the market today.

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Milled DynaFlex Dorsal®

member making it a great design for bruxing patients. The PDAC approved TAP® devices have the most documented studies available on a single sleep device. TAPs® have a fixed hinge, keeping the patient locked in and held forward through out the entirety of their sleep. The TAPS are great for patients missing posterior teeth since the hardware is placed in the anterior unlike the Dorsal, Herbst, or EMA. The EMA is a popular choice due to its simple but effective design using vacuum formed trays with custom elastics to advance the mandible. With each elastic advancing the device by 1mm, it’s a no brainer to titrate the device. When starting out and trying to select a device, keep it simple and ask yourself these questions. Does the patient need a Medicare approved device or do they brux? Herbst or TAP. Are they missing posterior teeth? TAP. Do they need to be able to open their mouth? Dorsal. Need something simple? EMA Start helping your community sleep better today. Have questions or want to learn more about sleep devices? Contact DynaFlex Dental Sleep Medicine Department at 800489-4020 or email me directly at alexb@ dynaflex.com.

Quality Sleep Begins With Quality Devices

Milled DynaFlex Adjustable Herbst®

Milled DynaFlex Dorsal®

Features & Benef its

§ Medicare E0486 verified

§ Superior 2-Piece Design

§ Allows Lateral & Vertical Movement

§ Superior Compliance

§ Up to 5mm of Advancement

§ Up to 6mm of Advancement

§ Accu-Fit Liner Available

“The combination of digital scans and the DynaFlex® milled sleep device means less chair time, more efficacy and more patients successfully treated.” Dr. Richard B. Drake Dental Sleep Solutions

DynaFlex’s New Dental Sleep Medicine Website Is Up! Scan To View

SLEEPhumor

...The Lighter Side of Sleep Apnea

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Imagine the Dawn of a New Era in Sleep Apnea Treatment with Oral Appliance Therapy.

While we can’t yet release the “How?, When?, and What?”, we know the “Why?”; objective data will help you and your collaborative prescribers Treat More Patients More Effectively. In the meantime, our Medical Initiative continues to drive the education, awareness, and adoption of oral appliance therapy by prescribers and their patients to SomnoMed’s most valued sleep dentist partners.

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To learn how we can help you Treat More Patients, contact us at ussales@somnomed.com or call us at 888.447.6673