Dental Sleep Practice Summer 2022

AADSM Special Section Clinician Spotlight

Dr. Robert Rogers founder of AADSM

Influencers Making

‘SHIFT’

Happen

ProSomnus Medical and Dental Scientific Leadership Drs. Edward Sall, Shouresh Charkhandeh, Mark Murphy, and John Remmers

SUMMER 2022 | dentalsleeppractice.com PLUS

Continuing Education

SRBD During Pregnancy The Impact of Intervention on Maternal and Fetal Health Outcomes Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Steve Lamberg, DDS, D.ABDSM

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INTRODUCTION

Make a Start Without Having to Know the Ending

T

his year marks the 30th anniversary of Drs. Robert Rogers, Alan Lowe, Arthur Strauss, Peter George, and others founding the Sleep Disorders Dental Society. As you will read in the interview with Rob Rogers, they had no idea it would grow to have such an impact on dentists’ practices and the lives of millions of people around the world.

Such it is for the beginnings of things.

There is no predicting the full consequences of taking the leap forward that alters how one sees, thinks about, or treats another. We healthcare professionals have our niche – for the patients we welcome to our clinics and to the community. How we use that special position creates the unknowable impact.

You can choose to treat one person – for Dr. Rogers, it was his father-in-law (brave fellow, that Rob) and stop there. Or you can treat the next, the next, and reach out to make connections with colleagues – and everything changes.

What are you curious about? We open the airway with our devices, we collaborate with colleagues for diagnosis, co-therapy, and follow-up. Where in this process do you find ways to create? Not working off a script is one of the requirements of individualized, precision health care. Each unique presentation requires clinical wisdom and medical decision-making that keeps our care out of the black boxes of robot AI. May it ever be thus.

It is in creativity that innovation blossoms.

Problem solving is, first, recognizing there is a problem! What is your process, your commitment, to understanding the impact

breathing problems are having for your patients? For their families? The cumulative effect on community health? Is it the numbers – the AHI, ODI, and HRV? Or is it the sleepiness, the crankiness, the low work productivity? Think you as an individual provider can’t change how your local population thrives? Can you know Steve Carstensen, DDS all the benefits treating one person may Diplomate, American Board of have on everyone in their circles? On Dental Sleep Medicine the circles beyond them? Of course not.

You can dig in and, getting to know your patient, offer the best solution for them. Be creative, because improving one airway has unknowable consequences.

Working to make sure millions of airBe creative, ways have been improved has even bigger because improving consequences. You may not need to begin a whole society of medical professionals, one airway has but you can form a group in your commuunknowable nity. Include everyone who your patients invite to their healthcare team, and learn consequences. from each other how creative, bold, brave steps can impact our world. If you feel gratitude toward those who have paved the way, opened doors, and taught their colleagues, honor that work by pushing the boundaries further out and make those early efforts pay off in even wider ways.

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 “Sleep Related Breathing Disorders During Pregnancy: The Impact of Intervention on Maternal and Fetal Health Outcomes” by Steve Lamberg, DDS, D.ABDSM, which starts on page 34.

DentalSleepPractice.com

1

CONTENTS

Influencers Making ‘SHIFT’ Happen

by Len Liptak, ProSomnus Co-founder and CEO, and Mark T. Murphy, DDS, D.ABDSM Precision therapy will influence and accelerate SHIFT.

MEDICAL

8

Cover Story

Medical Insight

22

Nasal Airway Obstruction and Precision Oral Appliance Therapy in the Treatment of OSA

by Edward T. Sall, MD, DDS, MBA This article introduces a novel in-office procedure for treatment of nasal airway obstruction that should increase the efficacy of OAT.

ProSomnus Medical and Dental Scientific Leadership Drs. Edward Sall, Shouresh Charkhandeh, Mark Murphy, and John Remmers

34

Continuing Education

Sleep Related Breathing Disorders During Pregnancy: The Impact of Intervention on Maternal and Fetal Health Outcomes

by Dr. Steve Lamberg You may not have thought a dentist could help this population.

32

2 CE CREDITS

28

Medical Insight

Changes in Home Sleep Testing Technology

by Dr. Jagdeep Bijwadia Respiratory events and sleep staging can be determined from nontraditional signals. Some newer home sleep testing devices are using nontraditional signals to determine important physiologic parameters with fewer signals.

Special Section

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2 DSP | Summer 2022

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CONTENTS

6

Publisher’s Perspective

A Little Bit of Summer

by Lisa Moler, Founder/CEO, MedMark Media

12 Bigger Picture

Out of Breath – A Documentary Feature Film

by Lisa Moler Getting the word out on the big screen.

47 Technology Benefits of Clean Air in the Home

by Dr. Greg Jeneary Are you sure you know what HEPA means?

50 Product Spotlight

Publisher | Lisa Moler lmoler@medmarkmedia.com

Addressing the elephant in the room.

Chief Medical Editor Lee A. Surkin, MD, FACC, FCCP, FASNC drsurkin@n3sleep.com

Defining the Next Generation in Oral Appliance Therapy

14 Communications Corner

52 Product Spotlight

by Dr. Susan Maples Simple systems make more effective results.

Gaining confidence with excellent mentors.

Facilitare! The Art of Making Sleep Medicine Easier

18 Clinician Spotlight Dr. Robert Rogers

A small group started it all.

26 Board Member

Edward T. Sall, MD, DDS, MBA Meet our new medical editorial board member Dr. Sall.

31 Board Member

Jagdeep Bijwadia, MD, MBA

Coaching and Consulting Can Help You Offer Services for Pain and Sleep

54 Product Spotlight Snoring and Sleep Apnea Treatment Made Easy with Glidewell Making it easier to offer solutions to your patients.

56 Education Spotlight

Global Solution to Global Problems

Meet our new medical editorial board member Dr. Bijwadia.

by Shibani Sahni, BDS, PGD, MMSc, and Leopoldo P. Correa, BDS, MS, D.ABDSM Breathing beyond borders.

40 Pediatric

58 Alternative View

Pediatric Orofacial Myofunctional Therapy

How the MandiTrac Device Improved My Sleep Practice

by Robyn Merkel-Walsh, MA, CCC-SLP, COM® Maximize your service by learning what else is possible.

by Michael Kanter, DMD, DICOI Less worry about bite changes.

44 Product Spotlight

Serena Sleep’s Elevate Appliance

Building a Customized Educational Pediatric SDB Program for Your Practice Connecting therapy with devices.

4 DSP | Summer 2022

Summer 2022

62 Product Spotlight

A new innovative design emerges.

64 Sleep Humor

The Lighter Side of Sleep Apnea

Chief Dental Editor Steve Carstensen, DDS, D.ABDSM stevec@medmarkmedia.com

Editorial Advisors Steven Bender, DDS Jagdeep Bijwadia, MD (Pulmonary, Sleep) Kevin Boyd, DDS Karen Parker Davidson, DHA, MSA, M.Ed., MSN, RN Kristie Gatto, MA, CCC-SLP, COM Amalia Geller, MD (Neurology, Sleep) William Hang, DDS, MSD Christopher Lettieri, MD (Pulmonary, Critical Care, Sleep) Pat McBride, PhD, CCSH Jyotsna Sahni, MD (Internal Medicine, Sleep) Ed Sall, MD (ENT, Sleep) Alan D. Steljes, MD (Cardiology, Sleep) Laura Sheppard, CDT, TE DeWitt Wilkerson, DMD Scott Williams, MD (Psychiatry, Sleep) Gy Yatros, DMD

National Account Manager Adrienne Good | agood@medmarkmedia.com Sales Assistant & Client Services Melissa Minnick | melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius | emedia@medmarkmedia.com Social Media & PR Manager April Gutierrez | medmarkmedia@medmarkmedia.com Webmaster Mike Campbell | webmaster@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 | Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rate: 1 year (4 issues) $149 ©MedMark, LLC 2022. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

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PUBLISHER’Sperspective

A Little Bit of Summer

W

hile writing my message for this summer issue, John Mayer’s song “Wildfire” started playing on the radio. It started me thinking about what summer means. The song says, “… a little bit of summer is what the whole year’s all about.” After the past 2 years of rethinking, regrouping, and reopening, we’ve all worked so hard to get back to business. Working hard is what dentists do best – outfitting the office with the best equipment, taking continuing education courses, and learning new management techniques to keep the offices running smoothly. All the while keeping patients happy and offering the best dental care. Throwing your practice into high gear takes lots of energy and diligence. But, we also must remember to take a step back and at least for a little while, enjoy some of the joys of summer.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Summer 2022

An article in Forbes, called, “The Evolving Definition of Work-Life Balance,” says that “maintaining work-life balance helps reduce stress and helps prevent burnout in the workplace.” It continues that stress is one of the most common health issues in the workplace, leading to high blood pressure, stomach issues, aches, pains, and heart problems. Emotionally, stress can lead to depression, anxiety, insomnia, irritability, and low work performance.1 Balance means different things to different people. To alleviate stress, some people just like to spend some quality time with family or friends; some want to hop back on that cruise ship, and others like to hit the hiking trails and commune with nature. Whatever brings a smile to your face will keep summer in your heart and mind for the rest of the year.

Take us with you! On vacation or on your backyard deck, you can still consider new concepts to bring back to your office. Whether you read our publications in print, on your laptop, iPad, or phone, our articles are meant to inform, intrigue, and inspire you to new techniques, products, and services that promote success. The Cover Story in our summer issue focuses on Influencers Making “Shift” Happen. Len Liptak, Prosomnus co-founder and CEO, and Dr. Mark T. Murphy show how Prosomnus is guided by research and product development that revolutionizes OAT. Our CE, “Sleep Related Breathing Disorders During Pregnancy” by Dr. Steve Lamberg, shows

how sleep-related breathing disorders during pregnancy increase the risks to both mother and baby. Our Clinician Spotlight shines on Dr. Robert Rogers, founder of the American Academy of Dental Sleep Medicine.

Read about the evolving role of the AADSM as well as the dentists and physicians in this niche.

• How do you know when to take a step back so that you can continue moving forward? Here are a few tips: • Be aware of your feelings. If you start to feel more sad or grouchy than energized and content, it’s time to figure out why.

• Consider your priorities. What is most important to you in life? Do you need more time for yourself, friends, family, or just your pet?

• Don’t be afraid to change. Once you decide on a plan – do it! A change or rearrange of office duties can result in a calmer or more effective workplace.

We love our work. But we also have to remember to include a bit of play. At work, you are changing lives, and at play you are making memories. We need to rest and rejuvenate to create. John Mayer’s lyrics sum it up so well – “a little bit of summer makes a lot of history.” To your best success!

1.

Kohll A. The Evolving Definition of Work-Life Balance. Forbes.

March 27,2018. Accessed April 21, 2022. https://www.forbes. com/sites/alankohll/2018/03/27/the-evolving-definition-ofwork-life-balance/?sh=78c3e10d9ed3.

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COVERstory

Dr. Edward Sall

Dr. Shouresh Charkhandeh

Influencers Making

‘SHIFT’ Dr. Mark Murphy

Happen

by Len Liptak, ProSomnus Co-founder and CEO, and Mark T. Murphy, DDS, D.ABDSM

A

rchitect Frank Lloyd Wright’s iconic Guggenheim Museum was made possible by using reinforced concrete materials that brothers Albert and Julius Kahn had patented to build bigger and more efficient automobile plants in the Motor City. Prior to this, large buildings were built wider not taller, and had wooden substructures at risk of fire and rot.

Influencers like the Kahn brothers and the innovative use of materials combined with great design allowed ‘SHIFT to Happen’.

Today, by using MG6™ Technology materials, artificial intelligence, precision design, and robotic manufacturing, ProSomnus® Sleep Technologies is building better not bigger. These smaller, stronger platforms require less dose, invite fewer side effects, and have better efficacy and effective-

“It has become increasingly difficult to offer appliances that don’t rhyme with ‘BEVO’ because my sleep assistants insist on consistency and satisfied patients. ProSomnus EVO has significantly improved the time it takes to deliver, and for those who know my penchant for statistics, 96% of our EVOs are delivered with zero adjustments.”

– Kent Smith, DDS, D.ABDSM, D.ASBA

8 DSP | Summer 2022

Dr. John Remmers

ness than predicate materials and designs. It is time for another ‘SHIFT’.

Influence SHIFT

The total North American sleep market was worth 28.6 billion in 2017. Pillows and mattresses accounted for nearly 18 billion, sleep centers 4.2 billion and CPAP placements 4.3 billion, you get the idea! The market opportunity for OAT is huge, yet we have not taken the steps necessary to jump from the 5-7% market segment pond we play in, and into the Great Lake that is 15-20 times larger. For years, DSM has been talking about crossing this chasm and working alongside medicine, but until ProSomnus came along, no one was really doing anything to make it happen.

The SHIFT of just 10% of the gatekeepers prescribing patterns would triple or quadruple the market share we have of OSA treatment.

By earning the trust of sleep physicians, PAs, NPs, and third-party payers, we can influence decisions on which therapy is prescribed. Our surveys of boarded sleep doctors have given us great insight into why they don’t trust OAT. Our voice of customer inputs and data has guided research and product development that begins to solve this issue.

Insufficient SHIFT

Einstein’s definition of insanity was “doing the same thing over and over again and expect-

COVERstory

“The ProSomnus platform and EVO sleep device have elevated the conversation with physicians. There is a mutual respect now and a bond of trust. My referring physicians are writing more prescriptions for OAT. The cases we work on together have better outcomes, require less dose, take less time to treat and our patients are delighted.”

– Brandon Hedgecock, DDS, D.ABDSM, D.ASBA

Total Sample Size, % OSA Improvement and Count of Studies (Bubble Size) by OAT Device Type 80%

75% ProSomnus, 645, 69%, 10 70%

% Improvement

ing a different result”. Using devices that are uncomfortable, bulky, require more dose, invite side effects, and do not have exceptional efficacy do not earn trust. Gunky materials with a higher incidence of delivery challenges, repair, and replacement does not excite patients, payers, or physicians. It is just math. If we continue to use the same cold and bench cured, handmade assembled materials and devices, or porous, less precise materials, we cannot expect to grow dental sleep medicine beyond the paltry 5% share of treatment options chosen today.

Recent posters, articles and publications have described the precision medical devices of ProSomnus as advantaged. Smaller, stronger, less dose, fewer side effects, and easier to keep clean are only the beginning. Exceptional efficacy and adherence are slowly winning the hearts and minds of prescribers and building bridges. The EVO-lution began with ProSomnus [IA], moved to a dorsal variant, [CA] LP and through a Precision Herbst, [PH]. Today, ProSomnus EVO™ presents as the device that will help clinicians influence SHIFT in a way that has not been possible before.

65% Anterior Hinge , 399, 59%, 14 60%

Rod/Strap , 454, 60%, 3

55% Generic Labs, 296, 57%, 14

Dorsal Post , 428, 56%, 7

50% Herbst , 84, 50%, 4 45% 0

100

200

300

400

500

600

700

Total Sample Size

Meta Analysis Efficacy Data

Len Liptak is the CEO of ProSomnus® Sleep Technologies.

An award-winning executive with expertise growing and operating innovation-oriented businesses, Len is a founding member of ProSomnus, and co-inventor of the company’s flagship product. Len also serves on the company’s Board of Directors. Prior to starting ProSomnus, Len was President of MicroDental Laboratories, where he led the commercialization of multiple, award-winning new products, guided business unit operations, and directed the expansion of the company’s digital supply chain.

During Len’s tenure, the company grew three times faster than the industry average, expanded gross margins, and set company records for profitability.

Len was named to ExecRank’s list of top executives for privately held companies in 2012 and 2013. In 2016, Len led the sale of MicroDental Laboratories to the Modern Dental Group (HKG:3600). Len also spent 10 years at 3M Company and Stryker Corporation in strategic business development, business unit management, and product development capacities. Len earned an M.B.A. from the University of Minnesota’s Carlson School of Management and a B.A. from Brown University. A lifelong learner, Len has completed executive education programs at John’s Hopkins, and is a member of the Young President’s Organization (YPO).

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.

DentalSleepPractice.com

9

COVERstory “I’m fortunate to have treated thousands of OSA patients with OAT for the past 25 years and have seen many changes. I am most impressed with the latest technology and innovation from ProSomnus and most recently their EVO snoring and OSA device which meets many of my clinical and patient needs. EVO drops right in with zero adjustment, easy to determine advancement room thereby cutting chair time in half. Patients find EVO easy to use and hygienic. I’m honored to be a part of the ‘SHIFT’ from CPAP to precision OAT.” – Nancy Addy, DDS, D.ABDSM Accelerate SHIFT

No other oral appliance medical device company has two physicians, two dentists, and a PhD on the payroll. This clinical orientation and scientific approach are producing more posters, abstracts, publications, and research that will help prescribers understand the advantages of precision OAT. That is an important differentiation. PRECISION therapy will influence and accelerate SHIFT. So, to will studies like FLOSAT (First Line OSA Treatment). Drs. Olivier Vanderveken, Marc Braem, and ProSomnus’ Global Scientific Committee Chair, Shouresh Charkhandeh are doing prospective randomized controlled crossover study that should demonstrate the value of EVO as a fist line therapy instead of CPAP. The University Hospital in Belgium is embracing this concept of precision Oral Appliance Therapy for patients struggling to get on CPAP due to the recall and shortages.

Here in North America, Pulmonologist and ProSomnus’ Chief Scientist John Remmers, MD, and our ENT and Medical Director Eddie Sall, MD, DDS, are involved in a clinical study that will produce data to support the expansion of ProSomnus EVO’s indications for use to include the treatment of severe OSA. This will

be a profound accomplishment in earning the trust of the medical community. To date, the AADSM and AASM guidelines only acknowledge the mild and moderate treatment choice FDA clearances. Objective remote patient monitoring will also strengthen the relationship and trust of providers and physicians. It would be unwarranted today to dispense a CPAP without a data-cloud connection for tracking patient success. Transparency and reporting of efficacy and compliance will result in better outcomes that medicine can embrace.

Choose SHIFT!

Our greatest power as human beings is our freedom to choose. We are free to choose what we do, how we feel about it and of course, when. These choices, and sometimes the absence of choice, will ultimately serve as the architect and construction of our lives and our profession. The best way to predict the future is to create it. That too is a choice. Manufacturers like ProSomnus can choose to make better devices. To earn physicians trust and the respect of payers, providers could choose to use better precision devices. Accelerators like evidence-based research, the Phillips recall and the AHRQ paper make it easier too.

In Conclusion

There is no price to pay for education…

There is a price to pay for ignorance.

There is a price to pay for good health…

And a price for sickness and disease.

There is a price to pay for attending to relationships…

And a price to pay for neglecting them.

There is a price for love and trust…

And a price to pay for fear and hate.

We cannot choose whether or not we will pay…

We can only choose for what it is we pay for.

10 DSP | Summer 2022

ProSomnus Precision Means Efficacy that Will Help You Sleep Better Studies indicate that ProSomnus precision OAT devices are the first to demonstrate efficacy on par with CPAP for mild and moderate OSA1,2,3,4 A recent independent, prospective clinical study published in the Journal of Clinical Sleep Medicine1 reported:

94% of Mild & Moderate Patients Successfully & Efficaciously Treated (ODI < 10 h-1)

81% of Patients of all Severities Successfully & Efficaciously Treated (ODI < 10 h-1)

97%

85%

of Patients Reported Reduction in Snoring Volume

of Patients Achieved Their Treatment Goal

Flexible, Easier Delivery | First Time Fit | Durability | Comfort | Biocompatibility | Precision | Featuring MG6™ Technology Mosca E; Remmers J; et al. In-home mandibular repositioning during sleep using MATRx plus predicts outcome and efficacious positioning for oral appliance treatment of obstructive sleep apnea. Journal of Clinical Sleep Medicine. Vol. 18, No. 3, March 2022.

Sall E. Precision Oral Appliance Therapy: The Prime - Time Treatment for OSA. World Sleep Congress. Rome, Italy. Poster Abstract #289. March 2022.

Smith K; et al. Efficacy of a Novel Precision Iterative Device and Material. World Sleep Congress. Rome, Italy. Poster Abstract #081. March 2022.

4 Murphy M; et al. Device Design’s Impact on Dose in Oral Appliance Therapy. Journal of Dental Sleep Medicine. Vol. 8, No. 3 2021. Abstract #004.

1 2 3

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BIGGERpicture

Out of Breath – A Documentary Feature Film

by Lisa Moler

T

here are millions of people worldwide who are not aware that they are suffering from OSA, never mind that there are treatments available to them to ease their suffering. One of those was documentary film director George T. Nierenberg. DSP sat down to learn more about how he’s using his unique talents to bring the message to the public, and to our profession.

DSP: George, tell us about how you, a filmmaker, became interested in making a movie about a medical condition, sleep apnea.

GN: Throughout my adult life, I had classic symptoms: snoring, falling asleep at work, social events, even at the wheel. I was depressed, easily agitated, often irritable – not the amiable person I wanted to be. I was told I had an underactive thyroid for years. When I finally got diagnosed with sleep apnea, I

couldn’t tolerate the CPAP and underwent the other option I was given: excruciating UPPP surgery. That didn’t work, either. Finally, five years ago, I tried a dental appliance and, at last, found relief.

DSP: OK, so what’s your goal?

GN: My films have reached wide audiences, have had a long-lasting impact, and have changed public opinion. When I discovered that I was one of a billion people who suffer from this crippling disease, I wanted to use the humanistic approach to filmmaking that I’d developed over my career to change public perception about this highly misunderstood disease. People need to be diagnosed and know what choices they have so they can be advocates for their own best treatment. This is what spearheaded the birth of the Out of Breath documentary film project three years ago.

DSP: What’s going to happen with your film? Netflix?

GN: My team of esteemed producers, advisors, and I want to create a movement with the film. We’ll reach a broad international audience through festivals, theatrical, TV broadcast, digital and educational releases, along with an aggressive outreach campaign that targets communities and organizations through public and private screenings and panel discussions with health care professionals.

DSP: Tell me more about Out of Breath.

George T. Nierenberg, Director/Producer

12 DSP | Summer 2022

GN: My goal is always to engage viewers emotionally as they connect with the film’s subjects. The influence of my films, such as Say

BIGGERpicture Amen Somebody which received widespread international acclaim, is felt to this day. Out of Breath will tell the story of a diverse group of people who have opened their homes, businesses, and families to let us share their emotions as they attempt to loosen the grip sleep apnea has had on their lives. They chronicled their journey 24/7 for over a year and a half, under my direction. My team and I are constantly inspired by the people we’ve met. Here’s a sneak preview of some of their stories: Kalyn is an animated 23-year-old who is moving in with her fiancée, but she has never been able to bring herself to share her diagnosis…or her CPAP, which has been hidden in the closet since they first met. The joys of her relationship are overshadowed by her fear that it may not survive in the face of her sleep apnea. She’s exploring whether orthodontics can improve her ability to breathe.

Keyonna is a courageous 28-year-old, whose escape from an abusive marriage landed her in a homeless shelter. She is plagued by exhaustion but has had no idea why. Despite it all, through will and determination, she managed to become a supervisor of a T-Mobile store and to buy her own car and home. But her constant exhaustion causes her to fall asleep at the dinner table or while trying to help her young daughter with homework.

Seeking out medical care for low blood pressure, she finally finds out she has OSA. Victor, who consistently wakes up in the middle of the night to find his CPAP off and his wife downstairs on the couch, where she flees in such instances, as he puts it, “to find sanctuary from” his wall-shaking snoring. His sleep apnea is crippling his ability to function in his cement business and is putting enormous stress on his marriage. And when he develops Covid, it is exacerbated by his sleep apnea and threatens his very life.

DSP: These stories are so real. How did you get them to be so open?

GN: The unique approach I’ve taken in this film of collecting the personal footage shot by the characters themselves at all hours of the day or night under my direction has created the opportunity to follow these people with an unprecedented level of intimacy, thus humanizing the struggles and the stigma that come with sleep apnea. This makes the film accessible and appealing to a broad audience and enables viewers to recognize OSA in themselves and/or loved ones. The film will

Zoom call: David Leach, Editor (top left); George T. Nierenberg, Director/Producer (top right); Keith Brown, Consulting Producer (bottom left); and Susan Margolin, Producer (bottom right)

also show them that the CPAP is not their only treatment option; they can turn to dentists for an alternative treatment, as I did. It will help viewers see that taking such action is imperative: our hope is that Out of Breath will show that OSA is far more serious than snoring; it can lead to the devastation of lives, families, careers, and health leading to strokes, My team and I diabetes, heart failure and even death. It can – and has – caused deadly car crashes are constantly and train wrecks. Action is necessary. inspired by the

DSP: You said the movie will be aimed at professionals, too.

people we’ve met.

GN: The broad reach of the film will open lines of communication between the currently siloed healthcare professionals so that they can work together toward providing the best care for their patients, finding new solutions. Further, it will help infuse the field with new experts and funders eager to fight this disease…all of which, in turn, will further expand patient awareness. Our goal is to create a level of awareness that will empower people to take action and conquer this currently silent and insidious disease.

DSP: How can readers get involved?

GN: I welcome members of the healthcare community to join our effort to raise public awareness. For more information, view our trailer and make a 100% tax-deductible contribution, visit www.sleepapneafilm.com. For a $2,500 donation, you will receive a branded trailer for your practice. Email us at director@ gtncreative.com.

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COMMUNICATIONScorner

Facilitare!

The Art of Making Sleep Medicine Easier by Dr. Susan Maples

A

s a sleep- and airway-astute dentist or hygienist, you have no doubt become a zealot for your patients, anxious to tell them what you see… and definitively what they might do about it. But just as we follow our built-in desires to educate, we bear witness that teaching-and-telling patients what to do usually doesn’t translate to action. (Let’s face it, if this style of education worked, ALL our patients would be daily flossers by now.)

Educate comes from the Latin word educare which means ‘to train or to mold’. It

14 DSP | Summer 2022

implies a one-way communication style.

And while it worked slightly better within the old-fashioned patriarchal medicine model, where every patient believed ‘doctor knows best’, it clearly doesn’t work well in today’s world. Today’s patients are internet savvy, less trusting of medical professionals, and more empowered to make their own decisions.

The good news is we can dissipate personal barriers if we are willing to learn a more facilitative communication style. Facilitation comes from the Italian word facilitare and it means ‘to make easy or easier’. It

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COMMUNICATIONScorner implies a two-way communication style that supports the patient’s self discovery. And it requires more listening than talking.

For each of us, learning takes place in our minds, not our ears. We must filter the words we are hearing (or reading) through the lens of what we already “know” (believe to be true). In that way, every adult has their own personal clinician inside of them, helping them make hundreds of personal deciBecome an Ask-it-All, sions every day.

If our job, as licensed professionals, not a Know-it-All. is to help our patients better understand new, evidence-based concepts, we must first understand what they already believe to be true. That means becoming an askit-all rather than a know-it-all, reserving any new information you might have to offer for after the patient’s curiosity is piqued.

Why is this necessary? There is good evidence in cognitive science that the most long-lasting learning is difficult, not easy. By stimulating challenges that help engage the brain, your patient has a chance to ponder the problem before they formulate possible strategies and solutions. You’re priming their mind for learning.

By the way, this concept is true for us too.

Think of the many times you really grappled with how to solve a clinical problem before you discovered the solution. Chances are you experienced a huge light-bulb moment once the answer came to you.

So, from now on, whenever you recognize the physical signs of an airway or sleep-related breathing disorder, begin with a few powerful open-ended questions.

Dr. Susan Maples is a passionate health educator and leads a successful, Total Health, insurance-independent dental practice in Holt, Michigan. She brings preventive and restorative dental expertise, a passion for mouth-body total health, a master’s degree in business/ marketing, and 30+ years of experience in private practice. Susan currently serves as President of the American Academy of Oral Systemic Health. She is the creator and founder of Total Health Academy, a complete online solution for dental teams to integrate all aspects of Total Health Dentistry, and developer of the HandsOn Learning Lab™ and SelfScreen.net. She is the author of BlabberMouth!

77 Secrets Only Your Mouth Can Tell You To Live a Healthier, Happier, Sexier Life. And Susan just released a new book titled, Brave Parent! Raising Healthy, Happy Kids (against all odds) in Today’s World.

16 DSP | Summer 2022

Perhaps lead with this: “I’m concerned that I might be recognizing some risk factors for sleep disturbances. Can I ask about the quality of your daytime energy?” Without giving them your established list of screening conditions (such as daytime sleepiness, brain fog, depression, anxiety, memory loss, etc.) you’re letting the patient think first and articulate their own challenges. Ask also about their nighttime sleep quality. Then ask them to describe any weight challenges, allergies, autoimmune disorders, or difficulties in healing/recovery. (Note that offering some airway-related conditions they hadn’t considered is not meant to lead to a list of yes-or-no answers, but to further arouse their curiosity about how these challenges might be related to a sleep deficit.)

Granted, this open-ended style is more difficult than answering a bunch of yes-orno questions. And that’s the point. Effortful learning makes it last! When a patient is allowed to articulate their own very personal challenges, they will be more apt to ask you for any answers to their problems. Wait for it. After listening, take a minute or two to restate the quandary and explore their own imagined solutions. In that way, their brain becomes super hungry for learning. Finally, you will get to deliver. The process make take a few minutes longer than you’re used to, but it’s worth it.

Of course, this facilitative approach lends itself beyond airway problems. If you’ve ever wondered why you (or your hygiene team members) struggle with case acceptance beyond what insurance allows, it might be time to sharpen your facilitation skills. This, too, takes effortful learning. Our old teachand-tell education model has become so ingrained in us that the shift requires a new mindset, new words, and a lot of practice.

Just like muscle memory, it takes continual repetition to become your team’s default communication style.

As a dentist, your offerings in sleep and airway medicine are extraordinary. Helping your patients extend their lifespan, and their healthspan, will pay you spiritual, emotional, and yes, financial rewards. Perhaps the coolest part about becoming an airway-astute clinician is who you get to become…personally become…to get there. Bravo to you for all your efforts!

It’s the dawn of a New Era in OSA Therapy

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CLINICIANspotlight

Dr. Robert Rogers

T

he American Academy of Dental Sleep Medicine celebrates its 30th Anniversary this year. To recognize this milestone, DSP called up the dentist who began it all, Dr. Robert Rogers.

DSP: We’re celebrating the 30th anniversary of the AADSM. What are your thoughts about that milestone?

Do you think, back when the small group formed the sleep disorders dental society, it would grow like this?

Dentists’ responsibilities will expand and be more integrated with the medical team.

Steve, it’s almost beyond words. What a rare occasion when one finds themself in a position so unique as to potentially impact the health of millions of people worldwide.

In 1990, I took a course from the late Dr. Tom Meade in San Antonio and learned how to fabricate a boil and bite Snore Guard. No one was more surprised than I to discover that it was effective for my father-in-law who ceased snoring and felt refreshed for the first time in 30 years. I found a handful of other dentists across the country who had similar experiences and we formed a “study club,” with monthly phone conversations. Arthur Strauss, Michael Alvarez, Alan Lowe, Peter George and one or two others were part of this initial group. After a few months, someone suggested we form a “society” comprised

of a membership of like-minded individuals.

We placed an ad in the Journal of the ADA and surprisingly, 75 people responded, becoming the original founding members of the Sleep Disorders Dental Society (SDDS).

I was chosen as the founding president, and we held our first annual meeting in Phoenix, AZ with an attendance of 25 dentists. It spanned little more than 24 hours with no vendors and only one speaker, albeit a great one, Alan Lowe. It was particularly challenging to grow our field in the absence of sufficient research, physician support, insurance reimbursement, and the leading-edge appliance designs we have today. This year, our 30th Anniversary Meeting will boast well over 1,000 participants, dozens of vendors, and world class speakers.

DSP: You and Mary Beth ran the society for over 10 years all by yourselves. What were some memorable events during that time?

Dr. Robert Rogers, Dr. Micheal Alvarez, Mary Beth Rogers, Dr. Arthur Strauss, and Dr. Alan Lowe

18 DSP | Summer 2022

Looking back, it’s hard to believe we managed the day-to-day operation of the SDDS (eventually the American Academy of Dental Sleep Medicine [AADSM]) for over 10 years completely out of our home with Mary Beth

CLINICIANspotlight

Dr. Robert and Mary Beth Rogers (left); Drs. Ken Hilsen, Arthur Strauss, and Rob Rogers (center); and Drs. Rob Rogers and Tom Meade

as the first executive director. I can remember Mary Beth being on the phone many hours each day fielding calls from our growing membership and organizing our annual meetings. A less pleasant memory involves being unceremoniously required to move our annual meeting out of the hotel that the physicians’ American Sleep Disorders Association had booked the same weekend because they viewed us as unqualified and somehow competing with them. My fondest memories are of the personal relationships I have established with the very many wonderful people who have stepped up to grow and develop our organization. I can honestly say that, outside of family, these relationships remain the most meaningful in my career.

DSP: How did the presence of the AADSM help your clinic work in Pittsburgh?

The number of ways the AADSM has benefitted its members is exhaustive. It certainly has helped me over the years. Initially, when our organization dovetailed with physicians’ groups, we obtained much-needed professional guidance. This, I think, was critical and helped develop professional integrity and thus the support of our medical colleagues.

Task forces were formed to create and update review papers, position papers, and practice parameters. Ultimately, a CPT code for oral appliances was created to allow us to work more efficiently with third-party insurance carriers. Presently the field of Dental Sleep Medicine has several magazines and professional journals. We have a board certification program for doctors. One of the most

outstanding features of our Academy is the impressive annual meeting with the opportunity to network with the most committed colleagues in the country.

DSP: Today’s dentist treating sleeprelated breathing disorders has a different relationship with physicians than in the early days. What do you think about the next 30 years? Or the next two to five years?

The roles of the dentist and the physician in treating sleep-related breathing disorders have certainly changed over the past 30 years. Our overall training and experience have evolved over the decades and oral ap-

Robert R. Rogers, DMD, D.ABDSM, has had a special interest in the treatment of sleep-disordered breathing since 1990 and has treated patients in conjunction with regional sleep centers around the Greater Pittsburgh area. Prior to retirement in 2021, he was Chief Dental Officer for Pittsburgh Dental Sleep Medicine, Inc. and limited his practice to dental sleep medicine. Dr. Rogers is the founding president of the American Academy of Dental Sleep Medicine (AADSM) and served again as president in 1995 and 1999. He is a Diplomate of the American Board of Dental Sleep Medicine and is the recipient of the AADSM Distinguished Service Award. Dr. Rogers was a member of the task force for the revision of the American Academy of Sleep Medicine Position Paper and Practice Parameters on Oral Appliance Therapy. He also co-authored the American Academy of Sleep Medicine Guidelines for the Evaluation, Management and Long-term Care of Adult Obstructive Sleep Apnea. Dr. Rogers was a frequent speaker at the AADSM Annual Meetings and has presented lectures on oral appliance therapy to physicians, dentists, and patient groups throughout the United States and Europe.

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CLINICIANspotlight pliance design has become advanced and nuanced. Many years of close collaboration with our medical colleagues has served us all well. I think it is easy to speculate that over time dentists’ responsibilities will expand, and we will become even more integrated with the medical team, taking a leadership role in appropriate situations. Dentists will be at the forefront of addressing and impacting the developing airway in children, leading to better breathing day and night.

DSP: Your accumulated clinical wisdom led you to develop the Medley, the oral appliance with more configuration options. That’s a daunting process, to introduce a new device.

What problem were you trying to solve?

Over the past 31 years, I have treated in excess of 11,000 patients with oral appliances and have used most of the designs available today. I have been “around the track” as they say and have experienced remarkable success with many of them and at the same time have had more than my share of frustrations. Over time, it became apparent to me that no single appliance design is effective for every patient. With this in mind, I created a “universal” appliance that offers three different advancement mechanisms on the same base platform. Hence, the name Medley. In less than a minute, chairside, the Medley appliance (FDA cleared and PDAC approved) can transform from a rigid nylon link, similar to a Panthera, to an elastomeric strap in the style of the EMA appliance.

And in another minute, take advantage of the Herbst rod/sleeve mechanism if indicated.

The variable Medley design offers dentists and patients a quick, easy, and economical way to utilize three different advancement approaches without having to incur additional lab expense or waste valuable treatment time. Presently, the Medley is undergoing some improvements to take advantage of the newer digital approaches and will again be available by the end of this year.

DSP: I’m curious about your thoughts on the name “Dental Sleep Medicine.” Do you think it is still the right label for what dentists do?

Drs. Rob Rogers, Harold Smith, and Michael Alvarez

Drs. Giles Lavigne, Harold Smith, and Rob Rogers (left); and Drs. Rob Rogers, Alan Bernstein, Harold Smith, Steve Scherr, and Ken Hilsen (right).

20 DSP | Summer 2022

I coined the term “dental sleep medicine” about 20 years ago during a lecture I g ave to the Association of Professional Sleep Societies (APSS), the forerunner of the American Academy of Sleep Medicine (AASM). At the time, it was very descriptive and focused on a new, innovative approach to address sleep-disordered breathing. I believe it is well accepted, well recognized, and has held up very well over the years. However, with much of dentistry now becoming “airway focused” and with innovative ways to manage pediatric airways, the generic term “dental” may be misleading or limiting. I believe dentists can positively affect the upper airway during wakefulness as well as during sleep. While I think that “dental sleep medicine” is the right label for what we are predominantly doing now, it may not the best label for what we will be doing in the future.

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MEDICAL

MEDICALinsight

Nasal Airway Obstruction and Precision Oral Appliance Therapy in the Treatment of OSA

by Edward T. Sall, MD, DDS, MBA

W

hile there has been increased acceptance of Mandibular Advancement Splints (MAS) in the treatment of OSA, physicians have concerns about the overall efficacy of OA’s to the known high efficacy of CPAP. It is clear that OSA is a complex disease and that the “gold standard” notion of CPAP or the one treatment approach to OSA is not consistent with our current understanding of the pathophysiology of OSA. While there has been increased awareness of the nonanatomic factors (loop gain, arousal index, and pharyngeal collapsibility) in the pathogenesis of OSA, anatomic factors are still felt to be responsible for the majority of the etiology of OSA.

Figure 1: A recent poster presented at the 2022 World Sleep Congress

22 DSP | Summer 2022

Oral appliances have greatly evolved since the introduction of monobloc and non-custom appliances, and previous papers have shown increased efficacy of custom appliances versus monobloc. Many physicians are only familiar with legacy appliances and are unaware of fourth generation precision appliances. Precision Oral Appliance Therapy (OAT) is characterized by bite transfer with <1mm of variance and a titration mechanism that holds the jaw in the target position throughout treatment. A recent poster presented at the 2022 World Sleep Congress on 115 consecutive cases showed that a precision oral appliance is capable of successfully treating patients with all levels of severity with most patients treated to an AHI <5. 29 severe patients with an average AHI of 51.5 were treated to a final average of 9.5 (Figure 1). This suggests that precision oral appliance therapy should be considered as the primary form of therapy for all levels of severity of OSA depending on the preference of the patient.

It is known that multilevel anatomic obstruction is often present in snoring and obstructive sleep apnea. Since the nose is the first anatomical boundary of the upper airway, nasal airway obstruction may contribute to sleep disordered breathing. The Starling resistor model, the unstable oral airway, the nasal ventilatory reflex and the role of nitric oxide (NO) may potentially explain the role of nasal pathology in OSA. While

there is not a linear correlation between the degree of nasal airway obstruction and the severity of OSA, patients with nasal obstruction have increased problems and decreased efficacy with OAT. Zeng et al. demonstrated that high levels of nasal resistance measured using supine posterior rhinometry predicted poor treatment outcomes with mandibular advancement. This article will introduce a novel in-office procedure for treatment of NAO that should increase the efficacy of OAT, particularly when used in conjunction with fourth generation precision oral appliance therapy.

Nasal Airway Obstruction

Nasal airway obstruction is responsible for many symptoms which include nasal congestion and stuffiness, headache, fatigue, sleep disturbance, daytime sleepiness, snoring, and an overall decline in health-related quality of life (Qol). NAO is one of the most frequent reasons that patients consult an Otolaryngologist and may affect up to 50% of the population. After correction of their nasal obstruction patient’s often report significantly better sleep, less awakenings, and less difficulty falling asleep as well as improved concentration and productivity.

The nose accounts for more than 50% of the total resistance of the upper airway, and nasal breathing serves important physiological functions, including humidification, heating, and filtration. Hipprocrates in “de Morbis Popularthis” noted that nasal polyps were associated with restless sleep and snoring.

Additionally, most people have experienced difficulty sleeping during episodes of virally induced nasal congestion. It has been shown that when nasal resistance exceeds a certain level there is a switch from nasal breathing to oral breathing. Mouth breathing is associated with up to 2.5 times higher total resistance and with narrowing of the pharyngeal lumen and a decrease in the retroglossal diameter as a result of further retraction of the tongue. In addition, there is increased oscillation of the soft palate and redundant pharyngeal tissue.

All these changes contribute to increased episodes of sleep related breathing disorders.

Common causes of nasal obstruction include deviated nasal septum, inferior turbinate hypertrophy, nasal polyposis, and allergic and nonallergic rhinitis. Medical treatments include nasal steroids, decongestants, leukotriene antagonists, and nasal dilators.

Traditionally, the most common surgical procedure for nasal obstruction has been a Septoplasty combined with reduction of the Inferior Turbinates. The most frequent cause of lack of relief of nasal airway obstruction with Septoplasty is failure to address the importance of the nasal valve.

Nasal valve collapse and dysfunction is now recognized as a primary source of nasal obstruction. That being said, it is often underdiagnosed and left untreated. The internal nasal valve is defined as the area between the cartilaginous septum, the caudal end of the upper lateral cartilage, and the anterior head of the inferior turbinate. It is the area of the nasal airway that has the greatest resistance to airflow. On physical examination, insertion of the nasal speculum bypasses the lateral nasal wall and thereby prevents evaluation of this critical structure of the nose.

In the past, surgical procedures that targeted the nasal valve to correct nasal airway obstruction (NAO) or nasal valve dysfunction (NVD) were collectively referred to as a functional rhinoplasty and/or nasal valve repair and include spreader and batten grafts. These procedures were invasive and technically challenging and thus not widely applied to the general population. Possible reasons for undertreating nasal valve collapse and NAO were both the underdiagnosis of this problem and the scarcity of minimally invasive treatment options to address this relatively common problem as an alternative to surgical repair.

The nasal valve offers the greatest resistance to airflow in the nasal cavity. The nor-

MEDICAL

MEDICALinsight

Figure 2: Illustration of nasal valve obstruction

Edward T. Sall, MD, DDS, MBA, is a licensed dentist and physician. He is board-certified in both Otolaryngology/ Head & Neck Surgery, and Sleep Medicine. Currently, he is in full-time private practice in Syracuse, New York as an Otolaryngologist and Sleep Physician. In 2019, Dr. Sall accepted the position as medical director of ProSomnus Sleep Technologies with the role of increasing physician acceptance of OAT in the treatment of OSA. In 2020, Dr. Sall became the President and CEO of BetterNight Medical group as well as SD Diagnostics, Inc, a home sleep testing company. Currently, Dr. Sall has medical licenses in 40 states which allows him to do telemedicine consultations in sleep medicine for BetterNight. In 2021, Dr. Sall accepted a position as a consultant to Aerin Medical. His role at Aerin Medical is to increase collaboration between sleep dentists and otolaryngologists in order to improve outcomes in patients with OSA treated with both OAT and CPAP.

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MEDICAL

MEDICALinsight mal angle between the upper lateral cartilages and the nasal septum is between 10 and 15 degrees. The narrower that angle, the more susceptible that area is prone to collapse (either static or dynamic). Normal airflow through the nasal valve depends on the Bernoulli principle and Poiseuille’s law.

The Bernoulli principle states that as the flow of air increases through a fixed space, the pressure in that space decreases. Thus, if the decrease in pressure overcomes the inherent rigidity of the flexible nasal sidewall collapse can occur resulting in nasal obstruction (dynamic obstruction). Poiseuille’s law states that airflow is inversely proportional to the fourth power of the radius (Figure 3). Small decreases in the radius of the nasal valve will have a dramatic impact in the flow of air through the nose (static obstruction). This principal is the physics behind increased airflow with “Breath-Rite” strips in patients who suffer from a narrowed nasal valve.

Radiofrequency for Treatment of NAO Radiofrequency (RF) induced heating has been shown to induce tissue tightening and contraction through effects of the collagen fiber network of the tissue. The effects induced by the RF treatment are both acute, through the immediate contraction of existing collagen proteins, and longer term, through induction of the production of new collagen.

The VivAer intranasal remodeling is a minimally invasive procedure that uses a stylus to deliver controlled and targeted low energy, temperature RF heating the nasal side wall to gently reshape the tissues of the internal nasal valve (Figure 4). Based on Poiseuille’s law, a small increase in the radius (or angle of the internal nasal valve) will have a dramatic increase in nasal airflow due to decreased nasal obstruction. It is an outpatient procedure performed in the office setting under local anesthesia.

Ephrat, Jacobowitz, and Driver (2021) demonstrated the safety and efficacy of a minimally invasive temperature-controlled RF device that was designed to cause these tissue tightening effects within the submucosal layer of the lateral nasal wall. The VivAer Airway remodeling procedure (Aerin Medical) was associated with stable and lasting improvement in symptoms of nasal obstruction and QoL through 24 months in a noncontrolled single-arm study.

Screening and Assessment of Patients with NAO

Figure 3: Poiseuille’s Law

Figure 4: VivAer Temperature Controlled Radiofrequency Tool

24 DSP | Summer 2022

The relationship of NAO to OSA necessitates that all practitioners systematically assess their patients for nasal obstruction with particular attention to the nasal valve. While endoscopic evaluation of the nasal cavity is not within the scope of practice of sleep dentists or medical practitioners, an evaluation of the nasal valve is certainly a necessary part of a thorough exam in a patient suspected of having OSA. The NOSE Score (Nasal Obstruction Symptom Evaluation) should be obtained on every patient as it has been shown to be a reliable indicator of nasal obstruction (Figure 5).

The score is obtained by adding the numbers and multiplying X 5 with the following key: • Score 30-50 = Moderate Obstruction • Score 55-75 = Severe Obstruction • Score 80-100 = Extreme Obstruction

The Cottle Maneuver (gently pulling the cheek laterally with 1-2 fingers to open the nasal valve) is a subjective but relatively reliable indicator of NAO secondary to dysfunction or narrowing of the internal nasal valve (Figure 6). Alternatively, the modified Cottle Maneuver (internally supporting the nasal valve with a curette or probe) is a good test for NAO and can easily be performed by any practitioner.

NAO and Precision Oral Therapy

The field of sleep medicine and specifically our understanding of the different phenotypes of OSA continue to evolve. The more we understand and address both the anatomic and non-anatomic factors in the pathophysiology of OSA the more likely we will increase the efficacy of OAT in the treatment of OSA. The overall efficacy of the 115 patients treated with precision oral appliance therapy could only be improved by critically assessing the presence or absence of NAO. Additionally, a device with a big bulky vertical or anterior component might compromise lip seal and exacerbate any issues with NAO. Clearly the design and performance of a precision appliance is an improvement with respect to these anatomic findings. The more detailed and comprehensive the examination, the more factors may be addressed to improve outcomes. This relationship is an excellent way for sleep dentists, sleep physicians, and otolaryngologists to collaborate to achieve the best outcomes for their patients.

Interestingly enough, one of the major reasons that patients discontinue treatment with CPAP is due to problems with nasal obstruction. Likewise, NAO is an important factor to address for optimal response to OAT in the treatment of OSA.

Take Home Points:

• Assess all patients for NAO prior to initiating OAT. • The NOSE Score is a validated survey that measures the reduced QoL attributed to nasal obstruction.

• Refer patient to Otolaryngologist if NAO suspected.

• VivAer nasal airway remodeling is a reliable and minimally invasive outpatient procedure for NAO secondary to abnormalities of the internal nasal valve.

Figure 5: NOSE Score (Nasal Obstruction Symptom Evaluation) Questionnaire

MEDICAL

MEDICALinsight

Figure 6: Cottle Maneuver

• Educate sleep physicians on the efficacy of precision OAT as compared to legacy appliances in the past.

• Educate Otolaryngologists on the dentist’s role and expertise in treating OSA with Oral Appliance Therapy.

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Sawa, A, et al. Assessment of screening for nasal obstruction among sleep dentistry outpatients with obstructive sleep apnea. Dent J 2020 Dec; 8 (4): 119.

Georgalas, C. The role of the nose in snoring and obstructive sleep apnoea: and update. Eur Arch Otorhinolaryngol 2011; 268 (9): 1365-1373.

Zeng et al. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep 2008 April 1; 31 (4): 543-547.

Jacobowitz, O, et al. In-office treatment of nasal valve obstruction using a novel, bipolar radiofrequency device. Laryngoscope Investig Otolaryngol 2019 Apr 4 (2): 211-217.

Ephrat M, et al. Quality-of-life impact after in-office treatment of nasal valve obstruction with a radiofrequency device: 2-year results from a multicenter, prospective clinical trial. International Forum of Allergy & Rhinology; Volume 11, Issue 4: 755-765.

Rossi A, et al. Clinical evidence in the treatment of Obstructive Sleep Apnoea with Oral Appliance: a systemic review. Int J Dent: 2021: 6676158.

Rhee, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 2010 Jul; 143 (1): 48-59.

Brehmer D, et al. A prospective, non-randomized evaluation of a novel low energy radiofrequency treatment for nasal obstruction and snoring. Eur Arch Otorhinolaryngol 2019; 276 (4): 1039-1047.

Sall, ET. 2022; Precision Oral Appliance Therapy: The Prime-Time Treatment for OSA. Poster presentation; World Sleep Congress, Rome, Italy. March 15, 2022.

Smith et al 2022; Efficacy of a Novel Precision Iterative Device and Material. Poster presentation; World Sleep Congress, Rome, Italy. March 14, 2022.

Mosca EV, et al. In-home mandibular repositioning during sleep using MATRx plus predicts outcome and efficacious positioning for oral appliance treatment of obstructive sleep apnea. JCSM. 2022; 18 (3): 911-919.

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BOARDmember

Edward T. Sall, MD, DDS, MBA Tell us about yourself.

I

am a licensed dentist and physician. I am board-certified in both Otolaryngology/Head & Neck Surgery, and Sleep Medicine. Currently, I am in full-time private practice in Syracuse, New York as an Otolaryngologist and Sleep Physician. My practice includes the medical and surgical management of sleep disorders, the treatment of Temporomandibular Joint and Orofacial Pain as well as the full spectrum of Otolaryngology with an emphasis on Sinonasal Disorders. In 2019, I accepted the position as medical director of ProSomnus Sleep Technologies with the role of increasing physician acceptance of OAT in the treatment of OSA. In 2020, I became the President and CEO of BetterNight Medical group as well as SD Diagnostics, Inc, a home sleep testing company. Currently, I have medical licenses in 40 states which allows me to do telemedicine consultations in sleep medicine for BetterNight. These services allow the referring dentist to treat the majority of their patients following a best-practices protocol for the total continuum of care. In 2021, I accepted a position as a consultant to Aerin Medical. My role at Aerin Medical is to increase collaboration between sleep dentists and otolaryngologists in order to improve outcomes in patients with OSA treated with both OAT and CPAP. How did you learn so much about how dentists work in their clinic?

As both an Otolaryngologist and dentist, I became acutely aware of the fact that dentists play an integral role in the management and treatment of patients with OSA. While surgical procedures have their place in the treatment of OSA, many patients want a nonsurgical option besides CPAP. There are approximately 300 Otolaryngologists who are now board certified in sleep medicine and have made sleep medicine a significant portion of their practice. Certainly, pursuing this sub-specialty, these Otolaryngologists understand the importance of Oral Appliance Therapy and welcome the assistance from their dental colleagues.

How do you see the future of dentistphysician collaboration going as communications improve?

The difficulty in treating patients with OSA is that they often require the services of multiple practitioners across many spe-

26 DSP | Summer 2022

cialties. The current system is cumbersome, inefficient, and wastes precious medical resources. With the advent of Home Sleep Apnea Testing (HSAT), dentists may collaborate with sleep physicians in order to confirm the diagnosis of OSA. Many Otolaryngologists and Dentists now make HSAT an integral part of their practice. Nasal Airway Obstruction is one of the most common reasons for which patients consult Otolaryngologists and clearly sleep dentists may screen patients for this problem and refer them to their ENT colleagues. Going forward, patients will benefit from collaboration between sleep dentists and ENT physicians. This increased awareness of this relationship will drive this collaboration. It has been well established that nasal obstruction will compromise the efficacy of OAT, so it is in the best interests of the sleep dentists to engage their ENT physicians and refer them appropriately. The future will embrace this bidirectional referral process as we all strive to deliver precision medicine and dentistry optimizing the patient experience.

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MEDICALinsight

Changes in Home Sleep Testing Technology

by Dr. Jagdeep Bijwadia

P

olysomnography remains the gold standard for the diagnosis of sleep apnea and other sleep disorders. Most published research has relied on this technology, which allows for the direct visualization of signals needed to score respiratory events.

For the diagnosis of more complex sleep disorders, polysomnography also gathers information from many other sensors that provide information about abnormal brain and muscle activity.

The three signals needed to recognize an apnea or hypopnea are airflow, respiratory effort, and oxygen saturation. Airflow is measured by thermistors or pressure transducers, respiratory effort by impendence belts, and oxygen saturation by oximetry. These signals can be continuously generated through the night, and in the case of polysomnography, sleep technologists supervising the patient in real time can adjust if signal quality is poor.

During polysomnography, sleep staging is accomplished by analysis of EEG signals in combination with eye movements and sensors for muscle-activity electromyography.

The first advances in home sleep apnea diagnosis took the three important signals for recognizing respiratory events and eliminated all other sensors used in polysomnography and the need for technologist supervision. For home sleep technology, advanced additional sensors were added to home sleep

28 DSP | Summer 2022

tests such as limited EEG, pulse rate, and accelerometry to estimate sleep time.

The transition to the home setting accelerated when Medicare and then commercial payers began accepting evidence that the measures for sleep apnea detection were similar in accuracy to polysomnography. The costs savings and convenience of home sleep testing has changed the landscape of sleep diagnostics. Most home sleep testing devices in the market were still using the traditional airflow, effort, oximetry, and EEG sensors to report AHI and sleep stages.

The most recent shift in diagnostics has come from the research that respiratory events and sleep staging can be determined from nontraditional signals. Each of the examples of home sleep testing devices outlined below uses nontraditional signals that allow for determination of important physiologic parameters with fewer signals.

In each case, before a new device could be marketed as a medical device, it had to be compared to a similar existing technology (usually polysomnography) and show substantial equivalence and safety as determined by the FDA.

It is important to recognize that the FDA determination that a medical device can be marketed safely and is substantially equivalent to a previously cleared technology is not the same as new technology being accepted as a standard of care by the specialty societies and practicing clinicians.

The academic rigor with which any device has been studied to get to FDA approval varies. Often the newer devices have not been studied in large populations or in subsets of patients’ specific medical problems or demographics, so clinicians need to be mindful of the FDA guidelines for use of these devices, be familiar with the scientific evidence, and understand the limitations of each one.

The newer signals from which AHI and sleep staging are derived vary with the device. Here are a few examples of the new technologies within the last year that report AHI and sleep staging using nontraditional signals.

NightOwl®

The NightOwl sensor (Ectosense) acquires accelerometry, pulse oximetry, and PPG signals. It is a home sleep apnea testing device with a finger-mounted sensor paired with cloud-based analytics software.

When a patient experiences an apnea or hypopnea, there is a change in heart rate and autonomic activity as well as a drop in oxygen saturations, which can be measured in blood vessels at the periphery. Each heartbeat causes a pressurized “pulse” of blood into the arteries of the body, which causes them to expand slightly before once again returning to their previous state. By shining a light on a patch of skin with an LED light source, the increased pulse pressure will cause a measurable difference in the amount of light reflected onto or transmitted through to a light sensor. Combining this signal with the drop in oxygen levels accurately reflects the occurrence of an apnea or hypopnea.

The NightOwl also reports total sleep time and REM time, which also is indirectly determined by changes in the PPG amplitude and frequency.

In terms of ease-of-use and the ability to deliver muti-night testing, the device offers some significant benefits. The device is uniquely disposable, reducing logistic burdens for practices.

SleepImage®

SleepImage (MyCardio, LLC) utilizes a small finger-worn wearable device (ring) to collect the data needed to run their cloudbased analytics software, Cardiopulmonary Coupling (CPC), to evaluate sleep. The ring device is paired to a smartphone app that transmits data to the cloud-based software for analysis and automated report generation.

CPC is a a technique that assesses sleep parameters through moment-to-moment changes in the autonomic nervous system.

The CPC-method analyzes interactions between autonomic heart rate variability (HRV) and respiratory oscillations. The PPG-signal is used to analyze fluctuations in sympathetic/parasympathetic influence affecting HRV and respirations during sleep. Oxygen-data (SpO2) is additionally used to calculate AHI and the output is reported as obstructive and central apneas as well as sleep time, NREM / REM sleep, sleep quality, sleep fragmentation, and periodicity.

DROWZLE®PRO

This home sleep testing device includes standalone smartphone software that can record and analyze patient respiratory patterns mid-sleep, in order to allow telemonitoring for obstructive sleep apnea (OSA). The smartphone application uses a proprietary algorithm to analyze sound recordings and gauge risk for OSA. It reports a Resonea index which has been validated against the AHI but does not have an oxygen-saturation measure.

The unique feature is the acoustic signal received by a smartphone placed next to the patient with the absence of any device attached to the patient.

NightOwl sensor

MEDICAL

MEDICALinsight

SleepImage ring device

DROWZLE PRO

Dr. Jagdeep Bijwadia is board certified in internal medicine, pulmonary, and sleep medicine. He is founder and CEO of a national sleep telemedicine practice (Sleepmedrx) serving all 50 US states. He also serves as Chief Medical Officer for Whole You and is a clinical consultant for Ectosense. He currently holds a faculty position as Assistant Professor in the Department of Pulmonary Critical Care and Sleep Medicine at the University of Minnesota and has a private practice in Saint Paul, Minnesota. Dr. Bijwadia has been named top doc by the Minneapolis magazine as well as US News and World Report. He served as president for the Minnesota Sleep Society from 2016 to 2018 and is active in promoting sleep health in Minnesota. He also has an MBA from the University of St. Thomas in Minneapolis.

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MEDICAL

MEDICALinsight Sunrise

Sunrise sensor

The Sunrise sensor (Sunrise SPRL) measures mandibular movement and calculates the obstructive respiratory disturbance index (ORDI) using proprietary artificial intelligence and machine learning (AI/ML) algorithms. The theory is that during sleep, there are a series of upper airway muscle activities that are reflected in mandibular movements.

By measuring these movements, the occurrence of respiratory events and other sleep physiologic parameters can be accurately determined. The device reports sleep stages, AHI, head position, sleep latency, total sleep time, micro-arousals, respiratory effort, and bruxism. The current version does not have an oxygen-saturation sensor. The device consists of a sensor applied to the chin.

AcuPebble®

AcuPebble

The AcuPebble (Acurable) is a home sleep-testing device with a sensor attached at the base of the neck to record the sounds generated by the patient’s respiratory and cardiac functions. The signals are transferred wirelessly to a mobile device and then up-

loaded to a secure cloud platform. Proprietary algorithms automatically extract signal-processing features and physiological parameters that can be used to report AHI for the diagnosis of obstructive sleep apnea.

Many of these devices aim at improving sleep-testing efficiency, patient comfort, and ease-of-use. As FDA-cleared devices, they have met the standard for substantial equivalence with previously approved sleep-testing devices. Multi-night testing and immediate availability of data once the study is completed represent significant advantages.

It should be noted, however, that the reports rely on automated scoring algorithms that are not available for scrutiny. There are no standardized scoring guidelines that would allow a sleep specialist to modify the scored events. These devices have often not been tested with demographics or groups of patients with specific comorbidities.

Keeping the FDA-approved uses in mind, understanding the benefits and limitations of each technology, and working collaboratively with sleep doctors who can help guide choice of device and management represents best practice.

www.dentalsleeppractice.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter CONNECT with us on social media

Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

30 DSP | Summer 2022

MEDICAL

BOARDmember

Jagdeep Bijwadia, MD, MBA Tell us about yourself.

I

am a practicing physician, board certified in internal medicine, pulmonary, and sleep medicine. I am also founder and CEO of a national sleep telemedicine practice (Sleepmedrx) serving all 50 US states. I currently hold a faculty position as Assistant Professor in the Department of Pulmonary Critical Care and Sleep Medicine at the University of Minnesota and have a private practice in Saint Paul, Minnesota. I was fortunate to have served as president for the Minnesota Sleep Society from 2016 to 2018 and am active in promoting sleep health in Minnesota. Completing an MBA from the University of St. Thomas in Minneapolis has helped me gain a wider perspective on important business aspects of Medicine. I serve as Chief Medical Officer for Whole You and am a clinical consultant for Ectosense.

With your background as a pulmonologist, how did you learn so much about how dentists work in their clinic?

I have been involved with dental sleep medicine for several years and am invested in improving collaboration between physicians and dentists while reducing barriers for patients to get their preferred therapy. As a sleep physician, I think offering alternatives to CPAP is a critical part of comprehensive patient management. Sleep disordered breathing is a natural extension of my work as a pulmonologist with noninvasive ventilation modalities such as CPAP and BIPAP. I realize however that adherence rates to CPAP are very poor and that dental devices are a very effective option in many cases. I have spent the last few years developing telemedicine-based pathways that follow all the clinical guidelines to help guide a patient from a dentist’s chair to diagnosis and prescription reducing barriers for patients. Being founder of SleepMedRx has helped me learn what the pain points are for dentists as they start down the dental sleep career path and

partner to help our mutual patients by reducing impediments to moving forward with the right treatment.

How do you see the future of dentist-physician collaboration going as communications improve.

Acceptance of dental devices is steadily growing amongst sleep physicians as the scientific evidence of their effectiveness grows, and patients are becoming more aware of alternatives to CPAP. Technology has played a big role in allowing sleep testing to become so much easier and more available. Telehealth is also allowing dentist-physician collaboration to occur across state lines and in places where dentists did not have easy access to sleep specialists. In the near future, technology to continuously monitor the compliance and effectiveness of dental devices will further increase acceptance of dental devices as a primary option for treatment of OSA. I therefore think the most exciting times for dentist and physician collaboration are in the very near future.

DentalSleepPractice.com

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SPECIALsection

Accu-Fit™ – An Innovative Liner That Makes a Difference in Your Sleep Devices Do you spend too much time trying to get your patients sleep device to fit? The overwhelming reason doctors request the Accu-Fit™ material in their sleep device is the guaranteed fit. The DynaFlex Dorsal® and Herbst® Accu-Fit™ designs fit first time, every time. No more taking an acrylic burr to your patients brand new sleep device to achieve a perfect fit. The dentist/staff places the device in preheated 160-degree water for precisely five seconds.

This simple five second process guarantees a perfect fit and reduces the delivery process to just a few seconds rather than minutes.

Besides a perfect fit, there are other benefits to the Accu-Fit™ liner. It’s great for patients who will be requiring restorative work or are in the process of having restorative work completed. This means the doctor will not have to order a new device after completed restorations. Finally, the Accu-Fit™ liner is ideal for maximizing retention and patient comfort for those patients with challenging retention and limited undercuts.

Your patient’s time is just as important as yours.

Call DynaFlex® today to start using Accu-fit™ and maximizing efficiency and quality in your practice.

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32 DSP | Summer 2022

www.dynaflex.com | 1.800.489.4020 040622 © DynaFlex® , Lake St. Louis, MO 63367. All rights reserved. *Medicare E0486 Verified is for The Milled Herbst Device Only.

SPECIALsection

ProSomnus Sleep Technologies ®

ProSomnus® Sleep Technologies will be featured again in this year’s scientific abstracts and case submission for the AADSM Annual Meeting, May 13-15 in Dallas, TX. These publications continue to demonstrate the efficacy, compliance, and effectiveness of precision Oral Appliance Therapy with lower dose and fewer side effects.

Abstracts Include:

The Use of a Digitally Milled Oral Appliance in the Treatment of Severe OSA

• Featuring data from John Remmers, MD and Erin Mosca, PhD, focused on a cohort from the NOTUS trials of SEVERE patients • 73.2% resolved at least 50% and 68.3% achieved an REI below 15.

• This data indicates the efficacy of ProSomnus Preci-

sion OAT for severe OSA and aligns comparably with other severe treatment clearances.

The Efficacy of a Novel Iterative Advancement Device and Material • Multicenter consecutive series of 55 patients, featuring ProSomnus EVO™.

• Efficacy of 85% below an AHI of 10 included a mix of mild, moderate and severe patients.

Recapturing Posterior Open Bite Using a Precision Milled MOG (Morning Occlusal Guide) • Case study showing the use of digital records and precision CAD/CAM were utilized to manage side effects and regain a lost MIP bite on a patient who had moved and lost their traditional MOG.

Visit ProSomnus at AADSM Booth No. 201

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ProSomnus Precision Therapy abstracts to be presented at 2022 AADSM 30th Anniversary Meeting 55 patients treated with ProSomnus EVO™ • •

85% of all severities treated below an AHI of 10 Poster #5 May 14, 2022 @ 4:00pm

ProSomnus Precision Therapy demonstrates efficacy in severe patients T 90 scores were also improved, even in the only moderately improved patients Poster #3 May 14, 2022 @ 10:00am

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Precision Morning Occlusal Guide used to recapture posterior open bite • •

ProSomnus [MOG] MIP resolved prior open bite that was previously made from a traditional OAT device Poster #4 May 14, 2022 @ 10:00am

The research abstracts are available in an online supplement at aadsm.org/abstracts

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DentalSleepPractice.com

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CONTINUINGeducation

Sleep Related Breathing Disorders During Pregnancy The Impact of Intervention on Maternal and Fetal Health Outcomes

by Steve Lamberg, DDS, D.ABDSM Educational Aims This self-instructional course for dentists aims to show sleep related breathing disorders during pregnancy increase the risk of adverse maternal and fetal outcomes. Each of these conditions are independently associated with inflammation, oxidative stress from hypoxia, and increased sympathetic nervous system activity. When they occur together however, the health consequences are even more severe. The adverse maternal outcomes include: hypertension, preeclampsia, diabetes, thromboembolism, and cardiomyopathies. The adverse fetal outcomes include: preterm birth, low birth weight, changes in developing palate morphology, as well as growth restrictions that potentially lead to airway deficiencies in the neonate and into adolescence. As SRBD in pregnancy is under diagnosed, there is an opportunity to improve the health outcomes of mother and fetus through screening, diagnosis and treatment.

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. Understand the pathophysiologic crossovers of pregnancy and SRBD. 2. Learn the impact of maternal SRBD during pregnancy on the developing fetus and how it may increase the risk of development of SRBD in the neonate and developing child, even into adulthood.

3. Appreciate the importance of screening and treatment to reduce the risk of adverse maternal and fetal outcomes.

34 DSP | Summer 2022

A

mple evidence exists showing Sleep Related Breathing Disorders or SRBD, have a negative impact on maternal and fetal outcomes. A growing body of evidence reveals therapeutic intervention directed at SRBD creates positive health outcomes.

SRBD cover a spectrum of medical conditions ranging from Upper Airway Resistance Syndrome “UARS” through severe Obstructive Sleep Apnea “OSA” and are frequently accompanied by the symptom of snoring.

The prevalence of OSA ranges from 7.8 to 77.2% in adults aged 30-69 years.1 Among obese pregnant women, 15%–20% have OSA and this prevalence increases along with body mass index and in the presence of other comorbidities.2 These prevalence statistics in women are considered to be significantly underestimated due to gender-related differences in diagnosis resulting from women underreporting symptoms as well as an increased prevalence of UARS that does not meet the criteria to be OSA. Airway re-

CONTINUINGeducation sistance even without a cortical arousal can upregulate the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis causing a rise in blood pressure.3 A diagnosis of OSA as well as its key symptom of habitual snoring have been linked to hypertensive disorders of pregnancy, insulin resistance.4 gestational diabetes, and poor fetal outcomes. Habitual snoring means at least 3 nights/week and pregnant women who are habitual snorers have a 2-fold greater risk of gestational hypertension relative to non-snorers, although it has also been shown that snoring onset during pregnancy has worse outcomes than if habitual snoring existed pre-pregnancy.5,6 During pregnancy as in menopause, women have an increased risk of SRBD attributable to changes in estrogen and progesterone as well as weight gain.7,8,9 Estrogen contributes to edema, vasodilation, and nasal congestion that could impact the upper airway by making it more collapsible while progesterone enhances respiratory drive creating a “vacuum effect” and could contribute to airway collapse.2 SRBD during pregnancy increase the risk of hypertensive disorders of pregnancy “HDP,” occurring in 1 of 10 pregnancies, and are associated with significant maternal morbidity and mortality.10,11 The study, employing the United States Healthcare Cost and Utilization Project-National Inpatient Sample, examined 7,907,139 deliveries and found women diagnosed with OSA were at higher risk of having pregnancies with preeclampsia [odds ratio (OR) 2.2], eclampsia (OR 4.1), chorioamnionitis (OR 1.4), postpartum hemorrhage (OR 1.4), venous thromboembolisms (OR 2.7), and delivery by caesarean section (OR 2.1). Gestational diabetes as well as cardiovascular and respiratory complications were also more

common among these women, as was maternal death, OR 4.2.12 Newborns of OSA mothers were at elevated risk of being premature, OR 1.3 and having congenital abnormalities, OR 2.3.12 The higher risk of congenital anomalies and resuscitation at birth in neonates of mothers with OSA, emphasizes the importance of identifying OSA in pregnant women and women of reproductive age.13 Fetal growth restriction was also more prevalent and is the basis of the Sleep Apnea and Fetal Growth Restriction study (SAFER).

Fetal growth restriction “FGR,” affecting 10% of all pregnancies, is a major con- A diagnosis of SRBD tributor to fetal and neonatal morbidity has been linked to and mortality with intrauterine, neonatal and lifelong complications. While previ- poor fetal outcomes. ous studies have reported an association between low birthweight and elevated blood pressure (BP) in adulthood, the recent Raine study14 explored the association between intrauterine fetal growth restriction from 1440 women and BP of their adult offspring. Their data revealed evidence that restricted fetal growth was associated with significantly higher adult BP over two decades later that corresponded with a 10% higher risk of death due to heart disease and a 10% higher risk of stroke. This study further reinforces the importance of the early intrauterine environment and its influence on adult BP. OSA has been hypothesized to be a modifiable risk factor for FGR.15,16 Premature birth is one that occurs before 37 weeks of gestation or having a low birth weight. The short-term and long-term effects of preterm birth “PTB” on a child’s physical and psychological growth and development have been a hot topic of interest. The brain, lungs, and eyes are the most susceptible organs, but facial bones and palate morphology

Dr. Steve Lamberg has been practicing comprehensive restorative dentistry in Northport, NY for 40 years. Always passionate about sleep and wellness, he became a Diplomate of the American Board of Dental Sleep Medicine in 2011 and has served on their board review faculty. He holds several patents, and is the inventor of the Lamberg SleepWell Appliance, which is FDA-cleared for the treatment of OSA. Dr. Lamberg also launched and serves as the director of the Pediatric and Adult Airway Network of New York (PAANNY), to provide a local platform where dentists, physicians, orofacial myologists, and other related professionals learn and collaborate on treatment patients of all ages. Additionally, Dr. Lamberg serves as a Scientific Advisor at the Kois Center in Seattle. His recently published book for the general public, “Treat the Cause…Treat the Airway” correlates many common medical conditions to airway and sleep and is available on Amazon.

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CONTINUINGeducation may also be affected. The prevalence or PTB ranges from 0-10% in children, and 10-70% in children with low birth weight. Palates of premature infants have narrower and deeper forms compared to the palates of non-premature infants. Additionally the mandibular arches are less developed and evidence shows that the lower the gestational age, the more the tooth development is delayed at age 9.17 Due to this, there is a greater risk of future malocclusion, difficulties in chewing or speaking, and aesthetic problems.18 Malocclusion traits including crossbite, open bite, midline shift, open bite, spacing, and Angle's Class 2, occurred significantly more often in early pre-term EPT (83.3%) and very pre-term VPT (73%) children, compared with full-term (51.2%) children. Deep bite was the most common malocclusion trait in the EPT and the VPT group. Higher orthodontic treatment need was found for the preterm children.19 Inadequate growth and development of the jaws compromises the airway and leads to compensations, which have consequences including orthodontic problems.

A normal physiological component of healthy pregnancy is fetal movement, which has been used both formally and informally as a marker of fetal well-being. Reductions in fetal movement accompanies complications such as fetal growth restriction. It has been hypothesized that SRBD may link pre-

Maternal sleep events such as OSA, sleep disruption, and time spent in certain body positions, may have negative effects on the fetus, resulting in altered growth, gestational length, and even death.

36 DSP | Summer 2022

eclampsia with reduced fetal movement and that treatment of sleep disordered breathing might improve fetal activity during sleep. A study by Blyton showed CPAP to be effective in improving fetal movements which suggests a pathogenic role for SRBD in reduced fetal activity and possibly other poor fetal outcomes associated with preeclampsia.20 Fetal hiccups were reduced in women with preeclampsia and through intervention with CPAP were found to increase, providing intriguing evidence of the pathogenic connection of airway and fetal health.21 Fetal hiccups may be a manifestation of programmed isometric inspiratory muscle exercise in preparation for postnatal respiratory function.22 A scoping review of the literature with meta-analysis shows that maternal sleep events such as OSA, sleep disruption, and time spent in certain body positions, may have negative effects on the fetus, resulting in altered growth, gestational length, and even death.23 As SRBD are a prevalent risk factor of gestational cardiometabolic disease, they are a potential therapeutic target to reduce cardiometabolic morbidity.24 Robust literature demonstrates SRBD as a consistent, strong, and positive predictor of gestational hypertension and preeclampsia, similar to studies of SRBD and hypertension in non-pregnant adults. A systematic review reported OR 2.4 of pregnancy related hypertension among women with habitual snoring or moderate to severe OSA.25 Therapeutic intervention has been shown to improve health outcomes in women. In a study of 11 women with preeclampsia and mild SDB, one night of CPAP reduced mean systolic (128 mmHg vs 146 mmHg ) and diastolic (73 mmHg vs 92 mmHg) blood pressure compared with a baseline night without treatment in the same women.26 In another study, 12 women with preeclampsia, a single night of CPAP in the third trimester improved cardiac output and reduced peripheral vascular resistance, whereas no improvement occurred in a nontreated preeclampsia group.27 Larger sample sizes are needed to be powered to assess gestational outcomes.

A phase III clinical trial is underway with 2,700 women to examine whether treating SDB in pregnancy reduces the risk of gestational hypertensive disease.28

CONTINUINGeducation Given our current level of knowledge, pregnant women who have even mild sleep apnea should be treated for their SRBD. Questionnaires are an effective and efficient way to educate patients and screen for SRBD, treatment of which will benefit maternal and fetal outcomes while possibly serving to optimize craniofacial growth from infancy into adolescence and beyond. It is time to consider vigilance of maternal SRBD as the first step towards the earliest intervention to prevent SRBD along life’s journey from neonate to adult.

Screening and treatment of SRBD in pregnant women requires an interdisciplinary approach. Dentists can and do play an essential role in the multidisciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients, including pregnant women, at greater risk of SRBD. The American Dental Association encourages dentists to screen patients as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, snoring or witnessed apneas and

1.

to evaluate risk factors such as obesity, retrognathia, age and hypertension. Whenever a risk is determined, patients can be referred to appropriate physicians for sleep testing and diagnosis. Pregnant women should undergo serial monitoring with questionnaires as SRBD increases from the first to the third trimester. If the onset of SRBD occurs during pregnancy, sleep testing 3-6 months postpartum is recommended to evaluate if the SRBD has been resolved. When SRBD is diagnosed, there are many treatment options including CPAP and oral appliance therapy.

Dentists with training in dental sleep medicine can fabricate a custom oral appliance to optimize the airway and breathing pattern.

There are also simpler temporary appliances that can be fit and delivered at the first visit if necessary.

Dentists and physicians can collaborate to enhance health outcomes of mother and fetus. We can even gift the expectant mother one of the many great books available to help her and her newborn along their way to optimal health.

Benjafield A V, Ayas N T, Eastwood P R, et al. Estimation of the global prevalence and burden of obstructive sleep apnea: a literature-based analysis. Lancet Respir Med. 2019;7(8):687–698.

adults. J Hypertens. 2022 Mar 1;40(3):478-489.

15.

Chen Y-H, Kang J-H, Lin C-C, et al. Obstructive sleep apnea and the risk of adverse pregnancy outcomes. Am J Obstet Gynecol 2012; 206: 136.e1–136.e5.

2.

Dominguez J E, Krystal A D, Habib A S. Obstructive sleep apnea in pregnant women: a review of pregnancy outcomes and an approach to management. Anesth Analg.

2018;127(5):1167–1177

16.

Pamidi S, Pinto LM, Marc I, et al. Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol 2014;210:p. 52 e1–52

3.

Lamberg S, Upper Airway Resistance Syndrome, Inside Dentistry, Jan 2021:60

17.

4.

Laura Sanapo, Margaret H Bublitz, Alice Bai, Niharika Mehta, Geralyn M Messerlian, Patrick Catalano, Ghada Bourjeily, Association between sleep disordered breathing in early pregnancy and glucose metabolism, Sleep, 2022, zsab281

Faulsson, L., Arvini, S., Bergström, N. et al. The impact of premature birth on dental maturation in the permanent dentition. Clin Oral Invest 23, 855–861 (2019).

18.

Layza Rossatto Oppitz et al, Can preterm birth affect the palate morphology? A systematic review, Research, Society and Development, v. 10, n. 10, e107101018812, 2021

5.

O’Brien LM, Bullough AS, Owusu JT, et al. Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study. Am J Obstet Gynecol.

2012;207(6): 487.e1–487.e9

19.

Liselotte Paulsson, Bjorn Soderfeldt, Lars Bondemark, Malocclusion Traits and Orthodontic Treatment Needs in Prematurely Born Children, Angle Orthod (2008) 78 (5): 786–792.

6.

Li L, Zhao K, Hua J, Li S. Association between sleep-disordered breathing during pregnancy and maternal and fetal outcomes: an updated systematic review and meta-analysis. Front Neurol. 2018; 9:91

20.

Blyton D M; Skilton M R; Edwards N; Hennessy A; Celermajer D S; Sullivan C E. Treatment of sleep disordered breathing reverses low fetal activity levels in preeclampsia.

SLEEP 2013;36(1):15-21

7.

Young T, Finn L, Austin D, Peterson A. Menopausal status and sleep-disordered breathing in the Wisconsin Sleep Cohort Study. Am J Respir Crit Care Med. 2003; 167(9):1181–1185.

21.

O’Brien LM. Positive airway pressure as a therapy for pre-eclampsia? SLEEP 2013;36(1):5-6

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Dunietz G L, Chervin R D, O’Brien LM. Sleep-disordered breathing during pregnancy: future implications for cardiovascular health. Obstet Gynecol Surv. 2014; 69(3):164– 176.

22.

Kahrilas PJ, Shi G. Why do we hiccup? Gut 1997;41:712-3.

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Jane Warland, Jillian Dorrian, Janna L. Morrison, Louise M. O’Brien, Maternal sleep during pregnancy and poor fetal outcomes: A scoping review of the literature with meta-analysis, Sleep Medicine Reviews 41 (2018)

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Aaron Laposky, PhD, Bictoria Pemberton, RNC, MS, CCRC, Sleep-Disordered Breathing and Pregnancy-Related Cardiovascular Disease, JOURNAL OF WOMEN’S HEALTH Volume 30, Number 2, 2021

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Balserak BI. Sleep-disordered breathing in pregnancy. Breathe. 2015;11(4):268–277.

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Zhang J, Troendle J, Levine R. Risks of hypertensive disorders in the second pregnancy.

Obstet Gynecol. 2000;95(4, Suppl 1): S77.

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James PR, Nelson-Piercy C. Management of hypertension before, during, and after pregnancy. Heart. 2004;90(12):1499–1504.

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Dunietz GL, Hao W, Shedden K, et al. Maternal habitual snoring and blood pressure trajectories in pregnancy. J Clin Sleep Med. 2022;18(1):31–38.

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Eloise Passarella, Nicholas Czuzoj-Shulman, Haim A Abenhaim, Maternal and fetal outcomes in pregnancies with obstructive sleep apnea, J Perinat Med, 2021 Sep 15;49(9):1064-1070

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Edwards N, Blyton DM, Kirjavainen T, Kesby GJ, Sullivan CE. Nasal continuous positive airway pressure reduces sleep-induced blood pressure increments in preeclampsia. Am J Respir Crit Care Med 2000; 162:252–257.

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Ghada Bourjeily , Valery A. Danilack, Margaret H. Bublitz, Janet Muri, Karen Rosene-Montella, Heather Lipkind, Maternal obstructive sleep apnea and neonatal birth outcomes in a population based sample, Sleep Med. 2020 February ; 66: 233–240

27.

Blyton DM, Sullivan CE, Edwards N. Reduced nocturnal cardiac output associated with preeclampsia is minimized with the use of nocturnal nasal CPAP. Sleep 2004;27: 79–84

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Yadav A, Beilin LJ, Huang RC, Vlaskovsky P, Newnham JP, White SW, Mori TA. The relationship between intrauterine foetal growth trajectories and blood pressure in young

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Sleep Related Breathing Disorders During Pregnancy: The Impact of Intervention on Maternal and Fetal Health Outcomes by Steve Lamberg, DDS, D.ABDSM 1. Who has an essential role in screening for SRBD in pregnant women? a. Primary Care Physician b. Obstetrician c. Dentist d. All of the above 2. If the SRBD is pregnancy onset, post-partum maternal follow-up is important __________. a. never b. always c. only when newborn has symptoms d. only when mother has symptoms 3. A diagnosis of OSA in pregnant women is associated with _______. a. Hypertensive disorders of pregnancy b. Insulin resistance c. gestational diabetes d. poor fetal outcomes e. All of the above 4. During pregnancy several factors increase the risk of SRBD including ____________. a. estrogen level rise b. progesterone level changes c. weight gain d. age e. all of the above 5. Newborns of SRBD mothers have a risk for preterm birth and the development of dental arch discrepancies causing them to have increased orthodontic needs. The most common orthodontic problem is ____________. a. Crossbite b. Spaces between teeth c. Crowding d. Anterior Open bite e. Deep bite

38 DSP | Summer 2022

6. Fetal Hiccups may represent programmed isometric inspiratory muscle exercise in preparation to postnatal respiratory function and is considered healthy. Maternal SRBD causes __________. a. Increase in hiccup activity b. Decrease in hiccup activity c. Can be restored with intervention d. a and c e. b and c 7. Fetal growth restriction affects what percentage of all pregnancies? a. 5% b. 10% c. 20% d. 30% e. 50% 8. The odds of having pregnancy related hypertension is increased more than 2 fold in women with ___________. a. Habitual snoring b. Moderate OSA c. Severe OSA d. All of the above 9. SRBD may link preeclampsia with which fetal movement pattern? a. increased movement b. decreased movement c. Intervention with CPAP improved fetal movement condition d. a and c e. b and c 10. Newborns of OSA mothers have an OR of congenital abnormalities of _________. a. 1.5 b. 2.3 c. 3.0 d. 4.3 e. 5.5

PEDIATRICS

Pediatric Orofacial Myofunctional Therapy: The Four Myo Domains

by Robyn Merkel-Walsh, MA, CCC-SLP, COM® Introduction:

Orofacial Myofunctional Disorders (OMDs) encompass the four “MYO Domains” of airway, feeding, structure and speech. OMDs occur across the lifespan, are the nexus of function and structure and consider the interaction of how atypical movement patterns result in structural changes and how structural anomalies impact functional skills. Historically, only two national organizations list orofacial myofunctional therapy (OMT) in the scopes of practice of professionals. Speech Language Pathologists (SLPs) have OMDs in scope via the American Speech-Language Hearing Association (ASHA) and in state licensure. Registered Dental Hygienists (RDHs) have two policies on OMDs, #9-92 and PR 11-20 Resolution. Pediatric Orofacial Myofunctional Therapy (OMT) incorporates four specific domains:

1 2 3 4

Often the signs and symptoms of OMDs are based on the lens of the professional looking at the child. The orthodontist is concerned about structure, the speech pathologist is focused on oral placements for speech sounds, and the physical therapist is concerned with the jaw, neck pain and activities of daily living. Therefore, an OMD team is critical for the patient, because if there are only puzzle pieces that never make the whole picture, the whole child will not be complete and the OMD will persist.

Orofacial Myofunctional Therapy: Airway is essential for sleep, attention, and well being

Feeding is essential to grow and thrive

Orofacial symmetry and harmony of the orofacial complex is desirable

Articulate speech is necessary for communication and success

40 DSP | Summer 2022

Historically, OMT was limited to patients 8-9 years and above (Hanson, 1978) but as the years have passed and the understanding of early intervention has grown, OMDs are now identified as early as infancy but the methodologies vary. OMDs fall under the oral motor umbrella (Merkel-Walsh, 2020) which includes other diseases and disorders that impact feeding, speech and structure in newborns, infants, and toddlers such as breastfeeding challenges and congenital hypotonia (Merkel-Walsh & Gatto, 2021).

There are three important principles to consider when a child has an OMD: 1) OMDs are treated by multi-modalities dependent on age and cognitive status of patient; 2) oral dysfunction requires oral motor intervention as the primary treatment modality with supportive interventions for the whole body and 3) while we can identify OMDS across the lifespan, scope of practice and evidence-based practices will determine who treats the child and by what modality (Merkel-Walsh & Gatto, 2021).

D’Onofrio (2019) pointed out that most infants are born with symmetrical faces and their acquired craniofacial dysmorphology are the results of chronic oral dysfunction. At any age, the lingual resting posture impacts the growth and shape of the palate, impacts speech intelligibility and is often related to prolonged sucking habits and malocclusion.

PEDIATRICS Therefore, it is critical that all pediatric dental professionals make oral resting posture and airway/sleep screenings a part of their examination process (Zimmerman, 1985; Mat Zin, Rasib, Suhaimi & Mariatti ,2021; Góis, Ribeiro-Júnior, Vale, Paiva, Serra-Negra, Ramos-Jorge & Pordeus, 2008).

While newborns, infants, toddlers and those with neurodiversity may be too young, or not able to engage in volitional exercises typical of OMT, pre-feeding, oral motor and feeding therapies would be appropriate to start early intervention (Merkel-Walsh, 2020).

Oral sensory-motor tools such as the Sensi® are used in therapy to stimulate movements to help prevent manifestations of OMDs. Children over 4 with typical motor planning and average cognition are more readily able to self-monitor and engage in traditional OMT. These sessions often focus on oral resting posture, practicing nasal breathing, chewing, collecting a bolus, swallowing a bolus, reducing noxious habits and correcting atypical oral placements for speech.

The Four MYO Domains:

Airway: When children are congested, many well-meaning pediatricians conclude it is a “normal” part of childhood. Typically, when parents report sleep disturbances, OMDs often go undetected. Common symptoms such as snoring are viewed as normal, but common does not equate to normal (Baxter, 2022).

Children born with craniofacial anomalies are at an even greater risk of these complications. Signs and symptoms such as bedwetting, snoring, poor sleep habits, ADHD symptoms and open-mouthed posture may be missed and/or the connection between the airway and other symptoms are not fully understood in mainstreamed medicine.

(Sano, Sano, Oka, Yoshino, & Kato,2013; Zhao, Zheng, Huang, Li, Liu & Hu, 2021; Mancini, Rudaizky, Pearcy, Marriner, Pestell, Gomez, Bucks, & Chen, 2019).

Etiology of airway dysfunction may include but is not limited to: • Adenoidal hypertrophy • Allergies • Anaerobic infections • Chronic rhinitis • Nasal polyps

• Otitis media • Sleep apnea • Sinusitis • Tonsillar hypertrophy • Turbinate issues • Upper airway resistance syndrome Children with these challenges will need support from otolaryngologists, sleep specialists, allergists, and other physicians to assess and treat the underlying causes of the OMD. Then at four and up, SLPs and RDHs assist patients with diaphragmatic breathing, respiratory control, posture and alignment, nasal breathing, healthy nasal hygiene habits and oral resting posture to optimize growth and symmetry of the orofacial complex (Gatto, 2016).

Feeding: The process of feeding is one which encompasses a primary function of life and requires a baseline of structural harmony, muscular strength and stability and specific sequences of motor planning. The ability to take in a bolus, prepare it, transport it, and swallow it requires intricate movement of the nerves and muscles of the mouth and pharynx. Remediation of feeding disorders and dysphagia require specific licensure and postgraduate trainings most often complete

by SLPs, but also studied by OTs and some PTs who work in very specific settings.

The oral phase of feeding may be impacted by an OMD and therefore those trained in orofacial myology often work on mastication, bolus preparation and the oral transport stage as a part of OMT. ASHA (n.d.) specifically lists modifying and handling of a bolus as a specific goal of OMT. It is important to note that while feeding problems overlap with OMT but are not synonymous.

Feeding challenges can start immediately at

Dentists should screen for OMDs and recognize when to refer.

Robyn Merkel-Walsh is a NJ and NY licensed speech-language pathologist and Board-Certified Orofacial Myologist with more than 27 years of experience. She works for the Ridgefield Board of Education, is the owner of Diamond Myo, is a speaker, author, and consultant for TalkTools®, Board Chair of the Oral Motor Institute, and an Ambassador of The Breathe Institute. She has authored and co-authored texts, therapy programs, and peerreviewed journal articles. She can be reached at robynslp95@aol.com.

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PEDIATRICS birth and while this may be caused by an OMD such as ankyloglossia, it may also be due to respiratory issues, intubation, gastroenterology disease, prematurity and /or cardiac problems. In addition, any disruption to the sensory-motor system may result in food aversion, refusal, gagging and vomiting that may mistakenly be diagnosed as behaviors.

In these cases, OMT would not be the appropriate plan of care and a feeding specialist; usually an SLP or an OT would need to be brought in for consultation (Overland & Merkel-Walsh, 2013).

Typically, in older children with OMDs, a “tongue-thrust” is noted, but this is usually a symptom of tethered oral tissue or airway concerns. In these cases, therapy generally consists of treating the underlying cause of the issue in addition to retraining the neuromuscular patterns of the tongue for swallowing with tongue retraction with tip elevation and lingual palatal suctioning Structure: The hard tissue, soft tissue, muscles, and cranial nerves are equally important when studying orofacial myology.

Benkert (2012), discussed the influence of environmental and function based on the work of Dr. Moss, knows as “Functional Matrix Theory” in which this theory was initially described. The longstanding debate of whether function impacts form or vice versa includes the functional and environmental influences impact the growth and development of the facial arches.

Form + Function

42 DSP | Summer 2022

Orofacial Myology

While SLPs are warned by ASHA that they cannot diagnose malocclusion or “move teeth”, studies have shown that OMT improves dental occlusion, decreasing open bite and overbite (Benkert, 1997, Van Dyck, Dekeyser, Vantricht, Manders, Goeleven, Fieuws & Willems, 2016). This is where the focus of OMT may sometimes vary between professions where orthodontists and dental professionals value OMT for the impact on dental alignment and prevention of orthodontic relapse while SLPs are more concerned with the improvement of speech clarity or swallowing. Both fields should recognize this form and function connection for the overall benefit for the pediatric patient.

Speech: The first three domains all have an impact on the articulatory placements for speech. SLPs specifically work on retraining the oral musculature through strength and resistance exercises, retraining oral placements and once the placements are corrected, drilling the sounds in words, phrases, sentences, and connected speech for improved clarity. They may use placement tools such as Bite Blocks or a Sensi (TalkTools®) to assist with correct oral placements. They may also work on vocal quality and pitch, oral versus nasal resonance and phonatory control all of which can be impacted by maladaptive muscle-based patterns (Ferreira, Mangilli, Sassi, Fortunato-Tavares, Limongi, Andrade CR, 2011; Zaghi, Valcu-Pinkerton, Jabara et al., 2019).

Referrals: As mentioned, the age of the patient and cognitive status impacts what modalities, techniques, exercises, and tools are used in therapy. In addition, the proper referral should always be made to licensed professionals who have specialized training in their area of expertise. National organizations make guidelines but ultimately state licensure is what dictates which professional is responsible for treatment in their state.

Babies should have their first dental examination by 12 months according to the American Academy of Pediatric Dentistry (2016).

They should also be screened for OMDs such as breastfeeding challenges, weight gain, differential dental eruption, digestive issues, hypotonia, genetic syndromes and tonguetie. Referrals for children under four years of age, who have special needs, or with sus-

PEDIATRICS pected OMDs, should be made to a licensed SLP or OMT who specializes in pediatric feeding. The referral depends on comorbidity of speech and language disorders, availability of local providers, and family finances.

In ages four and above, referrals are best directed to a licensed SLP or RDH with specialized training in orofacial myology, in particular, one who is a Board-Certified Orofacial Myologist (COM®).

Examples of signs and symptoms that warrant an OMD evaluation in pediatric patients four and above includes but is not limited to (Billings, D’Onofrio, Gatto, Merkel-Walsh & Archambault, 2018): • Anterior dental issues such as overjet and open bite • Articulation issues • Crowded teeth • Dental Malocclusion (overbite, open bite, overjet, etc.)

• Deviated septum • Diastemas of teeth • Enlarged tonsils and/or adenoids • High and /or narrow plate • Low, forward, or interdental lingual resting posture • Mouth breathing • Open mouthed posture • Orofacial hypotonia • Orthodontic relapse • Signs of nighttime arousals such as bedwetting, bruxism or restless sleep • Snoring • Tethered oral tissue • Thumb sucking or any noxious oral habits • Tongue scalloping or injuries • Tongue thrusting • Torus Palatinus • Upper Airway Resistance Syndrome (UARS) • Xerostomia (dry mouth)

Conclusions: OMT is an evidence-based approach to improve airway health, feeding, optimal orofacial growth and development and speech clarity for children and adults when performed by licensed professionals who have professional scope of practice and specialized training. OMT can support the goals of the dentist, oral surgeon and /

or orthodontist regarding dental health, alignment, and optimal surgical outcomes.

Dental professionals should have awareness of Orofacial Myofunctional Disorders and be able to screen for the signs and symptoms of OMDs and refer accordingly to optimize the overall health of their patients.

Information on orofacial myology, airway health, finding a trained OMT provider, and more can be found through the International Associational of Orofacial Myology, (www.iaom.com), The Academy of Applied Medicine and Physiology (www.aapmd.org) and The Oral Motor Institute (www.oralmotorinstitute.org) all of which are non-profit organizations.

•

American Academy of Pediatric Dentistry (2016). Guideline on perinatal and infant oral health care. Pediatr Dent, 38(special issue):150-154.

•

American Speech-Language-Hearing Association. (n.d.). Orofacial Myofunctional Disorders. (Practice Portal).

Retrieved February, 13, 2022 from www.asha.org/Practice-Portal/Clinical-Topics/Orofacial-MyofunctionalDisorders/.

•

Baxter, R. Tongue Tie Lite (2022). Presentation from The Alabama Tongue-Tie Center. Recorded and viewed February 27, 2022.

•

Benkert, K. K. (2012) The function junction. The Journal of American Orthodontic Society, May/June, 28-40.

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Benkert K. K. (1997). The effectiveness of orofacial myofunctional therapy in improving dental occlusion. The International journal of orofacial myology: official publication of the International Association of Orofacial Myology, 23, 35–46.

•

Billings, M., D’Onofrio, L., Gatto, K. Merkel-Walsh, R. & Archambault, N. (2018). Orofacial myofunctional disorders. Retrieved From: http://iaom.com/wp-content/uploads/2018/10/OMD-Overview-IAOM.pdf

•

D’Onofrio, L. (2019). Oral dysfunction as a cause of malocclusion. Orthod Craniof Res.22, (Suppl. 1): 43-48

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Ferreira TS, Mangilli LD, Sassi FC, Fortunato-Tavares T, Limongi SC, Andrade CR (2011). Speech and myofunctional exercise physiology: a critical review of the literature. Jornal da Sociedade Brasileira de Fonoaudiologia, Sep;23(3):288-96.

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Gatto, K. K. (2016). Understanding the orofacial complex: The evolution of dysfunction. Outskirts Press.

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Góis, E. G., Ribeiro-Júnior, H. C., Vale, M. P., Paiva, S. M., Serra-Negra, J. M., Ramos-Jorge, M. L., & Pordeus, I. A. (2008). Influence of nonnutritive sucking habits, breathing pattern and adenoid size on the development of malocclusion. The Angle orthodontist, 78(4), 647–654. https://doi.org/10.2319/0003-3219(2008)078[0647 :IONSHB]2.0.CO;2

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Mancini, V. O., Rudaizky, D., Pearcy, B., Marriner, A., Pestell, C. F., Gomez, R., Bucks, R. S., & Chen, W. (2019).

Factor structure of the Sleep Disturbance Scale for Children (SDSC) in those with Attention Deficit and Hyperactivity Disorder (ADHD). Sleep medicine: X, 1, 100006. https://doi.org/10.1016/j.sleepx.2019.100006

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Mat Zin, S., Md Rasib, S. Z., Suhaimi, F. M., & Mariatti, M. (2021). The technology of tongue and hard palate contact detection: a review. Biomedical engineering online, 20(1), 17. https://doi.org/10.1186/s12938-021-00854-y

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Merkel-Walsh, R. & Gatto, K. (2021). The Team approach in treating oral sensory-motor dysfunction in newborns, infants, and babies with a diagnosis of tethered oral tissue. Journal of the American Laser Study Club.

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Merkel-Walsh, R. (2020). Orofacial myofunctional therapy with children ages 0-4 and individuals with special needs. International Journal of Orofacial Myology and Myofunctional Therapy, 46(1), 22-36.DOI: https://doi. org/10.52010/ijom.2020.46.1.3

•

Overland, L. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.

•

Sano, M., Sano, S., Oka, N., Yoshino, K., & Kato, T. (2013). Increased oxygen load in the prefrontal cortex from mouth breathing: a vector-based near-infrared spectroscopy study. Neuroreport, 24(17), 935–940. https://doi. org/10.1097/WNR.0000000000000008

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Van Dyck, C., Dekeyser, A., Vantricht, E., Manders, E., Goeleven, A., Fieuws, S., & Willems, G. (2016). The effect of orofacial myofunctional treatment in children with anterior open bite and tongue dysfunction: a pilot study. European Journal of Orthodontics, 38(3), 227–234. https://doi.org/10.1093/ejo/cjv044

•

Zaghi, S., Valcu-Pinkerton, S., Jabara, M., Norouz-Knutsen, L., Govardhan, C., Moeller, J., Sinkus, V., Thorsen, R.S., Downing, V., Camacho, M., Yoon, A., Hang, W.M., Hockel, B., Guilleminault, C. and Liu, S.Y.-C. (2019), Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. Laryngoscope Investigative Otolaryngology, 4: 489-496. https://doi.org/10.1002/lio2.297

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Zimmerman E. F. (1985). Role of neurotransmitters in palate development and teratologic implications. Progress in clinical and biological research, 171, 283–294.

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Zhao, Z., Zheng, L., Huang, X., Li, C., Liu, J., & Hu, Y. (2021). Effects of mouth breathing on facial skeletal development in children: a systematic review and meta-analysis. BMC oral health, 21(1), 108. https://doi.org/10.1186/ s12903-021-01458-7

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PRODUCTspotlight

Building a Customized Educational Pediatric SDB Program for Your Practice

S

leep Disordered Breathing (SDB) is an area seeing tremendous growth for the dental profession. As a dentist, it is complicated to determine the “How” for implementation. Engaging in HealthyStart’s concierge program combines the highest level of education, a comprehensive treatment system, a support team made up of dentists, pediatric dentists, and orthodontists who assist with your cases, providing guidance throughout treatment and sharing over 50 years of experience with over 4 million patients treated.

3-year progress with the HealthyStart from age 5 (top) to age 8 (bottom).

8-month treatment with HealthyStart’s Class III Appliance.

44 DSP | Summer 2022

There has never been an educational program that is built and customized for you and your practice like HealthyStart’s Customized Educational Program. You can build the program that works for you, your available time, your staff’s abilities, and even utilize an educational platform that works best for your learning style – live courses, digital courses, accelerated weekend courses, or a combination of both live and digital courses.

The customization begins with a personalized HealthyStart Blueprint Meeting that comprehensively helps you to understand your practice’s potential, while also creating a personalized road map for implementation of pediatric SDB to your existing patients and increase your new patient base. Bottom line, helping children, educating parents on oral health, expanding your practice, and creating an enormous ROI. It’s a win-win.

The HealthyStart Customized Educational Program Includes and Provides: • Blueprint Meeting º Meetings are hosted by your personal HealthyStart ISR, whose mission it is to help you get organized and create a plan of action for getting HealthyStart implemented into your office. ISRs are also available for you throughout your entire journey with HealthyStart to ensure that all of your questions are answered and your office is implementing HealthyStart as effectively as possible.

• Office Display Units with Sample Devices • Guided Treatment º ByteChecks (HealthyStart’s treatment plan) offer guidance by expert dental professionals with continuous guidance through Progress Checks.

• Support Concierge º Personalized practice support is available by the HealthyStart team to ensure high ROIs and increase internal referrals for a larger patient base.

• Program Platforms: º 4-week digital course º Fast-paced 2-day streaming course º 2-day live courses º Combination program of both digital and live The Educational Objectives of HealthyStart’s Customized Educational Program: • Understanding SDB • Addressing the underlying root causes – skeletal, lack of growth and development, habitual issues, profile deficiencies, orthodontic conditions, and lifetime stability • Providing a hands-on learning experience with the HealthyStart comprehensive treatment system to address the outward symptoms of SDB + habitual issues + growth and development deficiencies + orthodontic conditions • Creating a dream team – a collabo-

Build Your Own Educational Program to Treat the 9 in 10 Children Exhibiting Symptoms of Sleep Disordered Breathing!

Basic

Standard

Deluxe

$2,800

$3,400

$4,000

Free Full Case (Exp. in 6 months)**

1

2

Free 30-min Private Mentorship ($145 value ea.)

1

2

Save $1,795!

Save $2,090!

Package Features Full 4-Week Digital Series (Or Live) 18 CE Credits (16 CEs for Live) 1 Free Habit Corrector 30-min Blueprint Meeting Sample Display Stand ($75 value ea.)

Stand and appliances shipped after Blueprint Meeting

Name/Location on HS Website

Live Course for Doctor + 3 Staff ($300 for Each Additional Staff) 5% off 6-month or 10% off 12-month Mentorship Free Habit Corrector With Each Paid Case Submitted Within First 3 Months

Add-Ons / Customizations Live Course $1500

30/60-min Mentorship Session $150/$250*

Full Case $650*

Max A, Class III, Habit Corrector $100 ea.*

Lecture ONLY $2,000*

regular price: $750

regular price: $125 ea.

for additional associates with package purchase

Sample Display Stand + Appliances $75

*Add-ons / customizations marked with asterisk are only available at time of course purchase - NO EXCEPTIONS **The expiration date on free case(s) is not a hard date and can be changed if needed. Please discuss with our Support Team if you need to alter the date.

Turn to page 44 to learn more about HealthyStart's Customized Educational Program to treat children with SDB and straighten teeth without braces.

Open-Bite

844-KID-HEALTHY

Overjet / Thumb Sucking

Crowding

contact@thehealthystart.com

Overbite

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PRODUCTspotlight Table 1 - Resultant Changes in Symptoms with Use of HealthyStart Habit-Corrector A Study of 220 Children (4-12 years) Using Appliance While Sleeping

#

A

B

Symptom

Symptom frequency in whole sample 220 Cases

C

D

E

F

G

H

Statistical difference Mean Mean % of cases % of Cases (C) (significance) correction of correction of Symptom having with 100% between before and those (D) with entire sample sample Size improvement correction (C) after treatment (t (C) improvement test)

I

Confidence Interval of Col. F 95%

1 Snore at all?

64%

142

78%

80%

63%

41%

P = 0.001

6.37*

2 Snore 1 night/week

39%

87

79%

84%

67%

51%

P = 0.001

8.34

3 Snore 2-4 nights/weeks

29%

63

81%

87%

71%

57%

P = 0.001

9.46

4 Snores 5-7 nights/week

19%

41

93%

84%

78%

56%

P = 0.001

9.23

5 Have labored, breathing at night

22%

48

90%

85%

76%

54%

P = 0.001

9.15 13.64

12.3%

27

85%

93%

79%

70%

P = 0.001

8 Hyperactive

37%

82

60%

67%

40%

26%

P = 0.001

8.97

9 Mouth breathes days

54%

120

75%

70%

53%

37%

P = 0.001

7.19

10 Mouth breathes nights

69%

155

83%

78%

65%

43%

P = 0.001

5.92

11 Headaches in A.M.

18%

40

98%

94%

91%

85%

P = 0.001

7.02

12 Allergies

45%

100

68%

71%

49%

31%

P = 0.001

8.21

13 Excessive sweating nights

39%

85

79%

74%

59%

38%

P = 0.001

8.31

14 Talks in sleep

57%

126

74%

83%

61%

48%

P = 0.001

7.41

15 Poor ability in school

18%

39

56%

70%

39%

23%

P = 0.001

12.77

16 Falls asleep watching TV

11%

25

68%

91%

62%

52%

P = 0.001

17.49

17 Wakes up at night

54%

120

73%

76%

55%

36%

P = 0.001

7.23

18 Attention deficit

29%

63

67%

65%

42%

24%

P = 0.001

10.5

19 Restless sleep

46%

101

75%

69%

51%

28%

P = 0.001

7.52

20 Grinds teeth

47%

103

80%

81%

68%

50%

P = 0.001

7.33

21 Throat infections

22%

50

74%

83%

62%

44%

P = 0.001

11.36

6, 7 Interrupted snoring / Stoppage of breathing

22 Sleepy and/or irritable daytime

49%

107

77%

73%

56%

27%

P = 0.001

7.08

23 Hard time listening and interrupts

58%

127

60%

62%

37%

19%

P = 0.001

6.72

24 Fidgets with hands, can't sit quietly

45%

99

71%

59%

42%

19%

P = 0.001

7.25

25 Ever wets the bed

21%

46

74%

81%

60%

46%

P = 0.001

12.45

26 Bluish color at night or days

3%

7

71%

96%

69%

57%

P = 0.01

32.52

27 Speech problems

24%

52

67%

63%

42%

29%

P = 0.001

10.95

66%

145

63%

66%

41%

25%

P = 0.001

6.83

B

C

D

E

F

G

I

J

Sample Size

Total Symptoms Studied

220

2055

ADHD A

#

Individual Symptoms

Mean 27

Statistical difference Mean Confidence % of Cases (B) Mean correction % of cases with (significance) between correction of Interval of Col. having of those (D) with 100% before and after entire sample F 95% improvement correction (B) improvement treatment (t test) (B)

75%

76%

59%

38%

P = 0.001

8.23

*Confidence Interval = There is 95% confidence that the mean correction (F) will be between 69% (63% + 6.37) and 57% (63% - 6.37). Mean treatment time = 6.4 months. © Ortho-Tain, Inc. 2018

Table 1 – A description of the frequency (Column B) of the 27 symptoms (Column A) in the sample (N=220) of treated cases with the HealthyStart® Habit-Corrector® with the sample size of each symptom (Column C) and the degree of improvement and statistics from T1 to T2 (Columns D-G, H, I).

ration of Pediatricians, ENTs, Sleep Physicians, and you, the Dentist (and now the Oral Physician) • Providing proprietary tools for detection and parent education • Utilizing Provider and Parent/Patient apps exclusive to HealthyStart Providers for consistent monitoring and ease of data collection • Accessing HealthyStart’s comprehensive research library and the ability

46 DSP | Summer 2022

to utilize HealthyStart’s research programs for Providers • Accessing patient insurance options • Additional bonus programs/lectures on Tongue Tie, TMJ, and T&A coblation wand available at no additional charge.

The HealthyStart program continues to educate providers with case selection, treatment protocol, progress checks, and additional support from fellow providers on the digital Facebook group platform. The proprietary documents and diagnostic forms give a comprehensive assessment of patients’ developmental deficiencies, habitual issues, and orthodontic conditions.

A recent published study showed that outward symptoms were reduced and/or eliminated in 220 patients after 6 months of HealthyStart treatment (see table at right).

This educational experience includes a hands-on portion of treating up to two patients, complimentary, with these patients being the doctor’s patients of choice.

Begin your journey, create your educational experience, and provide a comprehensive treatment that address your patient’s deficiencies in growth and development, proper habits, skeletal deficiencies, such as narrow arches, and orthodontic conditions that all impact the ability of your pediatric patient to breathe, sleep, and create a lifetime of better health.

This education platform that can be customized to a doctor’s schedule and availability creates a program that is more easily implemented within a practice and makes a greater impact on the community’s pediatric population. Every office will be able to work with their own concierge and create a customized blueprint for success. To begin implementation of a customized pediatric SDB program for your practice, please contact HealthyStart at contact@thehealthystart. com or visit www.thehealthystart.com to learn more.

1.

Bergersen EO, Stevens-Green B, Rosellini E. Efficacy of Preformed Sleep and Habit Appliances to Modify Symptoms of Sleep-Disordered Breathing and Oral Habits in Children With Focus on Resolution of Mouth Breathing. Compend Contin Educ Dent. 2022 Jan;43(1):e9-e12. PMID: 35019666.

TECHNOLOGY&innovation

Benefits of Clean Air in the Home

by Dr. Greg Jeneary

T

he quality of air that we breathe has always been a concern, but this has been kicked into hyperdrive due to the pandemic. The air we breathe contains many types of pollutants, and these can have an effect on our overall health. Air quality issues are not exclusive to outside air – they are in our homes as well.

With current homes being built with a strong emphasis on efficiency, in a sense they have become tightly sealed boxes. The ability of our homes to “breathe” becomes more challenging. Therefore, it is important for a home to have appropriate ventilation, filtration and humidification of the air.

One way to filter the air in a home is through pleated air filters that attach to a home’s HVAC (Heating, Ventilation and Air conditioning) unit. These filters receive a MERV (Minimum Efficiency Reporting Value) rating as given by the ASHRAE (American Society of Heating, Refrigeration and Air-Conditioning Engineers). The rating corresponds to the filters ability to trap air pollutants and ranges from 1 to 16. The higher the number, the better the filter is at collecting smaller sized particles. ASHRAE currently recommends a minimum filter rating of a MERV 13 for a home residence. This specific filter will capture at least 85% of particles sized 1 µm to 3 µm.

To take it a step further in terms of filtration, a HEPA filter is defined as a filter that can theoretically remove at least 99.97% of dust, pollen, mold, bacteria and other

airborne particles larger than 0.3 µm. The significance of the size of the 0.3 µm is described as the most penetrating particle size (MPPS) or better understood as the smallest particle size that could pass through the filter without being trapped. A HEPA filter, oddly enough, is not MERV rated, but if it was, it would be considered to have a MERV rating of 17-20. So think of a HEPA filter as the ultimate way to trap human aerosolized infectious particles.

Humidifying air is another way to improve indoor air quality. Studies sug- Investing in air gest that relative humidity can affect the pays off 24/7. incidence of respiratory infections and allergies. Experimental studies on airborne-transmitted infectious bacteria and viruses have shown that the survival or infectivity of these organisms is minimized by exposure to relative humidity between 40 and 70%.1 Symptoms of insufficient humidification range from dry itchy eyes, nose, throat, lips, and skin. The moisture added to dry air also helps alleviate common nuisances brought on by winter heating, such as static electricity, peeling wallpaper, and cracks in paint and furniture. However, too high hu-

quality

DentalSleepPractice.com

47

TECHNOLOGY&innovation midity can encourage the growth of biological organisms in the home.2 Keeping the air in your home between 40 and 70% relative humidity can reduce all of these problems.

If retrofitting an existing HVAC unit with filters and humidification is not an option, portable or room sized humidifier and air filter devices can work well. These units can be easily moved from one room to another and can be sized specifically to a homeowner’s needs. Regardless of the type of air filter or humidifier, regular maintenance and changing of the filter and components is required.

Since we are all spending more time at home, a small investment in air quality pays off 24/7.

Don’t make your nose do all the work.

Get your house air ready with a separate HEPA filtration unit or a portable unit. Start by making sure your HVAC device has a filter with a minimum 13 MERV rating. You and your family will sleep better.

1.

2.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1474709/ https://www.epa.gov/sites/default/files/2014-08/documents/humidifier_factsheet.pdf

Dr. Greg Jeneary graduated from the University of Iowa College of Dentistry in 2007. After graduation, he joined his father’s dental practice in Le Mars, Iowa, where the focus has been comprehensive dental care. Dr. Jeneary has completed numerous hours in all aspects of general dentistry but has immersed himself in the areas of Orthodontics, TMJ and Craniofacial Pain and Sleep Related Breathing Disorders and their impact on the mouth and body. He is a member of the Academy of General Dentistry, American Dental Association, American Academy of Craniofacial Pain, American Academy of Physiological Medicine and Dentistry, American Laser Study club and the American Orthodontic Society. He lives in Le Mars, Iowa with his wife, Anne, and their two children.

Dental Sleep Practice Webinar WATCH this free educational webinar “How Hazardous is Dental Office Air“ presented by Dr. David Crank on June 2, 2022.

Have you ever wondered about the risks associated with dental office air quality? After all, there is a lot that flies out of patients’ mouths that is not captured by our suction devices. In this fascinating webinar, we will briefly cover all the main concerns regarding dental air quality and evaluate the solutions designed to lower the risks.

CE Learning Objectives: 1. To identify and understand the airborne hazards associated with dentistry 2. To recognize respiratory risks involved with these hazards 3. To evaluate various mitigation strategies employed for reducing and removing airborne contaminants

REGISTER NOW at https://dentalsleeppractice.com/webinars/

48 DSP | Summer 2022

Eliminate Airborne Threats Air Quality Guard is a Clean Air System Designed for the Unique Challenges of Dental Practices Air quality is CRITICAL to your practice. Contaminants are everywhere: Pathogens, Pollutants, Viruses, Bacteria & Fungi all threaten our air quality and quality of care.

Pre-Filter

Gas Phase Media Filter

HEPA Filter

Clean air returned to hallway

Aerosols collected at source

Directional Airflow design ensures contaminants are removed at the source and replaced by fresh, clean air.

Benefits of Air Quality Guard: • Arm and ceiling intakes capture aerosols at the source and move them away from occupants • Contaminated air is filtered through a 3 layer system, removing greater than 99.99% of all contaminants • Reduces the spread of COVID-19 and reduces sick leave • Negative pressure airflow cycle ensures that contaminants are captured before they can circulate • Quietly and efficiently filters & replaces up to 100% of air with pure, clean air • Powerful enough to replace all the air in the room every 7 minutes* *Based on recommended system design principles. Customization may increase or decrease this value.

Learn More and Request a Consultation Today!

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PRODUCTspotlight

Defining the Next Generation in Oral Appliance Therapy

T

here are many appliances from which to choose for Oral Appliance Therapy (OAT) for the treatment of Obstructive Sleep Apnea (OSA). Unfortunately, the vast majority of oral appliances are designed to simply lock a patient’s mandible forward into a static position that presents a high risk for temporomandibular joint (TMJ) issues and a high risk for changes to the bite/occlusion. If left unchecked, changes to the TMJ and bite will lead to functional and esthetic compromises for the patient’s bite and smile along with eventual reduction in treatment efficacy of such appliances when treating OSA. The team at Bfit Sleep has ventured along a different path to provide a beneficial design change to what has been the status quo for OAT design.

Lack of a locked position allows for natural movements.

50 DSP | Summer 2022

The Bfit Sleep Oral Appliance has recently arrived as an FDA Cleared device that has introduced a new term in the treatment of OSA: “Dynamic Advancement”. Dynamic is defined by a process or system characterized by constant change, activity, or progress.

The Bfit Sleep Oral Appliance defines itself as a dynamic advancement oral appliance which allows full movement of the mandible during the transitions between various stages of sleep. When a patient loses muscle tone and the mandible would fall back, the Bfit Sleep Oral Appliance holds the mandible forward to reduce episodes of apnea. The forward pull is provided by elastics or by springs which are lighter than the muscles but strong enough to provide the desired forward movement when muscle tone is lost at key points of the sleep cycle. The lack of a locked position allows for natural movements to occur when muscles are active but strong enough to engage mandibular advancement when needed.

The team at Bfit Sleep reviewed results for patients treated with the Bfit Sleep Oral Appliance in a single private clinic. The study of 50 patients included both men and woman with a pretreatment range of 5 to 58 AHI. It was observed that there was an average AHI

reduction of around 50% from pretreatment values with 78% of patients considered to be treated (defined as 50% reduction in AHI or an AHI of less than 5). The office that provided this data switched away completely from static mandibular advancement appliances to the Bfit Sleep Oral Appliance’s dynamic mandibular advancement because of issues with bite changes and temporomandibular joint symptoms associated with the static advancement appliances that they were previously using.

Of the 50 patients, 5 reported TMJ discomfort from which 1 of the 5 discontinued care. Of the 50 patients, 2 discontinued care due to feelings of discomfort from having an appliance on the teeth despite being successfully treated with the appliance. No patients in this group of 50 were seen to have changes in their occlusion (after 6-12 months use). “Bite correction/reset appliances” or “morning aligners” are not used with the Bfit Sleep Oral Appliance.

Comfort is Key

The goal of the Bfit Sleep Oral Appliance is to have a sustainable, long term treatment process for patients. The Bfit Sleep Oral Appliance has been designed specifically to reduce the risks of TMJ changes and bite changes that seem to be common with static mandibular advancement appliances in order to provide a sustainable treatment method for patients to manage OSA.

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COMFORT COMFORT| |COMPLIANCE COMPLIANCE| |DELIVERY DELIVERY| |FDA FDACLEARED CLEARED| |DECREASED DECREASEDSIDE SIDEEFFECTS EFFECTS

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3D 3D

PRODUCTspotlight

Coaching and Consulting Can Help You Offer Services for Pain and Sleep

F

or every 100 people with obstructive sleep apnea, 80 don’t even know they have the condition. Similarly, while temporomandibular joint disorder (TMD) is the second most commonly occurring musculoskeletal condition that affects up to 12% of the population, only about half of those with TMD will actually seek treatment. This is where dentists can play an important role. But how can you best prepare yourself for offering services in these areas? Continuing education, coaching and consulting.

Session 2 of our Pain and Sleep Mini Residency.

Ben-Pat Institute offers a variety of continuing education courses that help dental teams better care for patients with TMD or sleep apnea. This is especially important because complications may arise when managing patients with these disorders with devices like oral appliances. Having a foundational understanding of oral appliance therapy gives you confidence to deal with such troubles and can also help your patients become more compliant with treatment.

Taking a comprehensive program in pain and sleep allows dentists to take in the knowledge base needed to appreciate the clinical presentation of patients new to the office and

Dr. Bennett demonstrating on taking a bite for appliance fabrication.

52 DSP | Summer 2022

during treatment. We chose a case-based didactic learning style for our courses and consulting because it helps dentists and their care teams have a clear understanding of the examination and diagnosis process as well as the treatment plan. Everything is intertwined and we want to make sure you understand it all.

At Ben-Pat Institute, it is our goal to help dentists build confidence in diagnostic skills and with preparing and understanding treatment plans. With an in-office hands-on component, dentists gain the skills they need to successfully implement pain and sleep treatment concepts in the comfort of their clinical practice. After all, the best way to make a new service real is to go beyond education to consulting to get a better look and feel for the flow of your clinical practice.

Coaching and consulting can help raise awareness and improve the implementation of dental sleep medicine and/or TMD into your office by: • Creating systems for identifying and diagnosing patients.

• Developing a network of referrals from your healthcare community.

• Implementing collateral marketing and educational material • Including your staff as a well-rounded team.

It’s time to take the next step in your dental practice’s pain and sleep journey with hands on education, coaching and consulting.

PRODUCTspotlight

Snoring and Sleep Apnea Treatment Made Easy with Glidewell

G

lidewell makes building your sleep practice easier than ever before. The provisional treatment protocol — along with the Silent Nite® Sleep Appliance — will help you treat patients simply and quickly, as it avoids the common hurdles and delays of the traditional sleep diagnostic process.

SLEEP THERAPY

Glidewell Clinical Twinpak™

Breathe Easier When You Prescribe the Silent Nite®

“The Silent Nite About 50% of patients say they snore, and Sleep Appliance as many as 70% of patients who seek treatis well suited for ment for snoring and sleep apnea cite bed partner disturbance as the primary motivating provisional ther- factor.1,2 With the Silent Nite appliance, you apy because it is can provide oral appliance therapy with the confidence that it will effectively relieve your clinically effective, patients’ snoring. That’s because Glidewell it includes a fast provides a money-back guarantee: Silent Nite stops the snoring or return it within 90 turnaround time, days for a full credit. This assurance further with only three expands access to quality care, so more patients can experience the health benefits days in the lab, and of sleep therapy. it fits the criteria Provisional Sleep Treatment: Free to ensure patients Resources To begin treatment immediately upon a have an optimal first positive screen for sleep-disordered breathexperience with oral ing, you may utilize the provisional mandibappliance therapy.” ular advancement device (PMAD) protocol.

– Bradley Eli, DMD, M.S.

This three-step method identifies and qualifies patients for PMAD therapy, ensures that patients are informed of the referral to a physician for evaluation of obstructive sleep apnea, and provides a provisional device

to be used in the interim to help alleviate symptoms.

Available for free, the Sleep Solutions Kit includes resources you can use to get started with PMAD therapy: • STOP-BANG Questionnaire: A reliable tool for predicting risk for obstructive sleep apnea • Informed Consent Document: Medicolegal document informs patients about provisional therapy • Sleep Appliance Comparison Matrix: Assists clinicians in determining which device best suits their patients’ needs “Any dental practice can very easily utilize the PMAD protocol,” said Dr. Bradley Eli, orofacial pain specialist, Encinitas, California. “It’s a simple, health-conscious approach that solves the time to treatment problem, and most importantly, it provides immediate treatment for a potentially life-threatening medical condition.”

For a simple way to treat snoring and sleep apnea, explore the provisional treatment protocol and download your free Sleep Solutions Kit. Visit glidewell.com/pmad or call 877-210-3338.

1.

2.

54 DSP | Summer 2022

Centers for Disease Control and Prevention (CDC). Unhealthy sleep-related behaviors — 12 states, 2009. MMWR Morb Mortal Wkly Rep. 2011 Mar 4;60(8):233-8.

Clare R. Over-the-counter snoring mouthguards: are they useful? Smile Bulletin. 2021 Feb 21. Available from: https:// glidewelldental.com/company/blog/over-the-counter-snoringmouthguards-are-they-useful.

EDUCATIONspotlight

Global Solution to Global Problems: We Are Going Worldwide

by Shibani Sahni, BDS, PGD, MMSc, and Leopoldo P. Correa, BDS, MS, D.ABDSM

I

t is estimated that approximately 1 billion people around the globe suffer from obstructive sleep apnea (OSA). The cummulative long-term effects of untreated sleep disorders have been associated with an extensive range of health consequences. Awareness of the global burden of OSA among the general public and health care professionals is needed.

Screening patients for OSA and other sleep disorders is important healthcare offered by dental professionals. Research and clinical practice in sleep is at the interface of many medical and scientific disciplines including dentistry. Dentists play an important role in managing OSA to reduce patient morbidity and mortality.

Aim

Dr. Sahni, Director of Continuing Education and Lifelong Learning Department, and Dr. Correa, Director of Craniofacial Pain Center and Dental Sleep Programs at Tufts University School of Dental Medicine, have joined hands in a collaborative effort for boosting awareness of dental sleep medicine through the globe. This cooperative work is aimed at amplifying education in somnology, sleep disorders, dental sleep medicine, and holistic patient care. By collaborating with universities and dental associations around the world, we can bring continuing education to where the need is. Dental sleep medicine is a fast growing field because of the global problem – universities need good programs to meet demand.

Methods

The enrichment opportunities would start from a global summit this summer where experts and outstanding faculty and clinicians in the field of den-

Shibani Sahni, BSD, Postgrad-Dip Restorative Dentistry, MMSc (Dental Education), is an Assistant Professor in the Department of Comprehensive Care and is the Program Director for Distance Education and Continuing Education/Lifelong Learning at Tufts University School of Dental Medicine.

Dr. Sahni can be reached at Shibani.sahni@tufts.edu.

Leopoldo P. Correa, BDS, MS, D.ABDSM, FICD, is the Director of Tufts Craniofacial Pain Center and Dental Sleep Fellowship Program at Tufts University School of Dental Medicine. Dr. Correa can be reached at leopoldo. correa@tufts.edu.

tal sleep would meet at the Tufts European Center in Talloires, France to exchange ideas, engage in discussion, and embody collaborative principles of being curators of knowledge. Best practices will be shared along with the exchange of the latest research and clinical expertise in the field in different continents. This is also in line with the Tufts European Center’s summer academic programs in Talloires which are aimed to explore important issues while promoting international understanding and global citizenship.

As dental sleep medicine grows in its role as a critical part of therapy, we must embrace evidence-based practice. With the recent development of dental sleep medicine standards and the collaboration between academic institutions and professional associations, the practice and teaching of dental sleep medicine will continue to grow globally.

Significance and Future Direction

We will not restrict our efforts to just the global summit and effort this summer. The energy emanating from this global summit will carry forward and spread throughout the year in collaboration between organizations around the world. Online events have no borders.

This unique outreach will bring together experts, faculty members, and clinicians from different continents who are interested in solving, supporting, and innovating ways of exchanging information and research.

Innovation brings energy and new ideas, and with these global efforts and advancements, we aim to assist in reducing the public health issues related to sleep deprivation and sleep disorders across the world.

References available at www.dentalsleeppractice.com.

56 DSP | Summer 2022

Dental Sleep Medicine & TMD Programs

Tufts University School of Dental Medicine is proud to provide high quality Dental Sleep Medicine and TMD programs that reflect the most up-to-date and revolutionary information on the subject.

TMD & Orofacial Pain Mini-Residency

Dental Sleep Medicine Mini-Residency*

2022 - 2023

2022 - 2023

Modules:

Modules:

Pediatric Dental Sleep Medicine Mini-Residency 2022 - 2023

Module I - Live-Streamed:

September 10, 2022 (Live-Streamed) November 17-19, 2022 (On Campus) February 4, 2023 (Live-Streamed) March 2-4, 2023 (On Campus) April 1, 2023 (Live-Streamed) May 25-27, 2023 (On Campus)

October 13-15, 2022 (Live-Streamed) January 19-21, 2023 (On Campus) April 20-22, 2023 (On Campus) December 10, 2022 (Live-Streamed) February 25, 2023 (Live-Streamed)

Module II - On Campus

Registration Open!

Registration Open!

Registration Open!

Intermodules:

December 9, 2022 February 24, 2023 March 31, 2023 June 2-4, 2023

For course dates and details visit us at dental.tufts.edu/CE Or contact us at 617.636.6629 dentalCE@tufts.edu All on campus sessions are conducted at Tufts University School of Dental Medicine in Boston, Massachusetts

*This program meets the accreditation standards to be an AADSM Mastery Program Provider; however, the AADSM does not endorse, recommend or give preference to this program; faculty; or any product, device, or appliance discussed within this program. Any opinion expressed or communication regarding any product, device or appliance is solely the opinion of the individual(s) expressing or communicating that opinion, and not that of the AADSM.

Keep a look out for our:

Tufts Global Dental Sleep Medicine Summit This program will be live-streamed virtually from the Tufts European Center in Talloires, France.

ALTERNATIVEview

How the MandiTrac Device Improved My Sleep Practice

by Michael Kanter, DMD, DICOI

B

ite change is a major and common complaint in dental sleep practices. The use of oral sleep devices requires informed consent about bite changes as a potential complication from treatment.1 While I began my career in dentistry over 40 years ago, I more recently started treating sleep breathing disorders. A passion for sleep dentistry developed immediately. The first few sleep patients I treated provided some of the most rewarding experiences I’ve had in dentistry. My patients reported better over-all sleep, less snoring, more daytime energy and improvements with their health. However, the good feelings waned quickly as complications began to arise. Some patients started to experience complications such as jaw pain, permanent changes to their bite, and TMJ symptoms.2-3 An active therapy After trying several different bite resetdevice, not a passive ting protocols, we still had patients and referring doctors disappointed about these morning guide. ongoing side effects. Additionally, the onset of COVID drastically increased the prevalence of bite changes as added stress or a change in patient routines stopped them from their morning reset routines. As my frustrations grew, my passion for sleep dentistry began to fade – I was ready to abandon my sleep practice. Fortunately, I came across the MandiTrac device which gave me hope to address my clinical disappointments. The following is my clinical experience.

The MandiTrac is a daytime intraoral orthotic. It is a prefabricated device to deprogram masticatory muscles, seat the condyles, and reduce the magnitude and frequency of bruxism events. Distinct from the passive morning occlusal guide, this device is intended for more active therapy, addressing preex-

58 DSP | Summer 2022

isting or iatrogenic conditions affecting the TMJ or masticatory musculature.

The physical therapy component of treatment is intended to stretch chronically contracted and fatigued muscles, increase ROM, and reduce muscular trigger point activity.

In the process, it may increase muscle tone, thereby improving airway support by decreasing the extent of airway collapse.4 The exercises are as follows: 1. Masseter activation: Place the rollers over the molars and gently bite down.

2. Pterygoid activation: Place the rollers over the premolars, protrude and retract the mandible.

3. Genioglossus activation: With the rollers still between the premolars, tilt the head up about 45 degrees towards the ceiling (increase your angle until you feel the stretch, then begin the same protrusion and retraction motions from previous exercise).

4. Each exercise is three repetitions of ten, to be completed 1 or 2x/day as directed by the practitioner.

As patients go through the exercises, it is common for the muscles of mastication to engage then fatigue before finally relaxing. Bruxism patients typically report a decrease in night grinding after as little as one session. Patients report excellent compliance since the exercises take under 1 minute to complete and the positive outcomes typically result in consistent use.

My first case using the MandiTrac was a little over a year ago. She was previously treated with an oral sleep device and presented with a chief complaint of a limited range of motion.

When she smiled, her mandible seemed shifted to one side. She had a 23mm maximum incisal opening, 5mm midline shift and a 3mm posterior open bite on both sides. I thought

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ALTERNATIVEview

Figure 1: Before and after photos of the pharyngometry test pre and post a single use of the MandiTrac. A)The green line is the baseline for normal breathing.

The red line is the collapse test. Pre MandiTrac Collapse was 19.5%. B) The second photo outlines a 95.6% improvement.

about the poor results I’d had recovering a ‘normal’ bite in similar cases, using other bite resetting devices.

After using the MandiTrac for only 1 minute her incisal opening increased to 28, her midline shift was down to 2mm and a 1mm posterior open bite.

I was surprised how quickly her bite had changed after a single use and I instructed her to follow the manufacturer’s protocol by using the MandiTrac once per day before bed. She was ecstatic and reported that following a week of use, her jaw felt relaxed and her bite more even than it had been in the previous year.

After one month of use, her incisal opening was 41mm, her midline was even, her open bite appeared to be closed, and she no longer

Dr. Michael S. Kanter was born and raised in Miami, Florida. He began his dental career in the United States Army as a dental hygienist. After completing his tour of duty, he began his formal training at the University of Florida where he received a Bachelor of Science degree in chemistry in 1978. He graduated from the University of Florida College of Dentistry in 1982. He then completed his residency training at the Jacksonville Health Education Programs in the Department of General Dentistry. Dr. Kanter then moved to Sarasota, FL., where most of his family lives, and opened his first dental practice at the Meadows in 1984.

In 1991, Dr. Kanter founded and established a second practice, Braden River Dental, in Bradenton, FL. After several years and the growth of the Lakewood Ranch Community, Dr. Kanter expanded his range of services in the area by developing his new office in Lakewood Ranch – a state-of-the-art facility with all the latest equipment and technology that modern dentistry has to offer.

Dr. Kanter has extensive training in bone grafting, dental implants, dental sleep medicine, and cosmetic restoration. He is a graduate of the prestigious Misch International Implant Institute and has earned his Diplomate Status with the International Congress of Oral Implantologists.

60 DSP | Summer 2022

deviated when she moved her mandible. She even claimed that it helped her sleep better, stop clenching and improved her ‘double chin’.

As my interest in the MandiTrac increased, I decided to test the airway volume before and after usage with my colleague’s pharyngometer.

We observed a substantial improvement in the total collapsibility volume after just one use.

Since then, the MandiTrac has been our go to device for resetting the mandible and is being included with every sleep case, whether they are using an oral sleep device, night guard, arch expansion and/or performing Nightlase. My protocol includes making a morning occlusal guide (MOG) for every oral appliance therapy (OAT) patient, only now I instruct them to also use the MandiTrac once per day and only use the MOG on occasion to verify their bite. I also prescribe it for my bruxers, oral facial pain patients, and Upper Airway Resistance Syndrome (UARS) patients.

The Manditrac has become an essential tool in my sleep practice, and I highly recommend it to all practitioners, especially those regularly delivering mandibular repositioning devices.

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J Pain Res. 2014; 7: 99–115. Published online 2014 Feb 21. doi: 10.2147/JPR.S37593 Sheats RD, Schell TG, Blanton AO, Braga PM, Demko BG, Dort LC, Farquhar D, Katz SG, Masse JF, Rogers RR, Scherr SC, Schwartz DB, Spencer J. Management of side effects of oral appliance therapy for sleep-disordered breathing. Journal of Dental Sleep Medicine. 2017;4(4):111–125.

Carra MC, Huynh N, Lavigne G. Sleep bruxism: a comprehensive overview for the dental clinician interested in sleep medicine.

Dent Clin North Am. 2012;56(2):387–413. [PubMed] [Google Scholar] CM; Rossi, RRP; Cunali, PA; Dal-Fabbro, C.; Bittencourt, L. Side effects of mandibular advancement splints for the treatment of snoring and obstructive … OFM De Martins, C Junior - Dent.

Press J. Orthod, 2018 Jul-Aug; 23(4): 45–54. doi: 10.1590/21776709.23.4.045-054.oar J Clin Aesthet Dermatol. 2017 May; 10(5): 49–55. Published online 2017 May 1. PMCID: MC5479477 PMID: 28670358

Learn from top educators

DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry. in sleep dentistry at the

Greater New York Dental Meeting Sleep Apnea Symposium brought to you by Dental Sleep Practice

Four half-days, each repeated once: 1. Basic Dental Sleep Medicine 2. Adult Airway Appliance Workshop 3. The Medical Connection to Sleep Breathing Problems 4. Myofunctional Therapy – You Can’t Treat Without It

SPEAKERS

Nov. 27-30, 2022 | Jacob K. Javits Convention Center | New York, NY

Steve Carstensen, DDS, FAGD, FACD, FICD, D-ABDSM

Kristie Gatto, MA, CCC-SLP, COM®

Jonathan Lown, MD

Brett Brocki Founder and CEO, N3Sleep

DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry.

Watch for more details this Summer at

www.gnydm.com/sleep-apnea-conference

PRODUCTspotlight

Serena Sleep’s Elevate Appliance

S

erena Sleep’s new, patented, FDA cleared dental sleep appliance named the “Elevate” was developed by Dr. Greg Ross, a Board-Certified Orthodontist and Diplomat of the American Board of Dental Sleep Medicine. Dr. Ross suffers from sleep apnea and like many others, he could never wear a CPAP throughout the night. He tried many oral appliances but found none to be entirely comfortable and long lasting. He experienced that most oral appliances were bulky and had parts that protruded into the cheeks.

In his orthodontic practice, he digitally designs many in-house clear aligner treatments. He wanted to add a mandibular advancement mechanism to the aligners for his Class II patients while still correcting their malignment. While working on his designs it occurred to him, why not use this revolutionary idea for a new design to make an oral appliance to treat sleep apnea?

As soon as he created a device for himself, he found it was the most comfortable sleep apnea appliance he had ever worn.

Instantly he knew this was life-changing for himself and it could also be for others. This was the start of the Elevate appliance.

The Elevate utilizes a patented mandibular advancement design using engagement blocks in the occlusal space, avoiding any buccal or lingual interference. The design of the occlusal blocks keeps the patient engaged

62 DSP | Summer 2022

(in protrusion) while offering freedom for lateral movement, adding to the appliances comfort, especially for lateral bruxers. The Elevate is designed to minimize teeth movement, which includes covering the terminal distal surfaces and anterior surfaces.

The Elevate’s custom design is made of 3D printed, clinical grade nylon material that is durable, flexible, and only 1mm thin.

The low profile of the Elevate maximizes oral cavity space. Unlike other nylon appliances, the Elevate’s proprietary finishing process minimizes bacteria build up, making the appliance easy to clean and creating a “silky smooth” feel.

Advancement is easy with 3 upper and 3 lower trays for 9 titrations, or 2 upper and 2 lower trays for 4 titrations. The amount of advancement can be customized with either 1mm or 0.5mm increments. With the 9A design, there are enough trays to allow up to 7 mm of advancement as well as retrusion (negative advancement). The 4A design can be used for those who have a predetermined range of effective position; there are 4 trays allowing for fine-tuning for maximum efficacy and comfort.

The graph to the left shows the results of six consecutive patients in the orthodontist’s dental sleep medicine practice. Using NightOwl HSAT, the AHI was measured pretreatment and with the Elevate appliance after titration. The patients range from mild to severe OSA. Each patient’s AHI was reduced, and the patient with severe obstructive sleep apnea AHI was reduced by more than fifty percent.

The Elevate is positioned to be a low cost, comfortable, highly effective oral sleep appliance.

Dental Sleep Education That Fits Your Schedule Dental Sleep Education that fits your schedule The Academy of Clinical Sleep Disorders Disciplines is the only organization offering a fully online and on-demand certificate in Dental Sleep Medicine.

Study theonly lectures and course materials at your own The Academy of Clinical Sleep Disorder Disciplines is the organization offering a fully online pace, then when you are ready, take theSleep exam.Medicine.

The C.DSM certificate from ACSDD provides the necessary and on-demand certificate in Dental Study the lectures and course materials at your own pace, then when you are ready, takeapproach the exam.

12 modules present both the medical and medical and dental knowledge to confidently physicians and seek insurance reimbursement. dental science of sleep a solidfor foundation for understanding The medicine certificate providing is a prerequisite ACSDD Fellow and Diplomate.clinical applications.

Most dentists are able to complete the 13 CE program in 4-6 months.

The certificate is a prerequisite for ACSDD Fellow and Diplomate.

Enroll ACSDD.ORG Enroll Today Today at at ACSDD.ORG

The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider.

This program has been submitted for approval by the ACSDD for a maximum of 13 credits as meeting general dental requirements.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider at info@acsdd.org or to ADA CERP at www.ada.org/goto/cerp.

SLEEPhumor

...The Lighter Side of Sleep Apnea

64 DSP | Summer 2022

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Each drug-free treatment plan is tailored to address the individual patient’s symptoms, and includes the use of several tested technologies, including ultrasound, photobiomodulation, microcurrent, and muscle manipulation.

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