Dental Sleep Practice Winter 2023 by MedMark, LLC

We Live in Exciting Times

by Teofilo Lee-Chiong, MD

SomnoMed 2023 Sleep Summit Leading Experts Explore the Newest Frontiers

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INTRODUCTION

A Snapshot of the Future of Sleep Medicine

leep matters. When I get consistent good quality sleep, I am focused, healthy, creative, and happy. A couple of late nights in front of a screen, and I have difficulty. And I bet that everyone else on the planet is the same.

Sleep medicine is a late comer to the field of medical research with the first sleep medicine clinic opening in 1964 at Stanford. Sleep medicine is now on the forefront of my mind and multiple news articles. Over 20 years ago, my cardiac intake questionnaire included a question about sleep. It was just a general question about the amount of sleep and whether the patient felt rested. I then included a question for those who had a bed-partner regarding snoring. It didn’t take long for me

to notice a direct correlation between my cardiac patients and their sleep. I was overwhelmed with the inconsistent sleep and the accompanying cardiac issues and knew that I had to learn as much as I could about sleep to provide the comprehensive care that my patients deserved. In my early days of practice, I appreciated the elegance and effectiveness of CPAP for Obstructive Sleep Apnea (OSA). My patients’ cardiac status improved over time, but I became frustrated with the challenge of CPAP adherence. For the patients that were unable to tolerate CPAP, I sought out collaborative relationships with dentists in my region until I realized that there was a significant paucity of qualified and well trained sleep dentists. Besides CPAP and surgery, there were no other treatment options in my region. Over the years, I have been a vocal proponent of a multi-faceted approach to treating OSA which has ultimately led to my involvement with DSP magazine and my role as chief medical officer of Nexus Dental Systems. During my career as a cardio-sleep physician, I have cultivated relationships with many different specialities prioritizing an individualized approach to treating OSA. These include, but are not limited to dentists, ENT physicians, allergists, neurologists, bariatric and medical weight loss specialists amongst others. What has become apparent to me is the importance of an interdisciplinary approach that offers collaboration and synergistic care for the patient. The future of sleep medicine is evolving in this direction where active research is being undertaken to identify the complexities of OSA phenotyping and different management approaches.

Phenotypes under current research include age, sex, BMI, symptoms, hypoxemia, comorbidities, and OSA severity. When examined in the individual, therapeutic options will be more targeted and management options will be available based on a combination of variable clinical characteristics. Adjunctive therapies may include cognitive behavior therapy for insomnia, sedative hypnotic therapy, positional therapy, upper airway muscle training, Lee A. Surkin, MD, FACC, FCCP, or supplemental O2/CO2. Pending outcomes of FASNC, FAASM, board certified in current trials, these phenotypes are expected to cardiology and sleep medicine become part of the fabric of OSA management. A critical mission of sleep health care providers is engaging in efficient screening and appropriate referral for testing. The last decade has seen explosive growth in home sleep apnea test (HSAT) utilization. In part, this has been driven by the need for greater access, patient preference, and third party payer requirements. As technology advances so too will the ability to expand different metrics. In addition, the rise of artificial intelligence (AI) will result in a greater degree of accessible data resulting in increased diagnostic value and ultiBe sure to read the mately enhancing patient care. recent interview with One such example that highlights these Dr. Lee Surkin on advances is the development of algorithms the National that have the ability to extract data from Geographic website: heart rate variability. This information can be on.natgeo.com/3t1TaRR a valuable tool in assisting health care providers with a screening tool assessing cardiac arrhythmia risk. Continuous research offers ongoing discoveries and advancements in patient care in sleep medicine. It is a responsibility of health care providers to incorporate new information in balance with their clinical training and expertise. As technological advancements become more widely accessible, we must not lose sight of the most critical aspect of health care delivery – the physician-patient relationship. Technology is a tool, not a replacement. There is no substitute for human interaction and the importance of a healthcare provider’s clinical judgment. The future of sleep medicine is very bright, but remember to dim your lights several hours before bedtime and turn off your electronics! DentalSleepPractice.com 1

CONTENTS

SomnoMed 2023 Sleep Summit: Leading Experts Explore the Newest Frontiers in Sleep Medicine

True collaboration as many perspectives blend together.

Subha Giri, BDS, MS, FAAOP, D.ABDSM (left) and Timothy I. Morgenthaler, MD (right)

Cardio-Sleep Corner Sleep Stages and How to Improve Sleep Quality

by Lee A. Surkin, MD, FACC, FCCP, FASNC A look at sleep cycles, stages, and quality.

MEDICAL

Cover Story

Medical Insight

The Importance of Addressing Sleep Apnea in Hospitalized Patients

by Bertrand de Silva, MD, FCCP How OSA complicates the presentation and recovery of hospital patients.

Continuing Education

Physical Therapy Collaboration in Dental Sleep Medicine by Brad Gilden, PT, DPT, FFMT, FAAOMPT, PRC, CSCS, and Bill Esser, MS, PT, CCTT Correct breathing is a whole-body condition.

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2 DSP | Winter 2023

Medical Insight

We Live in Exciting Times

by Teofilo Lee-Chiong, MD Discussing technology and today’s important drivers of change.

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CONTENTS

Winter 2023

Clinical Focus

Publisher | Lisa Moler lmoler@medmarkmedia.com

Relating Oral Physiology to Sleep Apnea Appliance Positioning

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

by Allen J. Moses, DDS, DABCP, D.ABDSM Joints are there to move. Restrict them at risk.

Publisher’s Perspective

Chief Medical Editor Lee A. Surkin, MD, FACC, FCCP, FASNC drsurkin@n3sleep.com Associate Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com

37 Book Review

Editorial Advisors

by Lisa Moler, Founder/CEO, MedMark Media

A Masterpiece in the Landscape of PatientCentered Education

12 Case Study

review by Pat Mc Bride, PhD, CCSH A complex subject presented in a novel, fun, and useful way.

Choose Faith Over Fear

See the Whole Picture, Treat What You Know – a Case Report by Benedict R. Miraglia, DDS Human body response to setting the fundamentals right.

18 Adjunctive Therapy

The Long Road to Diagnosis: A Dentist’s Journey with Undiagnosed Breathing Difficulties and the Surprising Solution by Margaret Meadows, DDS If you’ve been asked about ‘exercises,’ here’s one.

34 Practice Management It’s Time for Preauthorization Reform by Rose Nierman It just might get easier, after all!

36 Product Spotlight

How Precision OAT is Changing Dental Sleep Medicine Getting closer to the best treatment for the individual.

4 DSP | Winter 2023

38 Communications Corner Connections

by Mary Osborne, RDH 4 ways to relate to patients, team, friends, and family.

40 Education Spotlight

Tufts Global Academy an interview with Dr. Shibani Sahni Sharing the leading developments in dental medicine with the world.

51 Choosing Appliances

National Account Manager Adrienne Good | agood@medmarkmedia.com ®

Incorporating myTAP into Your Sleep Practice by Jason Hui, DDS, MAGD, D.ABDSM Being ready to take action when patients needs require it.

54 Education Spotlight Airway Palooza: March 15-16, 2024 by Lauren Gueits, BS, RDH Join us for fun and top quality education in one of the world’s great cities.

56 Seek and Sleep DSP Jumble

Jamila Battle, MD (Family/Sleep/Addiction) Steven Bender, DDS Jagdeep Bijwadia, MD (Pulmonary, Sleep) Kevin Boyd, DDS Alison Kole, MD, MPH, FCCP, FAASM (Sleep, Pulmonary, Critical Care) Karen Parker Davidson, DHA, MSA, M.Ed., MSN, RN Bertrand de Silva, MD, FCCP, D.ABSM Kristie Gatto, MA, CCC-SLP, COM Amalia Geller, MD (Neurology, Sleep) William Hang, DDS, MSD Steve Lamberg, DDS, D.ABDSM 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

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 Felicia Vaughn | felicia@medmarkmedia.com Website Support Eileen Kane | 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 2023. 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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OSA public awareness activities: website, social al strategic pillars. media,pillars. brochures, posters, videos, events and most Visit www.nexusdentalsystems.com Today! Sapphire istouniquely positioned impact turnkey the dental strategic eting organization drive adoption of ato national brand” importantly the B to C products

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501C3 Non-Profit Fully accredited, online, onOSA public awareness activities: website, social Complete turn-key, hands-on approach to Sleep 501C3 Non-Profit Fully accredited demand Dental Sleep Medicine credentialing. The coaching & support and implementation, ongoing media, brochures, posters, videos, events and most demand Dental Sleep Medicine cr one of its kind in the world. new sales of equipment, software and services only one of its kind in the world. importantly the B to Conly products Nexus Bill

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PUBLISHER’Sperspective

Choose Faith Over Fear

’m sitting at my computer on a beautiful day, writing my winter message, and Billy Joel’s song, “Keeping the Faith” started playing. It started me thinking of the past and the future and how sometimes, it seems easier to stay “lost in let’s remember” than move forward and face an often scary unknown.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Winter 2023

One of my most meaningful mantras is “faith over fear.” It is so easy to keep to the same schedule, keep the same business protocols, and the same way of doing things, in a safe comfort zone. MedMark Media publications are meant to help you break out of that habit. We want you to not only read about the expanding opportunities for every aspect of your practice, but also to have the foresight to bring these innovations into your practice for your patients and your own success. After almost 2 decades of dental publishing, I have seen many advancements revolutionize dental specialties. I remember when dentists were wary of finding a new use for their darkroom space and welcoming digital imaging into the practice. Now, not only X-rays, but a myriad of digital technologies connect every aspect of the practice, from X-rays, to practice management, to marketing, and connecting with patients. Even AI has found its way to the dental office. AI is constantly evolving, so all of you brave “early adopters” should be excited about the prospects on that topic! No matter your specialty, innovations have transformed the way dental professionals practice – choices for clear aligner materials and 3D printing for orthodontists, new implant technologies for implant-focused dentists, and files and equipment to clean the root canal space for longer-lasting endodontic results. I have a personal involvement in many important breakthroughs affecting and saving the lives of those who suffer from sleep-breathing disorders. We have been honored all these

years to bring new concepts and insights to our pages to bring you all of the latest clinical and business options. In our Winter issue, here are some articles that will help you to fulfill your ambitious and enlightened goals. Our Cover Story looks at SomnoMed’s Medical Initiative at the 2023 Sleep Summit, which provided a multimodality educational experience and deep dive into sleep-disordered breathing solutions. Leading experts explored the growth of sleep medicine in keeping with SomnoMed’s core philosophy of “The Right Therapy for the Right Patient, at the Right Time.” Our CE delves into “Physical Therapy Collaboration in Dental Sleep Medicine,” and how physical therapy can significantly increase stability and positive results. In our Medical Insight section, Teofilo LeeChiong, MD, explores the drivers of change in dental sleep medicine, such as technologies and targeting treatment to individual values and needs. We can do the research, but you have to take the leap of faith. Billy Joel’s song has the right idea about honoring the past but propelling ourselves into the future: “You can get just so much from a good thing You can linger too long in your dreams Say goodbye to the oldies but goodies ‘Cause the good ole days weren’t always good And tomorrow ain’t as bad as it seems.” Don’t linger too long while others take initiative. Choose faith over fear to flourish personally and professionally! To your best success, Lisa Moler

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COVERstory

SomnoMed 2023 Sleep Summit Leading Experts Explore the Newest Frontiers and Growth Avenues in Sleep Medicine Subha Giri, BDS, MS, FAAOP, D.ABDSM (left) and Timothy I. Morgenthaler, MD (right)

omnoMed’s market-leading Medical Initiative was on full display in Rancho Mirage, California, at the 2023 Sleep Summit. As the capstone of SomnoMed’s Medical Initiative - which has successfully bridged relationships between dentists and physicians across North America – the Summit provided attendees a cross-functional, multimodality educational experience, diving deep into sleep-disordered breathing solutions infused with SomnoMed’s core philosophy of “The Right Therapy for the Right Patient, at the Right Time.” The Summit centered solely upon sleep-disordered breathing and the solutions that benefit both doctors and their patients. The 2023 Sleep Summit Pathways to Therapy: Addressing Barriers to Care

The 2023 Summit was held at the Westin Rancho Mirage Golf Resort & Spa on Septem-

“SomnoMed put so many of my sleep inspirations under one roof with the Who’s Who of sleep medicine! It was a great representation of the Medical Initiative, to build collaboration among sleep physicians, dentists, psychologists, surgeons, and specialists.” – Suzanne Thai, DDS, 2023 Sleep Summit faculty 8 DSP | Winter 2023

ber 28–30. The 2023 Sleep Summit was not an oral appliance conference; rather, it served as a forum for examining current scientific research on obstructive sleep apnea and therapeutic options. In keeping with SomnoMed’s core philosophy – Right Therapy, Right Patient, Right Time – all therapeutic options that are currently or soon to be available were presented. As stated by Colleen Lance, MD, “It is very rare in discussing potential therapies that I am recommending just one form of therapy. The therapeutic options may also change across one’s lifetime.” This approach fits with the consistent vision of Neil Verdal-Austin, CEO and Managing Director of SomnoMed, and his relentless support of elevating education for all therapeutic options for obstructive sleep apnea. “The Sleep Summit is all about your patients and their treatment. It honors our vision that only talks about patients,” said Neil Verdal-Austin. “At SomnoMed, all we do is about the patient, walking the difficult patient pathway with you and ensuring that if we can help with their treatment, we absolutely want to have that opportunity. Our firm belief is that in treating a long term chronic degenerative disease, compliance is really important. Having a theoretical efficacy argument is only well and good if the patient remains in treatment. That’s where oral appliances really come into their own.

COVERstory We have a treatment solution where patients remain in treatment, and I don’t need to tell you that avoiding the far worse co-morbidities still to come, if untreated, is crucial. And we owe that to your patients,” stated Neil Verdal-Austin, CEO, SomnoMed.

“Great weekend with unsurpassed PhysicianDentist mingling, discussion and networking – all potentially changing the future of Sleep Medicine!” – John Viviano, DDS, D.ABDSM, 2023 Sleep Summit attendee

‘The Sleep Apnea Team’

At the heart of SomnoMed’s Medical Initiative is the drive to foster physician-dentist collaboration, a vision vividly showcased at this year’s Summit. Unlike typical conferences, the Summit embraced an intimate, roundtable format that facilitated genuine, real-time collaboration. Recognizing the value of spontaneous interactions, organizers remained attuned to attendee engagement, even adjusting formal Q&A times if rich discussions arose during breaks. This fluid approach to collaboration is crucial in crafting effective obstructive sleep apnea treatments. Attendees had afternoons free for further discussions or leisure at the resort, and with inclusive meals and receptions, conversations seamlessly continued. An added touch was the opportunity for attendees’ guests to join receptions for a nominal fee, and a highlight was the open-air gathering under California’s radiant Harvest Moon, an event that will be fondly remembered. The 2023 Sleep Summit emphasized the integral role of ‘The Sleep Apnea Team’ – a diverse group of professionals spanning from dentists and sleep physicians to dental hygienists, sleep psychologists, surgeons, cardiologists, sleep technologists, respiratory therapists, dental hygienists, sleep coaches, myofunctional therapists, and more. The Summit’s panel sessions served to underline various practice models these team members utilize. Highlights from the panel sessions include: • Drs. Subha Giri and Timothy Morgenthaler shared the Mayo ASPEN Clinic Model. This clinic is for patients who have been diagnosed with OSA but are not satisfied with therapy. They are seen in a multidisciplinary clinic, undergo testing if needed, the team huddles to review the case, and a therapeutic plan is designed in collaboration with the patient. • Drs. Andrew Soulimiotis and Nancy Collop shared their experience at Emory where an academic institution partners successfully with a sleep dentist in the community.

• Kriston Reisnour, along with Drs. Srujal Shah and Suzanne Thai shared the private dental practice model. Their panel discussed the common barriers facing the path to Oral Appliance Therapy (OAT) with an emphasis on education. Kriston has a truly unique experience as a dental hygienist who is also credentialled as a sleep coach and myofunctional therapist.

Top left: David M. Rapoport, MD. Top right: Attendees enjoy an al fresco dinner. Above: SomnoMed Team. DentalSleepPractice.com 9

COVERstory • Drs. Mitchell Levine, Michelle Drerup, and Colleen Lance held a Wrapping It All Up panel comprised of a guided discussion with attendees regarding common barriers faced by patients accessing therapy. Attendees of the 2023 Sleep Summit experienced four sessions with the following topics: • Precision Therapy, where we learned about: ° Clinical Phenotyping with Dr. Klar Yaggi ° Sex-Specific Differences in OSA with Dr. Reena Mehra ° Patient Selection with Dr. David Rapoport • Technological Advances, where we explored: ° Mandibular Movement in diagnostic testing with Chandler Miller ° AI & Big Data with Dr. Dennis Hwang ° Remote Patient Monitoring with Dr. Christoph Schoebel who travelled from Germany to share their European experience.

“Kudos to SomnoMed for putting this together and working to bridge the gap between dentistry and medicine for the improvement of communities across the globe.” – Jason Tierney, author, Transform Dental Sleep 10 DSP | Winter 2023

• Grand Rounds, where we were updated on: ° Hypoglossal Nerve Stimulation with Dr. Patrick Strollo ° OSA and Sleep Bruxism with Dr. Gilles Lavigne ° Multimodality Therapy with Dr. Colleen Lance • Pathways to Care: ° The Role of CBTi in COMISA and Treatment Adherence with Dr. Michelle Drerup ° TMD and Facial Pain with Dr. Aurelio Alonso

Reflecting On The 2023 Sleep Summit

Scanning the agenda and list of speakers from this year’s Summit, one can’t help but be struck by the depth of expertise on display from leading figures in Sleep Medicine and Dentistry. Their collective wisdom speaks to an evolving narrative centered on finding ‘The Right Therapy for the Right Patient at the Right Time.’ This story will unfold further in 2024 through various CE offerings. Reflecting on the recent Summit, the outpouring of positive feedback on both the depth of content and the hosting resort has been overwhelming. This continued education event, sponsored by SomnoMed North America and supported by other industry partners, has truly hit its mark. Dr. Colleen G. Lance, the Summit Chair, shared her insights, noting: “The theme of the last three annual conferences has been an ongoing story of finding The Right Therapy for the Right Patient at the Right Time. As a field, we are redefining our

Above: Colleen G. Lance, MD, Sleep Summit 2023 Chair (left); Mitchell Levine, DMD, MSD, D.ABDSM (middle); and Michelle Drerup, PsyD (right)

COVERstory approach to sleep-disordered breathing using clinical phenotyping, data analytics, and artificial intelligence. These themes were woven into the fabric of the conferences while presenting practical applications for the clinical setting. A central theme of the conference this year was Meeting Patients Where They Are, engaging them as a partner in finding the right combination of therapies to meet their needs.” Plans for the 2024 Sleep Summit are already underway, with the spotlight on a handpicked panel of experts for October 16-20: a rendezvous at The Broadmoor Resort in Colorado Springs. With a proud 5-star rating from the Forbes Travel Guide for an impressive 63 consecutive years, The Broadmoor promises not just an enlightening conference but also an unforgettable autumnal retreat. Much like this year, the 2024 agenda will intersperse serious deliberations with leisurely afternoons. Attendees can collaborate or simply enjoy some downtime with family. The inclusive packages will cover meals and evening soirees, and for those looking to extend the experience to their companions, guest passes are available for a nominal fee. The 2023 Sleep Summit could not have been possible without the direction and coordination of Kathryn Hansen, BS, CPC, CPMA of Integration Consultants, LLC. Owner; CME coordinator. Assisting Kathryn in Marketing and Promotion was Alison Hinck. Digital marketing and communications were handled by Blue Craze Media (BCM), represented by Carly Stokes. Additional unrestricted grant was provided by the American Academy of Cardiovascular Sleep Medicine. We would like to thank our industry partners who supported us at The Sleep Summit 2023: • SomnoMed North America: Neil Verdal-Austin, CEO and Managing Director, host of the 2023 Sleep Summit with an unrestricted education grant

“This is the best conference I have attended; great education from experts in the field!” – First-time Sleep Summit attendee

Other market leaders who exhibited at 2023 Sleep Summit include: • React Health: ° Tod York, EVP of Sales, DME • Nexus Dental Systems ° Brett Brocki, Founder and CEO • RestAssure • Dental Sleep Profits ° Todd Warren, Founder & CEO • Align iTero ° Kyle Dunlap, business development manager • INSPIRE ° Erika Melkesian – Medical Education Associate • Dexis Consulting Group-Esthetic Professionals ° Brian Vujnovich, Senior Sales Executive ° Chad Crispin, CTO, director of business development • HDX Corporation ° Isabella Peceli, Education Specialist Without the support of our faculty, exhibitors, and attendees, this conference would not have been possible. Plan to join us for another capstone event in 2024 at the famous Broadmoor Resort in Colorado Springs, CO.

Far left: J. Emerson Kerr III, SomnoMed Director of Clinical Sales and Education (left) and Srujal H. Shah, D.ABDSM, DASBA, DDS (right). Above: Warren G. Kramer III, MD (left) and J. Emerson Kerr III (right). Far right: Attendees enjoy lunch and learning from the many exhibitors. DentalSleepPractice.com 11

CASEstudy

See the Whole Picture, Treat What You Know – a Case Report by Benedict R. Miraglia, DDS

auren was referred to my office by Dr. Michael Gelb for consultation to explore expansive orthopedic and orthodontic treatment options. Lauren was 14 years old, post orthodontics, with chief complaints of exhaustion and lethargy, dizziness, morning headaches, nausea, difficulty concentrating, microsleeps (seizures have been ruled out), anxiety-induced depression, and drooling at night. She had complained of aches and pains in the mouth for years, with a history of GI issues. An endocrinologist had evaluated her for substandard growth. Lauren had long been a step behind in school and could be defined as obstinate. She had weekly cognitive behavioral therapy which were helpful. Her polysomnogram revealed sleep apnea and a multiple sleep latency test confirmed narcolepsy. She was not a candidate for adenotonsillectomy and a CPAP was prescribed. Dr. Gelb had diagnosed myofascial pain and TMJoint capsulitis and treated Lauren with day and night appliances. Within a few months she was stabilized and referred to my office. We took a full medical history, confirming the findings listed above, adding mild asthma and noting a history of clenching and

Figures 1 and 2: Lauren

12 DSP | Winter 2023

grinding her teeth at night. Full orthodontic and dental records to supplement the CBCT volume provided by Dr. Gelb included photographs, transverse measurement, Marchesan Frenum Protocol and a clinical examination. Next: a consultation appointment to discuss the records, findings, diagnosis, and treatment options. Our goal at the consultation appointment was to help her parents see what we saw: a primary foundation problem. After more than a decade being treated by the medical community for her symptoms, her many medical problems have resulted in a struggling, unhealthy child (Figure 1). Orthodontics left her with straight teeth but a narrow smile that failed to fill her normal, wide lip line (Figure 2). With our help, Lauren’s parents could see her underdeveloped jaws and appreciate a foundation first, tooth alignment and bite coordination second, treatment choice. The transverse measurement is the shortest distance at the gumline between primary teeth A and J or secondary teeth 3 and 14. The transverse measurement has its history with Dr. Edward A. Bogue and Dr. James McNamara from the University of Michigan. Dr.

Figure 3: Transverse dimension 29 mm. Figure 4

Figure 5

Figures 6 and 7

Figure 8

CASEstudy

Figure 9: Tightly attached lingual frenum

Bogue’s research explained that a child of 4 years old with 28mm or less between primary teeth A and J is underdeveloped and will progressively have irregular eruption and crowded teeth (Figure 3). His work provides dentistry the maxim that a child who has little to no spacing between their primary teeth will have crowded permanent teeth. Dr. McNamara’s research on growth and development showed that kids who developed healthy, ideal occlusions without any orthodontic intervention had transverse measurements of 35-39mm by the age of 12, without considering third molars. Dr. Robert Corruccini’s anthropology research shows well developed jaws with 32 teeth in naturally healthy occlusion have transverse measurements starting at 45mm. At age 14.5, Lauren’s Transverse Measurement is 29mm, a barely acceptable number at age 4. The maxilla defines the palate and much of the nose, consequently the more narrow and vaulted the palate, the smaller or more compromised is the nasal chamber. This restriction increases nasal airflow resistance and leads to mouth breathing. The phenotype for OSA is a V shaped arch and a narrow, vaulted palate (Figures 5-8). Lauren’s lower arch was narrower than the upper, with no crossbite, leaving insufficient space for her normal-sized tongue. Without considering the size of the arches, a sad perspective would be her tongue is ‘too big.’ Imagine what must happen during function – there is no place for her tongue to go except backwards into her airway – scalloping shows the body’s attempt to keep it forward, pressing it against the teeth (Figure 9). Another common directive is that crossbite is the only indication for expansion. Pre-treatment panoramic and cephalometric radiographs are included (Figures 10 and 11). Dr. Irene Marchesan’s Frenum Protocol objectively scores the level of tongue restriction. Her research supports tongue mobility

Figures 10 and 11: Pre-treatment panoramic and cephalometric radiographs

being related to jaw growth and development. The more mobile the tongue, the more developed the jaws are and the more restricted the tongue, the less developed the jaws. Her protocol incorporates measurements, frenum attachment locations, and tongue movements. The 0 (excellent) to 8 (fully restricted) scoring system guides clinicians to recommend revision with a score > 3. Lauren’s score was 5. Lauren’s 2019 pretreatment polysomnogram (PSG) showed a respiratory disturbance index (RDI) of 9.3 per hour and an apnea hypopnea index (AHI) of 6.7 per hour. Pediatric OSA in non-obese children is a disorder of oral-facial growth.1 Her 2019 multiple sleep

Benedict R. Miraglia, DDS, is a graduate of the State University of New York at Buffalo School of Dental Medicine, and he is a member of the ADA, the AGD, the NYSAGD, and the Ninth District Dental Society. Dr. Miraglia is a graduate of the United States Dental Institute where he learned his non-extraction, expansive orthodontic philosophy. He has been practicing dentistry in Mt. Kisco, New York for 30 years, including 20 years offering interceptive orthodontics. Dr. Miraglia is on the Board of Directors of the American Academy of Physiological Medicine and Dentistry as well as the Northern Westchester Hospital President’s Council. He is widely recognized for his lectures and continuing education courses focusing on craniofacial growth and development related to childhood sleep disordered breathing. Dr. Miraglia is the Chief Clinical Officer for Airway Health Solutions. He has trained thousands of dentists across the globe in all levels of clear aligner orthodontic treatment. Dr. Miraglia is currently the VP of GP Clinical Education at CandidPro.

DentalSleepPractice.com 13

CASEstudy

Figures 12 and 13: After expansion

Figure 14: Larger arch form increased the space available for the tongue

latency test (MSLT) results met both criteria for narcolepsy – sleeping in all four opportunities, with short sleep latency, and REM in 3 naps. Lauren’s school struggles were well documented: trouble getting to school on time, staying awake, managing assignments, and performing well on tests. Both her pediatric pulmonologist and I were asked to provide accommodation letters so school officials could understand her situation. Lauren’s diagnosis was Class 1 Malocclusion with maxillary and mandibular deficiency, transverse deficiency, lingual frenum and upper labial frenum restrictions, and soft tissue dysfunction. Multiple-level treatment recommendations followed a foundation first, teeth second approach: Upper and lower fixed expanders to address the maxillary, mandibular, and transverse deficiencies, followed by clear aligners to align the teeth and coordinate the bite. During the clear aligner phase, orofacial myofunctional therapy to treat the soft tissue dysfunction and coordinate with frenum releases by an oral surgeon. Nasal hygiene was to be performed daily. Lauren was advised to use a non-steroidal, natural nasal spray several times a day during treatment. Continuous nasal breathing was a primary goal of this treatment plan. This consultation process concludes with a discussion of the risks and benefits of treatment, alternatives, as well as the option not to treat. Her parents also understood that I was not treating Obstructive Sleep Apnea, ADHD, narcolepsy, insomnia, anxiety, depression, mild asthma, TMJ symptoms, morning headaches and/or any other symptom Lauren had struggled with over the last decade. I was treating her underdeveloped jaws. Lauren’s parents consented to treatment using fixed expanders first followed by CandidPro clear

Figures 15 and 16: Before foundation treatment (left) and after initial phases of foundation treatment (right)

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aligners. They also agreed to the orofacial myofunctional therapy with frenum revisions as described. A digital scan was taken and sent to Ohlendorf Appliance Laboratory in St. Louis, MO where maxillary and mandibular fixed expanders were fabricated. One month later Lauren’s upper expander was placed. Since she was nearly 15, a slow expansion rate was prescribed with her parents making the turns. Four weeks later, the lower fixed expander with a slow expansion rate was added. After nine months, her Transverse Measurement increased from 29mm to 38mm (Figures 12 and 13). The larger arch form and width increased the space available for the tongue and was a significant foundational increase when compared to pre-treatment (Figure 14). As expected, at this point in treatment the teeth are not well positioned nor is the bite correct. We basically ignore the teeth during foundational growth as the fixed expanders are designed to address the maxillary, mandibular, and transverse deficiencies and not the teeth. After 9 months, Lauren reports that she has been improving in all her symptoms. She states that she is starting to feel better and is excited to transition to clear aligners (Figures 15-18). At the same appointment the expanders are removed, we took photos and scans to order CandidPro clear aligners. She wore interim Essix clear retainers day and night to ensure perfect fit when the aligners were ready. Lauren was referred to Connecticut Orofacial Myology – one of the skilled team members there worked with her leading up to the frenum revisions and for months afterward. To follow maxillary and mandibular development, we needed an expansive clear aligner technique to continue the process, wider and forward. CandidPro clear aligners were chosen to align and coordinate the

Figures 17 and 18: Before foundation treatment (left) and after initial phases of foundation treatment (right)

CASEstudy

Figures 19 and 20: Significant increase in space

Figure 23: Note broad full smile without dark buccal corridors.

Figures 21 and 22

teeth into a healthy, stable, functional, comfortable, and esthetic occlusion. Within a few days, CandidPro posted a treatment plan that met our objectives, with no need for attachments, simplifying the process. An expansive plan removed any consideration of interproximal reduction. We accepted the plan and two weeks later Lauren started wearing her first set of aligners. Lauren wore 22 CandidPro aligners over 11 months to deliver a wider arch form with excellent tooth alignment and bite coordination. She engaged with the myofunctional therapist and had the lingual frenum and upper labial frenum revised by Dr. Scott Siegel, with therapy afterward to ensure proper healing, mobility, strength, and function. A final set of photographs was taken, and a full interview with Lauren and her parents was conducted to review her symptoms. Lauren had become a day and night nasal breather and her parents reported quiet sleep. She no longer missed school or fell asleep in class. She had achieved A student status without extra help or time. The fixed expanders increased Lauren’s Transverse Measurement from 29mm to 38mm; CandidPro aligners provided an additional 3mm for a final Transverse Measurement of 41mm – a 12mm improvement in space for her tongue (Figures 19 and 20). The frenum release and myofunctional therapy freed, strengthened, and trained the tongue to function properly in its newly developed

oral space. Compare Lauren’s senior portrait (Figure 23) to her pretreatment photo – not all results can be objectively measured. After treatment Lauren repeated an in lab PSG and MSLT. Her AHI was 0.4 per hour and a repeat MSLT failed to show any signs of narcolepsy. Lauren’s parents forwarded the new results accompanied with a note saying “Very interesting how she no longer presents with apnea or narcolepsy.” Lauren benefited from a conservative, non-surgical foundation first, teeth second approach to treatment. Her success was due to a supportive family and a collaborative care approach to treatment, incorporating necessary frenum releases and orofacial myofunctional therapy into her treatment plan. Developing her maxilla and mandible facilitated Lauren returning to nasal breathing as well as delivering an appropriate size chamber for her tongue to properly rest, swallow, speak, and function. After our 20 months of treatment, Lauren is no longer diagnosed with or treated for obstructive sleep apnea, insomnia, narcolepsy, ADHD, morning headaches, anxiety, depression, or any of the medical symptoms she had previously struggled with over the previous decade. Lauren is now over one year post treatment and enjoys living a healthy life free of the long list of struggles that previously held her back from her true potential. Recently, Lauren shared that she had won first place in a New York State Science competition (Figure 24). The big surprise was that she used flies to show that if their sleep/rest cycle is disrupted, they are not able to perform their daily tasks at the same level as flies that are not sleep disrupted. She was accepted to a top tier college and plans to pursue a career in research. 1.

Figure 24: First Place Science Winner

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Guilleminault C, Huang YS. From oral facial dysfunction to dysmorphism and the onset of pediatric OSA. Sleep Med Rev. 2018 Aug;40:203-214. doi: 10.1016/j.smrv.2017.06.008. Epub 2017 Jul 6. PMID: 29103943.

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.

ADJUNCTIVEtherapy

The Long Road to Diagnosis: A Dentist’s Journey with Undiagnosed Breathing Difficulties and the Surprising Solution by Margaret Meadows, DDS

n a world where everyone tells you that you’re fine, but deep down, you know something is wrong, it becomes essential to trust your instincts and be persistent in seeking answers. This was precisely the case for me as I embarked on a vigilant and resolute path of self-discovery and self-advocacy for my health. In 2019, while out on my usual bike ride, I had trouble fully expanding my chest. When I told my Primary Care doctor, they listened to my deep breaths and took a chest X-ray but found nothing unusual. One year later, I decided to tell my Rheumatologist. More tests, including another chest X-ray and a visit to a cardiologist, who told me that I had the “heart of a 25-yearold.” They said no more tests were needed, and I was left feeling unsure about my health once again. Despite their reassurances, I still couldn’t shake the feeling that something was wrong. To ease my worries, I started taking weekly readings of my O2 saturation levels, which ranged from 88% to only occasionally reaching 92%. Even though my ability to walk, play tennis, and do other moderate exercise was not affected, I still couldn’t help but worry about my health. Despite my breathing difficulty, I tried to remain optimistic and blamed it on the numerous medications I was taking for Polymyalgia Rheumatica (PMR), an autoimmune disease that affects tendons, muscles, and joints. It crossed my mind that the steroids or medicines prescribed to me could be affecting my ability to expand my lungs. My health started declining more quickly, including peripheral neuropathy in my feet and eye muscles. Sometimes, my eye

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movements made me feel narcoleptic, which was not ideal for my career as a dentist. An ophthalmologist and a neurologist both told me these issues were “just a normal part of aging, related to menopause, or may just be hormonal.” Looking back, I realized that my health decline was not sudden, but rather a gradual trajectory that may have started when I was 14 years old. I remembered gasping for air, but thought then it was just due to stress. A decade later, while in dental school, I noticed tori bilaterally on my mandible and maxilla. I promptly made myself a mouthguard, which I have worn for most of my life. No one connected oral conditions with sleep apnea back then. It wasn’t until 33 years later, after 22 years of marriage, that my husband started noticing that I snored every night. By chance, I was going to a dental sleep conference and decided to have my first sleep test done. To my not-so-surprised discovery, I had an AHI of 15 and was diagnosed with moderate obstructive sleep apnea and central sleep apnea. An Orofacial Myologist speaker talked about oral muscle exercises and their positive impact on the airway. We were also introduced to the REMplenish™ water bottle and nozzle, which had the potential to tighten up our tongue and neck muscles. It was also suggested that it could help tongue-tied patients learn how to suction correctly and aid in speech correction. While waiting for my dental orthotic sleep device, I started using REMplenish daily and noticed an improvement in my neck muscles and sleep patterns. My snoring decreased by 90% after 1 week of use, and my average

ADJUNCTIVEtherapy O2 levels improved from 88%-92% to 94% within 2-3 weeks. Within 4 weeks, my “turkey neck” was visibly reduced – I had been using a workout I read in a book for 8 months with no results! Despite coexisting issues, my cognitive alertness improved, I stopped waking up to use the bathroom, and my peripheral neuropathy completely resolved. At 8 weeks of regular use, I experienced improved sleep quality, no snoring, good O2 sats, and increased cognitive alertness. When I experimented by stopping its use for 4-5 days, I noticed a decline in sleep quality, a dip in my O2 saturation levels, and reduced alertness. I realized that the benefits of using the straw were quickly lost. It seems consistency is key to achieving the full benefits of REMplenish. Like any exercise routine, it must be sustained to produce results. Personally, I find it to be an effective “kick starter” in my health improvement journey, particularly in keeping my neck muscles taut and my airway open, resulting in better oxygen saturation levels – something my doctors never thought possible. Although I initially thought the device was intended for “others” with speech therapy or tongue tie issues, I now see it as a valuable partner in my own health and wellness. Personal use and insight can be a powerful tool in promoting treatment plans. Demonstrating a willingness to undertake the same treatments recommended to patients can help build trust and credibility. I have always been an advocate of this approach, having been both my first night guard and clear aligner patient. While I have treated patients with sleep appliances for years, my own experience with a sleep device has given me invaluable insights that I hope to leverage in treating even more patients with mild to moderate sleep apnea. In the end, it took me four decades to have my “ah ha” moment, but I am glad that I finally have some answers to my health concerns. As a result, I have been recommending the REMplenish straw to every patient who mentions snoring or exhibits a Modified Mallampati score of 2-3 or a Friedman score of 2-3. So far, every single patient who has used it has described it as a “miracle” that effectively eliminates their snoring. Many have noticed a decrease in tongue size, which we

At 8 weeks of regular use, I experienced improved sleep quality, no snoring, good O2 sats, and increased cognitive alertness.

know contributes to improved overall breathing. Just like my experience, if they stop using the straw, the snoring returns. This serves as clinical evidence that the straw exercise is the crucial factor in addressing snoring, and like any exercise, it needs to be practiced daily. Now that I understand firsthand the benefits of treating OSA, I am eager to continue sharing my experience and what I’ve seen in fellow patients. By modeling the personal approach that my patients have come to expect, I am confident that I can promote effective treatment plans and improve outcomes. I’m excited to continue working out my neck muscles with REMplenish every day and sharing my experience with friends, family, and patients!

Dr. Margaret Meadows graduated UCLA Dental School in 1989. She was in private practice in Coronado California for 30 years. She integrated Sleep Dentistry into her private practice in 2016. She recently made a move to Ohio and is practicing with Magnolia Dental Group (with 10 offices) in Columbus. Dr. Meadows completed the AADSM Mastery program in 2023 inspired by her personal heath journey, specifically her diagnosis last year of Sleep Apnea.

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CONTINUINGeducation

Physical Therapy Collaboration in Dental Sleep Medicine by Brad Gilden, PT, DPT, FFMT, FAAOMPT, PRC, CSCS, and Bill Esser, MS, PT, CCTT

Educational Aims This self-instructional course for dentists aims to help the reader understand more about physical therapy. Dentists who provide airway therapy in their practice have expanded their focus beyond the oral cavity into adjacent structures, e.g., the nose and oropharynx. Dentists who have considered temporomandibular disorders part of their service mix have embraced some orthopedic principles. Linking these physiologic characteristics is physical therapy. Far more than just a rehabilitation service, PT can add significant value to a treatment regimen, increasing the stability of positive results. This article will help the dental team learn more about what PT can add and provide some simple screening tools to identify which patient may benefit from a thorough physical therapy evaluation.

Expected Outcomes Dental Sleep Practice subscribers can answer the CE questions online at https://dentalsleeppractice.com/continuing-education/ to earn 2 hours of CE from reading the article. Correctly answering

the questions will demonstrate the reader can: 1. Recognize contributions of poor body function to clinical signs and symptoms 2. Develop office workflows for screening patients in this area 3. Open a conversation with physical therapists in their area to identify collaboration partners

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Role of an AirwayCentric® Physical Therapist in Dental Sleep Medicine

Physical Therapists are trained to recognize and treat faulty postural and movement patterns involving the human musculoskeletal and neuromuscular systems. When repetitive inefficiencies in skeletal alignment or aberrant movement patterns occur, compensations take over compromising the health of the system. The stomatognathic and respiratory systems are among the first regions of the body to be affected by these compensatory activities. Starting with the nasopharyngeal area extending down to the diaphragm. The primary driver of inhalation is the thoracic diaphragm. If the ribcage is not properly aligned over the pelvis, the diaphragm will remain in a hypertonic contracted state, leading to a cervical accessory muscle driven breathing pattern. When the neck becomes more involved in breathing, increased tension is developed in the craniofacial, orofacial, craniomandibular, cervical and thoracic regions that can lead to upper airway resistance. Increased nasopharyngeal resistance will manifest developing further compensations which may include: parafunction, nasal congestion, mouth breathing, excessive tongue activity, increased pressure on

CONTINUINGeducation the cardiovascular system and alteration of the body’s pressure systems. Symptoms that arise from these compensations may include headaches, tinnitus, dry mouth and throat, vestibular/balance deficits, scoliosis, TMJD, neck pain, GERD, ankyloglossia and the development of malocclusion. The role of an AirwayCentric Physical Therapist (ACPT) is to correct inefficiencies in postural and movement patterns to prevent or reverse the resulting compensatory tendencies. Reinstating efficient posture and body mechanics will not only help the reduction or elimination of painful symptoms, it will also support any dental work to prevent relapse. For the purpose of this text, ACPT is used to define a physical therapist that has specialized postgraduate education focused on the evaluation and treatment of patients with disorders related to the nasal and oral airway, such as obstructive sleep apnea (OSA). ACPT’s use a multi-disciplinary approach to provide medical and therapeutic interventions that aim to alleviate airway obstruction and improve patient’s quality of life. ACPT’s work in close collaboration with other healthcare professionals, including dentists, otolaryngologists, myofunctional therapists and pulmonologists, to ensure the patient receives the best possible care. You will not find a specific degree associated with this designation. There will be guidance at the end of this chapter on how to locate an ACPT in your area. When a patient presents to a medical professional with suspected nasopharyngeal abnormalities, there are both intrinsic and extrinsic factors contributing to the problem. Intrinsic factors may include anatomical anomalies that increase resistance to airflow such as a narrow maxilla, swollen tonsils/ adenoids, retruded mandible, malocclusion or ankyloglossia. Extrinsic factors that can increase airway resistance may include forward head posturing, parafunctional habits such as nail biting, poor workstation or sleeping positions, an inflammatory diet and poor stress management skills. Having a multi-disciplinary approach to first recognize and make appropriate referrals to a trusted colleague can be the difference between success and failure. Building a team that includes an Airway Centric Physical Therapist to help identify and treat intrinsic and extrinsic factors is paramount.

Temporomandibular Joint Dysfunction (TMD)

In 1934, JB Costen, an otolaryngologist, published an article implicating occlusion as the primary cause of TMD. Ten years later a second article further solidified the framework for occlusion being the cause of TMDs. For the next 75 years, the field of dentistry embraced TMD as its own in an attempt to treat

Dr. Brad Gilden has been practicing physical therapy since graduating from New York Medical College in 2000. He has worked in a variety of settings treating patients with various neurological, orthopedic and postural related dysfunctions. In 2004, he completed a clinical doctorate in upper quarter and hand therapy from Drexel University. He joined Elite Health Services as a managing partner and rehabilitation coordinator in 2005 and co-founded IPA Manhattan Physical Therapy in 2011, and Kinetichain Integrative Manual Therapy in Aspen, Colorado in 2019. He is certified in both Functional Manual Therapy and Postural Restoration aimed at illuminating movement dysfunction and postural awareness while integrating patients back to their highest level of health. In 2010, he completed an intensive certification in functional manual therapy through the Institute of Physical Art. In 2014, he completed a three-year long fellowship in functional manual therapy through the IPA and American Academy of Orthopedic Manual Physical Therapy. In 2020, he completed certification through the Postural Restoration Institute. He is an active member of the American Physical Therapy Association, American Academy of Orthopaedic Manual Physical Therapy, and the American Academy of Physiological Medicine and Dentistry. He lectures internationally at various medical conferences and on the adverse effects of breathing pattern disorders and chronic sympathetic overload on the human body. Bill Esser, MS, PT, CCTT, graduated in 1979 with a master’s degree from Purdue University and in 1981 from the University of Iowa Graduate Program in Physical Therapy. Bill‘s career has been as an outpatient orthopedic physical therapist including being an owner/partner in private practices in Southern Oregon 1986-2013. He retired from ownership in 2013 to concentrate on teaching. He is a diplomate of the Physical Therapy Board of Craniofacial Therapeutics, established in 1999 by an international group of physical therapists, and he holds the title Certified Cervical and Temporomandibular Therapist (CCTT). There are fewer than 100 diplomates worldwide. Bill has over 4 decades of multidisciplinary training and clinical experience in management of TMD, complex facial pain, and cranial and cervical spine dysfunction. In 2019, he completed a dental mini-residency under Jeff Okeson, DMD. Bill has been an instructor for Empiridence and Myopain Seminars, Professional Therapies Northwest, and as an adjunct instructor on TMD for the Schools of Physical Therapy at Pacific University and George Fox University. Bill has also taught for the Oregon Physical Therapy Association and Oregon Dental Association on TMD.

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CONTINUINGeducation TMD by altering the patient’s occlusal schema. Taking on the mantle of responsibility for TMDs dentists are currently considered the primary providers for, authority on, and are considered legally responsible for, the evaluation and treatment of the TMD patient (H. Clifton Simmons III, DDS, Journal of Craniomandibular Practice & Sleep Practice. 2016, Vol 34, No.2). With the exception of a few physical therapists (Mariano Racabado, Steve Kraus, Harry VonPiekartz) the medical field appears grateful to have placed the burden of care and treatment of this complex diagnosis upon their dental colleagues’ shoulders. Over the past 25 years, a mounting body of research has questioned and is reaching the conclusion that occlusion does not stand alone as the initiator, sustainer, and perpetuator of TMDs. Jeffrey Okeson DMD presents at his annual University of Kentucky TMD, Orofacial Pain and Dental Sleep Medicine Residency in 2019 that a systematic review, looking at 349 studies from 1966-2002 (with only 4 relevant studies fulfilling the inclusion criteria) concluded “There were very few associations reported between malocclusions, functional occlusion, and TMD. Research shows that almost every type of occlusal relationship and maxillomandibular relationship can be found in equal proportions among patients with TMD and non – symptomatic patients (1. Pullinger AG.Selgman DA. Quantification and validation of predictive values of occlusal variables in temporomandibular disorders using multifactorial analysis. 2. Michelotti A, Iodine G. The role of orthodontics in temporomandibular disorders. J. Oral Rehab. 2010:37, 411-429). A recent article in AJO-DO

Table I: Qualifying Questions for Referral to an ACPT • • • • • • • • • •

Are you experiencing pain or stiffness in any part of your body that is affecting your mobility, posture, or range of motion? Have you recently been injured or undergone surgery that has limited your ability to perform daily activities? Do you notice any changes in your posture, gait, or balance that may be affecting your overall movement and functionality? Do you have increased pain upon waking in the morning? Do you snore or gasp for air during sleep? Do you breathe through your mouth during the day or night? Do you have fullness or ringing in your ears? Do you experience dizziness/lightheadedness when changing position, e.g., Sit to stand? Do you experience tension headaches and/or migraines? Do you experience jaw pain and/or clicking?

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(American Journal of Orthodontia and Dentofacial Orthopedics 2022 Jun;161 (6):769-774) “What have we learned from 1992 – 2022”, states orthodontists should avoid diagnosing and treating TMDs within the traditional mechanical and dental-orthodontic based frameworks and that TMD’s complexity may be best approached from a biopsychosocial standpoint. It is becoming clearer that the complexity of what initiates, sustains, and perpetuates TMDs is multidimensional requiring the expertise of both dentistry and medicine. To effectively address the TMD patient, dental and medical professionals need an interdisciplinary understanding of the anatomy and function of the teeth, occlusion, head, neck, and trunk as they relate to TMD. The TMD practitioner must understand the interrelation of these multiple components and how dysfunction of any single or multiple elements of this system can initiate and sustain TMD. Unilaterally treating TMD patients from a dental or medical therapy approach has led to the current confusion and often failed treatment the TMD patient experiences.

When to Refer a Patient to an AirwayCentric Physical Therapist?

The first step adding physical therapy to your patient’s plan of care is to properly identify when a referral for physical therapy is appropriate. Many of your patients may already be working with a rehabilitation professional – (Physical Therapist, Chiropractor, Occupational Therapist, Osteopath). It is a good policy to ask if they enjoy working with this professional and understand their approach to the airway. This could be an opportunity to add a qualified professional to your team whom your patient already values and trusts. There are specific parameters to determine the appropriateness for a referral to an ACPT. Below is a list of qualifying questions that would lead you to consider making a referral.

Physical Therapy Airway Screen

The following represents a quick screen a dentist can use to determine if a patient is a good candidate for an ACPT referral. You should expect asymmetrical craniofacial patterns in every patient during this screen. However, when there is a large clustering of asymmetries, combined with subjective complaints of pain or loss of stomatognathic function, a referral to an ACPT should be considered.

CONTINUINGeducation Physical Therapy Airway Screener I.

Static Postural Assessment Have the patient standing with their back to a blank wall. (A graphing grid on the wall can be very helpful.) Ask the patient to relax and look straight ahead. Taking pictures with a digital camera is recommended to measure facial symmetry and track changes throughout the course of care. A. Frontal Plane Assessment

B. Determination if convergence and a mandible shift is present: 1. Draw a line through the pupils and across the lip line 2. Determine if the lines converge to one side. A high correlation exists between disc displacement and a lack of development of the condyle and ramus and the side of convergence. Condylar movement posterior and superior onto the retrodiscal tissue is felt to affect arterial flow and joint nutrition. C. Determining altered chin position from midline 1. Mark a point between the eyes and the middle of the bridge of the nose (Nasion) 2. Mark a point in midline just under the nose (Subnasion) 3. Mark a point in the middle of the chin 4. Drop an imaginary line cephalad to caudal to see if the chin is in line or shifted to one side ❒ R mandible shift ❒ L mandible shift 5. Correlate chin deviation with convergence to that side and also the labial frenulum D. Additional observations in the frontal plane 1. Ear Height ❒ Level ❒ Right higher ❒ Left higher 2. Ear show ❒ Equal ❒ Right greater ❒ Left greater 3. Eyebrow height ❒ Level ❒ Right greater ❒ Left greater 4. Lip seal ❒ Sealed no chin strain ❒ Sealed chin strain ❒ Apart ❒ Level 5. Pupil Height ❒ Right greater ❒ Left greater 6. Nasal bone ❒ Midline ❒ Right deviated ❒ Left deviated ❒ Midline 7. Chin ❒ Right deviated ❒ Left deviated ❒ Midline 8. Throat ❒ Right deviated ❒ Left deviated 9. Shoulder Height ❒ Level ❒ Right higher ❒ Left higher E. Sagittal Plane Assessment 1. Forward Head Position - Craniovertebral Angle (CVA) - Acute Angle that formed from tragus of the ear to C7 with horizontal line at C7 ❒ > 50 degrees ❒ < 50 degrees = FHP 2. Mandibular Skeletal Class: with the lips lightly closed, a line drawn superior to inferior should touch the forehead, maxilla, and chin. a. ❒ Class I - aligned forehead, maxilla and mandible b. ❒ Class II - retruded mandible c. ❒ Class III - protruded mandible ❒ Level ❒ Right forward ❒ Left forward 3. Shoulder Position 4. Sternum relationship to floor ❒ Elevated ❒ Depressed ❒ perpendicular to floor

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CONTINUINGeducation Physical Therapy Airway Screener (continued) II. Soft tissue and Intra-oral Inspection A. Note Scar(s) on Face/Chin sign of previous macrotrauma to the face. *Scar often opposite the side of disc displacement and convergence 1. Scar present on chin ❒ Right ❒ Left B. Scalloping of Tongue Scalloping usually indicates lower tongue resting posture and potential for patient using tongue against/between teeth at night to brace. This is an indication of airway compromise. 1. Stick tongue out to assess scalloping ❒ none ❒ mild ❒ moderate ❒ severe C. Labial/Buccal Inspection 1. With the teeth lightly touching, lift the upper and lower lips away from one another and inspect the alignment of the lower frenulum. ❒ Lower frenulum in line with upper frenulum ❒ Lower frenulum to the right of upper frenulum ❒ Lower frenulum to the left with upper frenulum 2. Is the frenulum/buccal tie limiting lip mobility ❒ No ❒ Yes, upper ❒ Yes Lower ❒ Upper and lower limited D. Dentition Observation of the relationship between lower teeth to the upper teeth with the teeth in light contact. 1. Overbite: How far do the top incisors extend beyond the bottom incisors from cephalad/caudal relationship (Ideal is 2-3 mm) ❒ _______ mm 2. Overjet: How far do the top incisors extend over the bottom incisors from an anterior to posterior relationship (Ideal is 2-3 mm) ❒ _______ mm 3. Tori: Assessment for extra bone at the center of maxilla and inside the lower mandibular teeth. Tori are compensatory boney depositions by the musculoskeletal system found midline superiorly on the maxilla or inferiorly medial to the lower teeth of the mandible. The extra bone deposition results from exorbitant stresses applied to the teeth during night parafunction particularly to grinding activity which applies a torsional stress to the teeth. ❒ None ❒ Maxillary Tori ❒ Mandibular Tori 4. Clench Lines: are fibrotic lines inside lateral borders of the cheeks. The dental term for clench lines is linea alba – white line. They are best observed with the use of a flashlight. Pull the cheeks out away from the teeth with a tongue blade and record if present. Since they are epithelial versus fibrotic changes, they may disappear over time if clenching behavior can be decreased. ❒ Not Present ❒ Present 5. Additional comments regarding dentition (tooth wear, gum health) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ E. Tongue Position and Mobility 1. Tongue Resting position - ask patient where there tongue is at rest ❒ Roof of mouth ❒ Bottom jaw ❒ Front of teeth ❒ Not touching anything 2. Jaw and Tongue ROM - Measure with calipers a. Total jaw range of motion (from upper to lower incisor) _____ mm b. Tongue tip on palate measure opening TIP _____ mm c. Tongue Suctioned to Palate Lingual Palatal Suction LPS ______ mm d. Ratio of TRMR/TIP x 100 __________% e. Ratio of TRMR/LSP x 100 __________%

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CONTINUINGeducation Physical Therapy Airway Screener (continued) III. Range of Motion Assessment A. Cervical 1. Upper cervical rotation test - Determine if C1 is rotated out of neutral a. Have the patient flex head to chest, then have them rotate right and mark an imaginary line on the clavicle. Keeping head flexed, have them rotate left and mark an imaginary line on the clavicle. Compare the difference. ❒ Rotation equal ❒ Rotation right > ❒ Rotation Left > b. Full Cervical Rotation - turn head toward each shoulder i. Right ❒ non limited pain-free ❒ limited pain free ❒ limited painful ii. Left ❒ non limited pain-free ❒ limited pain free ❒ limited painful 2. Side bending - Bring ear to shoulder, keep the shoulder relaxed a. Right ❒ non limited pain-free ❒ limited pain free ❒ limited painful b. Left ❒ non limited pain-free ❒ limited pain free ❒ limited painful 3. Flexion - Look down to floor with mouth closed - can chin touch chest ❒ non limited pain-free ❒ limited pain free ❒ limited painful 4. Extension - Look up to ceiling ❒ non limited pain-free ❒ limited pain free ❒ limited painful B. Facial Muscles 1. Smile - Have the patient smile and note right to left lip excursion ❒ Even ❒ Right higher ❒ Left higher 2. Eyebrow Lift ❒ Even ❒ Right higher ❒ Left higher C. TMJ Charting Having an easy and consistent way of charting temporomandibular joint triplanar range of motion is essential to diagnose and track progress. 1. Mark on the chart opening, protrusion and lateral movement noting deflection, deviation, time of clicks and if pain not present (NPOP), painful (POP) [Normal opening is measured from right top and bottom central incisor as are lateral movements] a. Initial oral opening, rotation should be the primary movement first 25 mm followed by translation. Note if translation occurs early b. Normal opening 0 - 45 mm checked with slight overpressure - Record total range and pain with overpressure (POP) c. Deviations - Movement to one side then return to midline. Typically caused by a displaced disc on the side, the patient deviates toward. At time of reduction (click), jaw will return to midline. Record clicks at mm of opening and side they occurred. d. Deflections - movement to one side without return to midline typically caused by displaced disc which does not reduce or tight joint capsule on side of deflection - Record ROM and pattern. e. Lateral movement (Trusion) - normal is 10 mm without pain at end movement with overpressure (NPOP), or Painful with overpressure (POP). mark total range and mm at which a click is palpated/heard) f. Protrusion - normal is straight ahead movement without deflection or deviation. Mark total range and click at mm palpated/heard g. Jaw Closing: Is the patient able to close jaw completely. Dentist lightly place both pinkies in each ear and notate the following i. Full closure ❒ no pain ❒ pain right ear ❒ pain left ear ii. Condylar pressure ❒ no pressure ❒ pressure right ear ❒ pressure left ear See example at right of a normal bilateral TMJ function chart.

DentalSleepPractice.com 25

CONTINUINGeducation Physical Therapy Airway Screener (continued) D. Palpation of facial muscle trigger points and retrodiscitis - Developed by Mariano Racabado, DPT. The dentist should palpate each point on the face using enough pressure to blanch the nail bed. Maintain this consistent pressure throughout the examination. have the patient raise their hand when the pain is elicited and provide a 1-10 number describing severity of pain. A number 1 represents minimal pain and 10 represents worst possible pain. Ask the patient to lightly bite down on teeth during each palpation, then relax. 1. (R)____ (L)____ Anterior temporalis (behind orbit of eye) 2. (R)____ (L)____ Middle portion of temporalis 3. (R)____ (L)____ Posterior portion of temporalis 4. (R)____ (L)____ Tendon of the temporalis muscle found above zygomatic arch 5. (R)____ (L)____ Temporalis tendon’s sttachment to the coronoid process. Place your index fingers anteriorly, under the zygomatic arch, and have the patient open their mouth into your fingers. 6. (R)____ (L)____ Superficial masseter at the angle of mandible 7. (R)____ (L)____ Aponeurosis attachment of the superficial masseter muscle found just under the zygomatic arch 8. (R)____ (L)____ Deep masseter muscle found with strong clenching just anterior to the condyle 9. (R)____ (L)____ Retrodiscal tissue externally – pinky in ear, open mouth slightly to gain access and have patient close gently and condyle will move posterior 10. (R)____ (L)____ Medial pterygoid – Palpate internally, bottom of mouth between tongue and mandible as posterior as possible. Can also palate externally just beneath and medial to the ramus of the mandible 11. (R)____ (L)____ Lateral pterygoid – using pinky, palpate internally, lateral and posterior between upper cheek and molars. Proceed posterior into the pocket

Table 2: List of Symptoms that Trigger a Referral to an ACPT Craniofacial • Tension in the neck and upper back that progresses into the head • Tension in the face, head, jaw & neck that progresses throughout the day • Headaches/Migraines • Cranial or facial discomfort while actively going through orthodontia Orofacial • Pain in one or both TM joints with talking, chewing, or upon waking • Fatigue in the jaw with talking or chewing • Mouth breathing, difficulty clearing nasal breath • Jaw discomfort while actively going through orthodontia • Limited/locked jaw opening or closing • Day or night time parafunction Cervical • Asymmetrical limitation in neck movements • Neck pain at rest or with movement • Referred pain down the arm with neck ROM assessment • Excessive cervical muscle involvement with breathing • Neck discomfort while actively going through orthodontia Shoulder and Thoracic • Chest tightness with breathing • Back and/or shoulder pain with limited ROM Other presenting symptoms • Gait and/or balance disturbances • Poor posture and/or body mechanics • Fatigue, shortness of breath with daily activities • Pain and/or slow progress going through orthodontia

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In conclusion, collaboration between physical therapists and dental professionals is crucial in addressing the complex issues related to dental sleep medicine and TMD. Physical therapists, specifically AirwayCentric Physical Therapists (ACPTs), possess the knowledge and expertise to identify and treat musculoskeletal and neuromuscular dysfunctions that contribute to airway obstruction and TMD. By correcting faulty postural and movement patterns, ACPTs can alleviate pain, improve mobility, and support dental treatments to prevent relapse. It is essential for dental professionals to recognize the symptoms that warrant a referral to an ACPT, such as pain, stiffness, changes in posture or balance, snoring, mouth breathing, and jaw issues. By incorporating physical therapy into the patient’s care plan, dental professionals can provide comprehensive and interdisciplinary treatment, leading to improved patient outcomes and quality of life. I encourage dental professionals to seek collaboration with qualified ACPTs in their area to enhance the care they provide and ensure the best possible outcomes for their patients. Together, we can optimize the management of dental sleep medicine and TMD, addressing the multidimensional nature of these conditions and improving patient well-being. For more information, contact the author of this article at gildenpt@gmail.com.

CONTINUINGeducation

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Physical Therapy Collaboration in Dental Sleep Medicine by Brad Gilden, PT, DPT, FFMT, FAAOMPT, PRC, CSCS, and Bill Esser, MS, PT, CCTT 1. Keep in mind while assessing a patient for airway insufficiencies, __________. a. It is critical to have them stand up straight b. Their posture may indicate a breakdown in the musculoskeletal system c. How they sit, stand and move is unrelated to how they breathe d. Only back sleepers suffer from both OSA and poor posture 2. The relationship between the cranium, cervical spine and mandibular position ___________. a. Is not supported by scientific literature b. Is only important when patients are in pain c. Is generally thought to be a scam to generate unnecessary therapy d. Is bidirectional – the clinician cannot assess any area independently of the others 3. Presenting symptoms that should trigger a referral to an airway centric physical therapist include __________. a. Neck pain with movement b. Chest tightness with breathing c. Poor posture and / or body mechanics d. All of the above, and about a dozen more you should know about 4. Tracking the TM Joint range of motion is easy, thorough, and serves as a progress check ____________. a. Using a TMJ triangle b. Only when the patient is out of pain c. Best done on a triplanar chart with standardized process d. With electronic gear able to detect fine changes to tissue position 5. Forward Head Posture is often associated with compensation for poor breathing. This is defined by _____________. a. An angle between a line drawn from C7 to the tragus and a horizontal line being less than 50 degrees b. The chin being forward of the clavicular notch c. A forward tilt in the long axis of the pinna d. Seeing more of the sclera below the pupil than above it due to keeping the eyes facing forward with the head tilted down

6. Patients you are considering for a referral to physical therapy should be asked _________. a. If PT is covered by their insurance plan b. If they are available during the day for PT appointments c. If they are already working with a rehabilitation professional d. How they feel about bodyworkers 7. Temporomandibular disorders are related to functional occlusion and malocclusion ___________. a. Directly, with occlusal therapy being a vital component of correcting TMD b. Indirectly, with psychosocial compensations being more vital c. Tangentially, with bite issues seen as a comorbid factor only d. Not related, with a complex interaction with the patient’s environment being primary. 8. An AirwayCentric Physical Therapist is defined as __________. a. A physical therapist who has become trained in providing oral appliance therapy for OSA b. A physical therapist who has credentials as a breathing coach c. A physical therapist who has specialized education focused on disorders related to the nasal and oral airway d. A physical therapist who was first a speech and language professional 9. One goal of physical therapy related to breathing effort is __________. a. To address symptoms of obstructive sleep apnea b. To guide the patient to prevent or reverse compensations that might inhibit breathing c. To reduce pain when sleeping supine d. To enhance adherence to oral appliance therapy or CPAP 10. The primary driver of respiration, the thoracic diaphragm, __________. a. Functions independently so breathing is not compromised b. Induces compensations in other body functions if diaphragm function is in a hypertonic contracted state c. Has attachments to the spine, rib cage, and pelvis d. Produces disparate symptoms such as abdominal pain, tinnitus, and gluten intolerance when breathing is imbalanced DentalSleepPractice.com 27

CARDIO-SLEEPcorner

Sleep Stages and How to Improve Sleep Quality by Lee A. Surkin, MD, FACC, FCCP, FASNC, FAASM

here’s no doubt that sleep is crucial for optimal health. During sleep, the body gets the chance to repair muscles, manage hormones, grow bones, and arrange memories. But sleep duration isn’t the only factor to consider, as many mistakenly believe. Indeed, sleep quality is just as important. So, you have to focus on how many sleep cycles per night your body goes through. That said, to get high-quality sleep, your body has to go through four to five healthy sleep cycles, each lasting 90 to 120 minutes and consisting of four individual stages. Precisely speaking, a normal sleep cycle includes three non-rapid eye movement (NREM) sleep stages and one rapid eye movement (REM) sleep stage.

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The Four Sleep Stages NREM sleep normally occurs first in adults and includes three stages of which the last one is when the person is in deep sleep (N3) and the individual is unaware of their surroundings and is more difficult to arouse. On the other hand, REM sleep typically occurs an hour to an hour and a half after falling asleep and it is characterized by having the most vivid dreams. Now, let’s discuss the four stages in detail.

CARDIO-SLEEPcorner Stage 1 – NREM Sleep (N1) Stage N1 is the transition from being awake to being asleep and typically lasts for only a few minutes. Stage 1 is the lightest stage in a sleep cycle and the person can be easily awakened. Characteristics: • Slow eye movements, heartbeat, and breathing • Muscles reduce tension and start to relax • The brain produces both alpha and theta waves

Stage 2 – NREM Sleep (N2) Stage N2 comprises the largest percentage of total sleep time. It is still easy to wake up a person from this stage as it is considered to be a lighter one and precedes the stage of deep sleep. Characteristics: • No eye movements • Heartbeat and breathing at a much slower rate • Body temperature decreases • The brain produces sleep spindles (bursts of rapid, rhythmic brain activity)

Stage 3 – NREM Sleep (N3) The last NREM sleep stage N3 is the deepest sleep stage, also known as delta or slowwave sleep. When a person enters this stage, it is very difficult to wake them up. Stage N3 is vital for many bodily processes for optimal health such as cell regeneration and tissue repair and growth. Characteristics: • Still no eye movements • Heartbeat and breathing reach the slowest rate • The brain produces delta waves

Stage 4 – REM Sleep (R) Two divisions of REM sleep include phasic (with bursts of rapid eye movements) and tonic (without those bursts). The REM sleep stage lasts about 10 minutes in the first sleep cycle and increases its duration with each upcoming cycle. There are typically 3-5 REM sleep cycles during the sleep period. Characteristics: • Rapid eye movements

• Accelerated heart rate and breathing • Paralyzed skeletal muscles with occasional twitches (breathing is diaphragmatic) • Increased brain activity

How to Have Healthier Sleep Quality?

Even though having full control Even though having full over your sleep cycles isn’t possible, certain steps can help you improve control over your sleep your chances of having a healthier cycles isn’t possible, sleep quality. One of the key elements certain steps can help to focus on is following good sleep hygiene practices which include the you improve your following: chances of having a • Stick to a strict sleep schedule • Increase exposure to natural healthier sleep quality. daylight • Avoid alcohol and caffeine several hours before bedtime • Remove light and noise disruptions at least 2-3 hours prior to planned bedtime • Make your bed sleep-friendly and comfortable We know you take great care of your patients, but do you get quality sleep? If not, consult your doctor to get the right treatment.

Lee A. Surkin, MD, is the Chief Medical Officer of Nexus Dental Systems. A private practitioner in cardiology, sleep medicine, and obesity medicine, he is one of a small group of physicians to be triple board certified in cardiology, sleep medicine, and nuclear cardiology. In 2009, he created Carolina Sleep – the only dedicated sleep medicine practice in eastern NC. Dr. Surkin has created a cardiovascular and sleep healthcare model that includes a multi-faceted diagnostic and treatment approach that is enhanced by a network of relationships with physicians, dentists, respiratory therapists, sleep technologists, and public officials who recognize the important role that sleep medicine has in our daily life. In 2012, Dr. Surkin founded the American Academy of Cardiovascular Sleep Medicine which is a not-for-profit academic organization dedicated to educating healthcare providers, supporting research, and increasing public awareness of the convergence between cardiovascular disease and sleep disorders. In 2014, Dr. Surkin created a new multi-specialty practice called Carolina Clinic for Health and Wellness which combines his specialties with primary care, gynecology, behavioral health and a medical spa. Dr. Surkin is married with three daughters and a golden retriever and resides in Greenville, NC.

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MEDICAL

MEDICALinsight

The Importance of Addressing Sleep Apnea in Hospitalized Patients by Bertrand de Silva, MD, FCCP

leep is an essential aspect of human well-being. Quality sleep promotes healing, cognitive function, mood stabilization, and overall health. In contrast, disruptions in sleep patterns can lead to a multitude of health issues, both physical and psychological. One such disruption is sleep apnea, a condition characterized by repeated interruptions in breathing during sleep. While sleep apnea is a concern in any setting, it becomes particularly critical in hospitalized patients. Addressing this issue can pave the way for quicker recovery, reduced hospital stay, and better patient outcomes. In hospital setting, the presence of obstructive versus central and mixed sleep apnea may further complicate the presentation and recovery of patients, especially with strokes, heart failure, and pulmonary disease. This disease process which is not often recognized results in increased mortality and morbidity in the hospital setting with delayed discharge from the intensive care unit and readmissions to the intensive care unit as well as readmissions on the same diagnostic related group (DRG).

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Why is Sleep Apnea a Concern for Hospitalized Patients?

1. Compromised Healing Process: A good night’s sleep is critical for the body’s healing processes. For hospitalized patients, these restorative phases of sleep are vital. Sleep apnea, however, can disturb these phases, slowing down recovery. 2. Cardiovascular Strain: Sleep apnea often leads to sudden drops in blood oxygen levels, which can strain the cardiovascular system, leading to conditions like hypertension, heart attacks, and strokes. In hospitalized patients, especially those with preexisting heart conditions, this can be perilous. 3. Impaired Cognitive Function: Sleepdeprived patients, due to untreated sleep apnea, may experience memory issues, mood changes, and decreased concentration, affecting their capacity to understand medical instructions and participate actively in their recovery. 4. Increased Medication Sensitivity: Sleep apnea can alter a patient’s re-

sponse to sedatives, pain medications, and anesthesia. This can lead to complications during surgical procedures or prolonged sedation periods. 5. Higher Risk of Complications: Hospitalized patients with undiagnosed or untreated sleep apnea have a higher risk of postoperative complications. This includes respiratory failure, cardiac events, and longer stays in intensive care units. 6. There is a higher incidence of sleep apnea in hospitalized patients, especially in the intensive care unit that masquerades as multiple comorbidities. Recognition of this condition in the intensive care unit stay is essential in aiding early extubation and, if diagnosed prior to discharge, could result in discharge of the patient with the appropriate positive airways pressure equipment thereby reducing post hospitalization mortality morbidity and readmission under the same DRG 7. Cerebrovascular accident exacerbates both central and obstructive sleep apnea and if identified early can lead to improved outcomes.

Identifying and Managing Sleep Apnea in the Hospital Setting

Hospital staff should prioritize identifying patients at risk of sleep apnea. A comprehensive medical history, physical examination, and if necessary, a hospital-based sleep study, can help in the diagnosis. Common signs include loud snoring, observed episodes of stopped breathing, abrupt awakenings followed by gasping, excessive daytime sleepiness, and difficulty concentrating. Witnessed apneas during procedures together with sudden episodes of tachycardia/bradycardia on monitored units are examples of easily assessed signs of obstructive and central sleep apnea. Management approaches for hospitalized patients with sleep apnea include: 1. Positional Therapy: Keeping the patient in a side-sleeping position can prevent the collapse of the airway, especially in OSA cases. 2. Continuous Positive Airway Pressure (CPAP): This is a machine that delivers a steady stream of air through a mask,

MEDICAL

MEDICALinsight helping to keep the airways open. It’s the primary treatment for OSA. 3. Adaptive Servo-Ventilation (ASV): This device is beneficial for central sleep apnea patients. It adjusts the amount of air supplied based on detected abnormalities. 4. Medications: While drugs are not the primary treatment for sleep apnea, some can alleviate symptoms or treat underlying causes. 5. Educating Hospital Staff: All hospital staff, from nurses to anesthesiologists, should be educated on the risks associated with sleep apnea. This can lead to more personalized patient care and a proactive approach to managing potential complications.

Conclusion

For hospitalized patients, the risks associated with untreated sleep apnea are magnified. Recognizing and addressing this condition can substantially improve patient outcomes. As medical professionals, prioritizing sleep health is not just about ensuring rest but about optimizing the very processes that enable healing, recovery, and overall wellness. Sleep apnea is not merely an inconvenience; in the hospital setting, it can be the difference between rapid recovery and severe complications. Every patient deserves comprehensive care, and addressing sleep health is a critical component.

Bertrand de Silva, MD, FCCP, is a graduate of the St. Thomas Hospital Medical School, University of London, England 1986. He was awarded a Medical Research Council Scholarship as well as Medical Research Council Fellowship. He was also awarded a $2 million Research Grant by Burroughs Wellcome Foundation and became a Burroughs Wellcome Research Foundation Scholar. He completed his Internship at Kern Medical Center, Bakersfield and Internal Medicine training at USC County Hospital, Los Angeles and a Pulmonary, Critical Care and Sleep Fellowship at Cedars Sinai Hospital. He is board certified in all these fields. Dr. de Silva is currently a Staff Intensivist for Sound Physicians Intensivist Group at St. Bernadine’s Medical Center in San Bernardino, for Benchmark at Palomar Regional Medical Center in Escondido. He is the Medical Director of the Sleep Services at St Judes Fullerton, at Preferred Sleep Solutions in Fullerton. He serves as a national consultant to American Imaging Management, AIM Specialty Health (Anthem Subsidiary) in developing the National Sleep Apnea Treatment and Diagnosis Clinical Guidelines.

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MEDICAL

MEDICALinsight

We Live in Exciting Times by Teofilo Lee-Chiong, MD

he future of Sleep Medicine is fast approaching, and every new discovery, technology, and policy takes us one step closer to it. Each new breakthrough in the sleep sciences and new innovations in sleep therapies has the potential to drastically alter clinical care, disrupt business practices, and change patient lives. There are many trends in Sleep Medicine that are already self-evident – growing healthcare inequity, personalized medicine, environmental stewardship, and commoditization and politization of healthcare, to name just a few – and, therefore, are not included in this exploration of our future. Their exclusion does not diminish their impact on regional, national, or global healthcare, but simply reflects the present-day acknowledgement by other, better thinkers. As we start thinking about and choosing our future in Sleep Medicine, in general, and

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in sleep apnea therapy, in particular, it is vital that we consider today’s important drivers of change. 1. Interconnectedness – We must understand the impact of therapy on everyone, including patients, societies, as well as on fiscal sustainability. We need to move beyond measures of an individual’s medical outcomes, mortality, and quality of life, and focus as well on the well-being of families, communities, and the environment. 2. Accommodation of multiple solutions – We should strive for closer collaboration among medical clinicians, dentists, surgeons, technologists, weight counselors, and researchers, and recognize that patients have preferences for healthcare that should be respected. 3. Fair resource distribution – Everywhere, resources are limited, and everywhere, allocation is unavoidable; we must, therefore, compare the

outcomes of our solutions with other health interventions, such as better access to care, housing, food security, clean water, mosquito control, among others. Lastly, we have to acknowledge that not every person who needs therapy can afford it – where policy ends, philanthropy must begin. 4. Uncertainty and continuous reassessment – Let’s be mindful that the greatest danger of policy and “science” is when it becomes dogma or ideology. Focusing on technology alone is not the solution to improving human welfare. It is tempting to dream that the technologies of the future (e.g., artificial intelligence, nanotechnology, additive manufacturing, wearables and virtual care, or genetic modification) will address many, if not all, of today’s health concerns, including (a) advancing access and timeliness of care, (b) increasing efficiency, effectiveness, safety, affordability, and quality of care, (c) improving health outcomes, (d) elevating patient experience, (e) enhancing professional satisfaction, (f) fulfilling public health needs, and (g) supporting research and innovation. However, technology, by itself, cannot foster human well-being because technology is silenced, disconnected, and excluded from human values. Technology is not immoral; it is simply amoral. We see its actions but not its plan; we feel its impact but not its meaning; and we trust its decisions but not its purpose. Technology and data may improve medical knowledge, but not understanding. So how do we ensure that technology and data are harnessed to enhance personhood? We link them to actual lives. In designing our devices, we also design our future. The creation of technology and artificial intelligence by humans may be flawed by biased, sexist, and racist data and algorithms. Whereas it may be straightforward to detect biases, sexism, racism, and poverty-ism in human behavior, these may go unnoticed and unchallenged in devices and algorithms. Without lived experiences, technology, and data, left on their own, may eventually rob Sleep Medicine of its humanity. The future of Sleep Medicine lies not in advances in technology or regulations – not in a better device, a better mask, a better program, or even a better policy. The greatest advance in Sleep Medicine will be in the way

“Technology, by itself, cannot foster human wellbeing because technology is silenced, disconnected, and excluded from human values. Technology is not immoral; it is simply amoral.”

we think. We will rebuild our undifferentiated technologies to ones that are targeted to each individual’s needs and values. We will reshape our fossilized policies to ones that matches today’s realities and tomorrow’s aspirations. We will reorganize our protocolized healthcare strategies to ones that humanize lives. We will recognize that change is not only necessary, but possible. Predicting the future of sleep medicine is not a prophecy of how the future will exactly unfold, but rather approximates probabilities to reduce uncertainties so that we can better prepare for them. This requires addressing equity, sustainability, public safety, and quality through a commitment to advocacy, knowledge creation, and philanthropy. Predicting the future is also not a surrender to the whims and fickleness of fate but is a conviction that our future is our responsibility.

MEDICAL

MEDICALinsight

Dr. Teofilo Lee-Chiong is a well-known sleep medicine educator and frequent speaker at sleep medicine conferences. He is board certified in Internal Medicine, Pulmonary Medicine, Critical Care Medicine, and Sleep Medicine. Dr. Lee-Chiong is a pulmonologist in Denver, Colorado and is affiliated with National Jewish Health-Denver. He received his medical degree from University of the East College of Medicine and has been in practice for more than 30 years. He is also a Professor in the Department of Medicine at the University of Colorado Denver. He has authored or edited more than 20 textbooks in sleep medicine and pulmonary medicine. In addition, he developed and serves as the consulting editor of Sleep Medicine Clinics, and is a member of the editorial board and reviewer of several medical journals and publications. He served as the chair of the Nosology Committee of the American Academy of Sleep Medicine (AASM), vice-chair of the Associated Professional Sleep Societies LLC (APSS) Program Committee, and chair of both the Sleep Medicine NetWork and Sleep Institute Steering Committees of the American College of Chest Medicine (ACCP). He also has served on the Council of Governors for the ACCP. He is the recipient of the 2012 American Academy of Sleep Medicine Excellence in Education Award.

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PRACTICEmanagement

It’s Time for Preauthorization Reform by Rose Nierman, CEO, Nierman Practice Management

rior authorization has long been a thorn in the side of physicians, dental sleep medicine (DSM) providers, and patients. This process often results in unnecessary delays in essential care. Recently, CMS (Centers for Medicare & Medicaid Services), the AMA (American Medical Association), and Congress have taken steps to compel insurers to streamline preauthorization requirements. Challenges with Prior Authorization

According to the AMA, 80% of the physicians surveyed indicated that patients abandon treatment due to authorization struggles with health insurers. A survey of 1,000 providers revealed that one-third reported that prior authorization had led to serious adverse events for their patients and delays caused permanent bodily damage in up to 9% of cases.

To keep abreast of reform efforts with prior authorization, Medical Insurance Preauthorization visit the website Reforms A promising outlook emerges as insurers FixPriorAuth.org. initiated significant measures to ease the ex-

isting burden. Notably, UnitedHealthcare has eliminated the prior authorization necessity for almost 20% of their prior authorization volume, while Cigna has made strides by removing 25% of their requirements. Additionally, Aetna and other insurers are pursuing reforms in this area. Despite many insurers still mandating preauthorization for sleep apnea-related services, Nierman Practice Management remains committed to closely monitoring these developments throughout 2024.

Rose Nierman is the CEO of Nierman Practice Management (NPM) and medical billing services for dentists and creator of the DentalWriter Plus+ software. For over 30 years, Rose has taught dental practices successful and ethical medical billing through the iconic Successful Medical Insurance in Dentistry seminars. Contact NPM at 1-800879-6468 or at Coding@dentalwriter.com.

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Tools to Expedite Claims

• If an insurer states no preauthorization is needed for an oral appliance, it is prudent to inquire whether this policy applies if the fee exceeds $1,000. Preauthorization requirements may vary based on the dollar amount. • Visit an insurers website for lists of codes that require preauthorization. • Inquire about the insurer’s commitment to integrate national standards for the electronic exchange of clinical documents. • Check your state laws regarding newer preauthorization mandates. I’ve seen state mandates such as “the prior authorization is considered granted if the insurer fails to act within 7 calendar days of the original submission”. Remember this mandate applies once you have your ducks in a row with your necessary documentation ready to go! SOAP reports showing the subjective, objective, assessment and plan, the sleep study, a physician Rx and other documents substantially streamline reimbursement. • To keep abreast of reform efforts with prior authorization, visit the website FixPriorAuth.org. As we witness these changes unfold, it becomes clear that they hold the potential to help lighten the load for DSM providers, minimize care delays, and most importantly, enhance the overall well-being of patients. At Nierman Practice Mangement, we remain dedicated to championing these advancements. Join us in our mission to embrace a future where DSM reimbursement processes are more efficient and patient-centric than ever before.

PRODUCTspotlight

How Precision OAT is Changing Dental Sleep Medicine

he most important impact of precision medical applications in DSM is in reducing the number of ‘False Non-Responders’. False non-responders are patients who would or could have responded to OAT but did not because of device inaccuracy, fit, comfort, bulk, side effects, etc. OAT has long suffered distrust from physicians because of unqualified dentists, inadequate AHI reduction, frequent side effects and poor published scientific data. Nobody wants to find out they had a ‘false negative’ Pregnancy or Covid screening test. NOT responding to the detection of human chorionic gonadotropin or specific proteins segments for the SARS-CoV-2 virus can lead to unintended consequences and treatment decisions. No medication, treatment or protocol is 100% efficacious or adherent. By utilizing precision medical designs and manufacturing, OAT has taken two giant steps forward in reducing the number of false non-responders. First, precise bite transfer, stabilization, and advancement along with smaller device volume and improved tongue space have increased the number of OSA patients that CAN respond to mandibular advancement treatment. Advancing the mandible opens the airway, but not everyone can tolerate the distance or bulkiness of custom devices. Second, the use of medical grade materials, and the above-mentioned precision attributes have reduced both the AERs (adverse event reports in FDA database) and common side effects by reducing the dose of advancement required. With ProSomnus precision designs, less advancement is required and therefore it is easier to return to MIP, more people respond and there is more comfort. Medical Grade VI materials did not even appear in the 57% or AERs that included tissue reactions, hypersensitivity, toxicity, and allergic reactions. The AADSM has outlined the criteria for an ‘Effective

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ProSomnus® EVO® Sleep and Snore Device

OA for OSA’ in their 2014 definition. Devices should be able to position and stabilize the mandible accurately and advance in increments of 1 mm or less for at least 5 mm. The construct of replicating the construction bite and stabilizing the mandible in the treatment position are seminal to a precision medical model. Precision devices have demonstrated accurate bite transfer (confirmed using articulators) and retrusion prevention using the 90-degree post design. The figure below demonstrated a 1.8 mm loss of dose or advancement with a jaw drop of just 5 mm. The AADSM’s 2018 ‘Standards for Screening, Treating and Managing Patients’ and the 2017 ‘Management of Side Effects’ position papers support more precise screening, treatment, management, and side effect prevention constructs. Most literature we have depended on to support treatment decisions and communicate with the medical community has fallen short. In the last few years, independent peer reviewed articles demonstrating the efficacy and adherence of ProSomnus precision mandibular advancement devices have appeared in; JCSM, CHEST and the JDSM, posters at the AAO-HNSF, AASM, AADSM, World Sleep, iBEDSSMA and the ESRS. Head-to-head trials with CPAP and Hypoglossal Nerve Stimulation along with the FDA Severe Indication Clearance Trial will advance precision even more.

BOOKreview

A Masterpiece in the Landscape of Patient-Centered Education A book review by Pat Mc Bride, PhD, CCSH

“T

his book is a marvel. Don’t let the friendly tone fool you. Empowered Sleep Apnea is serious patient-centered teaching, presented in such an engaging way, you hardly realize it when you’ve learned something. It is visually stunning, intellectually engaging, and transports the reader on a unbiased life changing journey of understanding, empathy, and respect for one of our most serious and misunderstood major health problems, obstructive sleep apnea. Deconstructing the siloed thinking of modern sleep medicine algorithms and corporatized practitioners, McCarty and Stothard gracefully guide readers from isolation to collaboration then empowerment; be they the physician or patient. There will be more than a few people who see themselves in the iconic cartoons – it’s okay to laugh at ourselves sometimes too! No one is left behind in this rare compendium that knows no demographic bias. It is for everyone. McCarty and Stothard’s magical Island is a safe and empowering place to be, and the geography they describe erases borders in Sleep Apnea management. This wondrous patient-centered space is available to all providers caring for this complex disorder. Whether you are a Sleep Medicine spe-

cialist, an Airway-Centered Dentist, a sleep psychologist, or a primary care physician, you’ll enjoy bonding with your patient over this book, all while helping them discover better sleep and better health. Empowered Sleep Apnea is a masterpiece in the landscape of patient-centered education.

Pat Mc Bride, PhD, CCSH, has spent 38 years as a full time clinician, educator, and author in the fields of dentistry, respiratory medicine, and dental sleep medicine. Her extensive experience in clinical, laboratory, research, and educational arenas has led to the development of interdisciplinary care model delivery systems used in collaboration by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. In addition to teaching and writing, Pat continues to work hands on in the patient care arena. Serving the underserved and marginalized patient remains a passion and priority for her. She sits on numerous Boards such as the AAPMD and is the Executive Director for The Foundation for Airway Health. She has one grown daughter who shares her passion for social justice and education, serving as a sixth grade teacher in the inner city Oakland.

DentalSleepPractice.com 37

COMMUNICATIONScorner

Connections by Mary Osborne, RDH

ow would your practice be different if you took just a few minutes after you see a new patient, or an existing patient, to reflect on the values they expressed? To ask yourself what you learned about what is important to that person. What they care about. Is family important? Faith? Quiet time? Nature? Friends? Learning? Adventure? What did you hear? What if you made a note or two in their record? The next time you see that patient, instead of talking about the weather, look for an opportunity to mention what you heard: “I’ve been thinking about our conversation the last time you were here, Mrs. White, I got the sense that _______ is important to you.” Allow her to respond. Notice her facial expression, her tone of voice. Ask yourself if you sense a different connection with that patient, perhaps a deeper level of trust. Is there more you would like to learn? Patients are often faced with making difficult decisions in a dental office. People are better able to make difficult decisions when they feel safe, and they feel safe to the degree to which they feel connected to you. There are a variety of ways we can and do connect with our patients.

Authority

The traditional way of connecting with patients has been through authority. It involves telling people what they need to do and expecting that they will do it because you have stature or information they do not have. This is a valid connection and works well with people who are unable or unwilling to make decisions for themselves. It is not unusual for elderly people who were raised

38 DSP | Winter 2023

at a time when a doctor’s authority was unquestioned to feel comfortable with this connection. It is also sometimes the way we must connect with children. It is not the most effective way to connect with most adults.

Information

It is also possible to connect with patients through information. There is a lot they do not understand about dentistry and dental health, and they depend on us to inform them. We have a wealth of information we can share, and this tends to be a comfortable way for dental professionals to connect. We tend to feel safe in our knowledge; we may enjoy the sense of control it offers. It is also the way most patients are accustomed to relating with their dentist, so it may be comfortable for them as well. They may be grateful for the information and impressed with our knowledge.

Commonalities

Another way to connect with patients is in terms of commonalities. This is the way most people initially connect in social situations. It comes from a belief that people enjoy people who are like them, so we look for things we have in common with others. We try to find interests, experiences, and likes and dislikes that we share. This connection goes beyond authority and information which keep the focus on dentistry; it is more

COMMUNICATIONScorner of a personal connection. When we establish things we have in common, we move out of the strictly professional relationship and demonstrate that we care about the person on more than one level. When we find things we have in common with someone else it tends to put both of us more at ease. We have something we both enjoy talking about that doesn’t involve dentistry. More importantly, there is a perception that if we have similar experiences, on some level we know each other better. We tend to believe that we understand each other better, which contributes to a sense of safety. This connection is very important to people who value relationships. It is also more important in certain communities and cultures than in others. People who do not place a high value on relationship, however, may be skeptical of an attempt to connect on this level.

Compassion

You can connect with your patients on the level of compassion. This level of care involves an emotional connection. We understand our patients’ lives are sometimes complex and difficult. When someone is in pain or fearful, we can identify with his experience and treat him gently, both physically and emotionally. When we have genuine compassion for people in a dental office, we understand that information alone will not allay their fears. We are acutely aware that pain is a matter of perspective, and only the person experiencing it can determine how much is too much. We understand that shame is emotionally painful and do everything we can to make sure our patients feel accepted as they are. Compassion is easier with some people than with others. Patients who complain a lot can lose our compassion. A new patient in obvious pain usually wins our compassion. But sometimes it is harder to bring that compassion to the relationship when the person has been a part of the practice for a while. It’s not that we don’t care; we can just lose our awareness. Dentistry can become somewhat routine for us, and we can forget that for some people, it will never be routine. The more we keep our attention on the patient, the more likely we will pick up subtle signals that tell us how to care for him or her. And it is a powerful connection to have in a dental office with every patient, every day.

Values

All of the connections we have talked about are appropriate in a dental office at various times with different individuals. Combining several of them enhances the bond we are creating. For example, when information is appropriate, it will be a stronger connection if you bring your compassion. But one connection is stronger than any of the others. That is a connection on the level of values. Understanding what is important to someone else can be a powerful link that goes beyond “hot buttons.” You may hear some values that directly apply to dentistry and that is help- One connection is stronger ful. But when people feel really un- than any of the others. derstood on the level of their values, the relationship changes. The connection goes right to the core of who they are. When we reflect back values we are hearing we enable patients to access those values and apply them to choices they make about their health. Connections are easier for some of us than they are for others. They are more important to some than to others. But keep in mind that connections are a two-way street. As you focus on connecting with others, you will have the opportunity to experience a different connection from them. In our busy world of dentistry it is easy to lose sight of the impact we have on the lives of those we serve. If you are open to it, you can find new meaning in your work by allowing in the difference you make in people’s lives. Connect with people on the level of values, and give yourself permission to fully experience the appreciation your patients feel for the impact of your care on their lives.

Mary Osborne, RDH, has worked in dentistry for over 50 years as a hygienist, patient facilitator, and teacher. Her writing is published in national magazines, and she has spoken extensively to state, national, and international organizations. Her programs are designed to challenge your thinking, and provide real world, practical ideas to enhance your communication in both your personal and professional life. For more information and a deeper understanding of how you can have a greater impact on those you serve, please visit https://maryosborne.com/ leadership-guide/.

DentalSleepPractice.com 39

EDUCATIONspotlight

Tufts Global Academy An interview with Dr. Shibani Sahni

USDM Global Academy, started by Dr. Shibani Sahni, has provided a unique opportunity to qualified dentists across the world, and is helping further improve the knowledge, skills and access to advice and materials in placing implants, cranio-facial pain, TMJ, and other facets of dentistry with confidence. The workshops have a didactic and hands-on component allowing participants to gain and apply skills as they learn. This venture grew out of a desire she has to put good training into practice to ensure leading developments in dental medicine got out of teaching institutions into the wider dental community. Australian students at Tufts University’s recent Craniofacial Pain and Dental Sleep Medicine workshops in Sydney and Melbourne voted with their feet and seized the opportunity to learn from some of the best without having to leave the country. More dentists are expected to embark on the in-depth hybrid implant mini residency course which will offer the advantage of world-class dental teaching facilities and expert facilitators, providing comprehensive skills development to fast track their learning. Dr Sahni said Tufts had built strong relationships with leading practitioners around the world, including Tufts University alumni from Australia who had completed earlier courses at the university. “These dentists have used the knowledge and skills gained to advance their careers and become leaders in their field as a result and are now willing advocates and ambassadors

Dr. Shibani Sahni is the Program Director of CE/Lifelong Learning and Distance Education, and an Assistant Professor in the Department of Comprehensive Care at Tufts University School of Dental Medicine. She started the Global Academy under the Continuing Education department and has been instrumental in bringing different dental education programs to various parts of the world including Australia and the Asia Pacific region. She is passionate about seeing that the world’s dental professionals get access to the leading knowledge and hands-on techniques.

40 DSP | White 2023

Professor Nadeem Karimbux, DMD, MMSc, Dean of Tufts Uiveristy School of Dental Medicine (left) and Shibani Sahni, BSD, Postgrad-Dip Restorative Dentistry, MMSc Dental Education, Director CE/Lifelong Learning and Distance Education, Assistant Professor Department of Comprehensive Care (right)

for training in new and improved techniques for a range of skillsets.” This includes implant courses and workshops and further studies into Craniofacial Pain and Dental Sleep Medicine among other courses on offer through the university. “Our ambassadors are all for changing patient care and extending dental education based on evidence-based research and practical application of the techniques learned,” Dr Sahni said. “Tufts is not just about ‘teaching’, but about ‘doing,’ and this is evidenced in the ability of our graduates to go away and apply their newly acquired skills in their own practices and in their own countries. “The Tufts University School of Dental Medicine is now spreading globally and is a recognized leader in dental education across the globe. I am very pleased to be able to bring this opportunity to Australian dental practitioners.” She said Tufts University will be continuing to grow its courses and raise awareness of the opportunities available throughout Europe, Middle East, Asia Pacific, and Africa. “The response to these courses from Australian dentists has been very encouraging, and we welcome everyone to be part of the Tufts family and hope to see them at our next courses.” For course dates and details, contact Tufts University at dentalCE@tufts.edu or visit the Tufts University website.

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CLINICALfocus

Relating Oral Physiology to Sleep Apnea Appliance Positioning by Allen J. Moses, DDS, DABCP, D.ABDSM

Evolutionary Focus

In lower animals the spinal column comes out the back of the head, is oriented horizontally and parallel to the ground. The head is cantilevered off the spinal column. Humans have evolved to an erect posture and the spinal column is vertical to the ground. Humans are bipodal – walk on two legs. Orchestrating balance of the big human head and enlarged brain on top of the spinal column requires coordinated, complex neuromuscular effort. Humans’ survival as a species evolved based on accomplishing this feat with repositioned, reconditioned, rebuilt, redesigned, miniaturized and in many cases less-capable, parts designed for olfaction, mastication, swallowing, hearing, breathing, and conditioning of inspired air. “Sleep Dentistry,” concerned with anatomic management of Obstructive Sleep Apnea (OSA) must direct stringent attention to the unique human evolutionary combination of foodway and airway. The design of an oral prosthesis to treat OSA by repositioning the anatomic components of the mouth, tongue, hyoid bone, neck musculature and achieve pharyngeal airway dilation and stenting is the subject of this article.

Pharynx

The human pharynx is a three-dimensional muscular tube lined with mucus membrane downstream from the mouth. It extends from the soft palate to the epiglottis. The anterior of the oropharynx is formed primarily by the soft palate and rounded tongue that has a 90 degree bend so 2/3 is horizontal and the posterior 1/3 is vertical. Behind the tongue at the anterior of the pharynx is a hole between the bottom of the soft palate and the upper edge of the epiglottis by which

42 DSP | Winter 2023

the mouth transcends into the pharyngeal tube (see figure 1). The pharynx is classified as non-intranarial because its design deflects food around the epiglottis into the esophagus while air passes into the larynx. This arrangement explains the combined foodway and airway, unique to humans. The posterior oropharyngeal wall is comprised of the superior, middle, and inferior constrictor muscles. As a result of the nonintranarial arrangement, adult humans cannot breathe and swallow simultaneously. The positive evolutionary development is the ability to speak. The negative consequences are choking, snoring and obstructive sleep apnea (OSA). In most obstructive sleep apnea patients, the collapse or narrowing during sleep occurs in the retropalatal and retroglossal areas between the upper margin of the soft palate to top of the larynx. OSA occurs when the luminal cross-sectional area of the upper airway collapses during inspiration, at or below the level of the soft palate and above the epiglottis. The pharynx is the only collapsible segment of the human respiratory tract. The human pharynx is unique among mammals because it is not supported by or attached to any bone and functions as a shared airway and foodway. Pharyngeal airway patency is maintained by two counter-

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CLINICALfocus acting forces: the activity of the upper airway muscles which dilate and stiffen the airway, and negative intraluminal pressure. Atonia of the tongue and airway muscles during OSA reduces intraluminal pressure. Narrowing at the retropalatal region is associated with a further decline in intraluminal pressure during inspiration. Increases in nasal resistance will produce greater negative intraluminal pharyngeal pressure and reduced pharyngeal cross-sectional area. Airway dilation by increasing the pharyngeal volume such as in oral sleep appliances decrease intraluminal pressure During nasal breathing with the mouth closed, the base of the tongue is in contact with the palatal mucosa of the soft palate. Mouth opening destabilizes the airway by freeing the mucosal contact of the tongue and soft palate allowing the freely moving soft palate to move posteriorly and compromise the pharyngeal airway. Jaw posture also influences the size of the upper airway. Opening the jaw slightly (rest position for example) increases tongue space

• Vertical Increase • Horizontal Advance • Tongue Advance Upward & Forward • Hyoid Advancement Upward & Forward • Oral Airway Dilation

Figure 1: What an oral appliance does – demonstrates the multiplicity of directions that anatomic components of the mouth and neck can move to affect airway dilation. The net sum is never a predictable straight line.

in the oral cavity. Progressive mandibular opening leads to posterior movement of the genu of the mandible. More movement causes the tongue and hyoid apparatus to move posterior and narrow the pharynx.

Hyoid

The hyoid bone is unique to humans. It is the only bone intimately connected to the pharynx. It is a floating bone at the base of the tongue, suspended between the temporal bones and the sternum by a series of muscles and ligaments. It is the center of action for most movements of the pharynx. The hyoid bone maintains the posture of the head with complex connections between the mandible and the cervical spine. It supports the tongue which sits above it and holds up the larynx which hangs below it. The position of the hyoid bone is determined by the status of the eleven muscle attachments affixed to it.1 Muscles attached to the hyoid bone include geniohyoid and genioglossus, capable of moving the hyoid in anterior and superior directions. Changes in hyoid position tend to relate to changes in mandibular position and because of its unique anatomical position it also has a vital role in maintaining upper airway patency and dimension. Neck flexion changes the position of the hyoid bone, altering the anatomic relationships of other muscles attached to it. Positioning and coordination of the hyoid, the tongue, jaws, cervical vertebrae, and larynx requires frequent intermittent adjustments during breathing, speech, swallowing, mandibular function, and apnea episodes. Maintaining head balance during this constant repositioning and coordination of changing function requires tremendous neurologic circuitry. The position of the hyoid changes particularly in mouth breathers with their low

Allen J. Moses, DDS, DABCP, D.ABDSM, was in private dental practice for 48 years in Chicago Illinois and assistant professor at Rush University Medical School in the Department of Sleep Disorders and Research for 13 years. He holds three US Patents for intraoral sleep devices and a Patent Pending for a shim system for registering the posterior interarch jaw relationship for intraoral sleep appliances. He was a member of the United States Food and Drug Administration Dental Products Panel for 10 years, has authored a book on temporomandibular disorders and over 30 scientific papers on TMDs and sleep dentistry. He was book review editor of Cranio for 10 years.

44 DSP | Winter 2023

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CLINICALfocus tongue position. The lower the hyoid, the more forward is the head position on the spinal column and the lower the tongue, the smaller the pharyngeal airway. The largest oropharyngeal airway is created with nose breathing, lips sealed, dorsum of the tongue as far forward as possible and sealed against the hard and soft palate. The tongue and hyoid must coordinate as the mandible moves posteriorly in relation to the other craniofacial structures or it would encroach on the airway and impinge respiratory function. The patency of the upper airway is preserved by inferior and posterior positioning of the hyoid apparatus as is seen in Class II subjects. The hyoid bone in Class III subjects is positioned in a more anterior position.2 Variations, however, are to be seen in both upper and lower oropharyngeal widths and posture of the tongue and hyoid bone position in all growth patterns.3

Variability of Pharyngeal Muscle Activation and Coordination

There are more than 20 skeletal muscles surrounding the pharyngeal airway.4 Medial pterygoid, tensor palatini, genioglossus, geniohyoid and sternohyoid promote a patent pharyngeal lumen by dilating the airway and stiffening the airway walls. They regulate the

Figure 2: Three dimensional CT scans of the same patient, lateral, coronal and frontal; all taken the same day. The top three views show the airway with the patient in rest position. Views on the bottom row are with the oral sleep appliance in place. In most cases the comparable linear gain is 20 – 30%, but the gain in volume is substantially greater and the gain in airway volume involves mandibular movement in the multiple directions shown in Figure1.

46 DSP | Winter 2023

position of the soft palate, tongue, hyoid apparatus, and posterior-lateral pharyngeal walls. Other muscles can have antagonistic effects on the pharyngeal wall. Levator palatini and superior pharyngeal constrictor narrow the retropalatal airway. Glossopharyngeus and palatopharyngeus dilate the airway in the retropalatal area. Extrinsic tongue muscles genioglossus and geniohyoid protrude the tongue – hyoglossus and styloglossus are tongue retractors. Pharyngeal muscles can have different effects when activated individually than when activated in concert.5 The same pharyngeal muscles can play a role in such disparate activities as breathing, swallowing, and speaking. Activation of a given muscle can have different effects on the airway depending on what other muscles are simultaneously doing and their precise anatomic arrangements at the time of activation. The ability of a given muscle fiber to produce different mechanical effects may be due to changes in muscle fiber orientation with concomitant changes in airway size and shape.6 Studies have also shown that a particular pharyngeal muscle may have different mechanical effects on the airway depending on the size of the airway at the time of muscle activation.7,8 Mandibular repositioning devices increase airway size more in the retroglossal than in the retropalatal region because they advance the mandible and consequently pull the tongue forward.9,10 Another study has shown that mandibular repositioning appliances may in some cases increase cross-sectional area in the retropalatal as well as retroglossal region. The increase in the retropalatal area was mostly in the lateral dimension.11 This suggests that dilation of the oral airway by oral sleep appliances may be more complex than simply pulling the tongue and soft palate forward, the mechanical adjustment mechanism found on most oral sleep appliances. That the neurologically coordinated movement of over 20 muscles moving in multiple directions with unpredictable firing sequences anchored and guided by the irregular, asymmetric shapes of the hyoid bone, condyles and glenoid fossae should move in tandem and in a straight unidirectional dimension set arbitrarily in a dental lab is contrary to any known anatomic principles.

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CLINICALfocus

Figure 3: Shows ten mechanically adjustable oral sleep appliances available in the dental marketplace. The array of adjustment mechanisms consists of screws, tubes, rubber bands, hinges, and springs. By virtue of all being unidirectional none of them replicate biological jaw movement.

Finite Element Modeling (FEM) is a means to study complex mouth movements and muscle activation whose origin is in the temporomandibular joint. The mouth is an important human motion system whose positioning is essential in regulating airway volume. A wide range of functional and parafunctional movements are performed many times during the course of a day that are multidimensional rotation and translation.12 Mandibles, with two joints that each function in synchrony with cartilaginous discs, produce many movement patterns. The six muscle activation patterns shown by Sag13 et.al. were each different, asymmetric, unpredictable, and multidimensional.

Figure 4: TMJ capsule representation from front, lateral and medial; top row: closed state; bottom row opened position. AL anterior ligament; LL lateral ligament; ML medial ligament; PL posterior ligament. Muscle activation patterns as shown by the direction of ligament pull are asymmetric and multidimensional. From Sagl et.at. 2019, Frontiers of Physiology

48 DSP | Winter 2023

Discussion

Optimal pharyngeal dilation is a soft tissue phenomenon determined by the coordinated functioning of the mandibular condyles, articular discs, the hyoid bone, ligaments, muscles, and nerves. Stenting this coordinated effort position is difficult to predict precisely because it is a soft tissue stance. A close approximation to this stance position can be guessed at, stented with an oral appliance, and measured non-invasively by polysomnographic study. But polysomnography cannot predict how close that stent is to optimal performance. What direction and how much more or less the clinician must go to achieve greater airway dilation is an unanswered question. There are two means of addressing sleep apnea treatment: (1) make more room in the mouth for the tongue, and (2) dilate the pharynx open. • Human jaw movement can be either multidimensional or asymmetric and is usually both simultaneously. • There are recognized anatomic, biological, ergonomic and physiological principles of oral appliance design to establish appropriate vertical, antero-posterior and lateral support in a stabilized position of the dental arches that optimally enlarges the oral airway, prevents its collapsibility, comfortably supports the TMJ, muscles, nerves, and ligaments, facilitatating physiologic tongue position against the hard palate, closed lips, and nasal breathing. • Optimal airway volume appears to be a multidimensional position. To initially achieve optimal airway dilation and stenting, the dimensions of verti-

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CLINICALfocus Unidirectional mechanisms neither capture nor replicate biologic movement. Research into innovative methods for titrating the interarch jaw relationship for oral sleep appliances is warranted.

• •

•

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

50 DSP | Winter 2023

cal, lateral, protrusive and slant must be factored into positioning. Unidirectional movement does not appear to be the way to achieve optimal airway and stenting. Built-in mechanical expansion mechanisms are unidirectional, never having concurrent multi-dimensionality, almost universally horizontal, very rarely vertical or programmed for asymmetric movement. Built-in adjustment mechanisms in oral sleep appliances are not specifically pre-calibrated for the direction necessary to achieve optimal airway dilation/stenting. Current mechanical adjustment mechanisms consisting of tubes, straps, setscrews, rubber bands, hinges, hooks, and springs are unidirectional and do not replicate human condylar movement. If the position of optimal airway dilation and stenting were achieved at the initial fitting, a mechanical adjustment mechanism would be unnecessary. Most conventional oral sleep appliances do not employ ergonomic principles that integrate the biomechanical elements of the human oropharyngeal

system into design and function to optimize overall system performance. Examples of non-ergonomic appliances are those with wires or hardware that prevent the tongue from resting on the palate, those with restrictive anteriors preventing the tongue from reaching the lips, or those whose vertical height in the anterior is so great that the patient cannot comfortably close their lips.

Conclusion

Mechanically adjustable oral sleep appliances are still in a primitive state of scientific development. Unidirectional mechanisms such as screws, tubes, hooks, springs, hinges, and rubber bands neither capture nor replicate biologic movement. Research into innovative methods for titrating the interarch jaw relationship for oral sleep appliances is warranted. Being a collapsible tube, more expansion of the pharynx in one direction does not always predict greater dilation; it may result in less dilation. A clinician can keep guessing that more advancement in one direction is better, but it may be more conservative to introduce and manipulate more variable dimensions by just starting over. An oral sleep appliance that can easily remade from scratch, such as one generated by computer printing from electronic scans, may be more practical, more biologically appropriate, and have a stronger scientific basis than those built with unidimensional adjustment mechanisms.

Auvenshine RC, Pettit NJ. The hyoid bone: an overview. Cranio 2020;38:6–14. Battagel JM, Johal A, et.al, Changes in airway and hyoid position in response to mandibular protrusion in subjects with obstructive sleep apnea. Eur J Orthod; 1999;21:363-76 Adamides IP, Spryopolous MN. Hyoid bone position and position in Class I and Class III malocclusions. Am J Orthod Dentofacial Orthop.1992’101:308-12 Netter F. “Atlas of Human Anatomy”2 ed Novartus, E Hanover NJ Schwab RJ, Kuna ST, Remmers JE. “Anatomy and Physiology of Upper Airway Obstruction” in Kryger, Roth Dement, Principles and Practice of Sleep Medicine; 4 ed; Elsevier Saunders; Philadelphia Schwab RJ, Kuna ST, Remmers JE. “Anatomy and Physiology of Upper Airway Obstruction” in Kryger, Roth Dement, Principles and Practice of Sleep Medicine; 4 ed; Elsevier Saunders; Philadelphia Kuna ST, Vanoye CR; Mechanical effects of pharyngeal constrictor activation on pharyngeal airway function. J Appl Physiology;1999;86:411-417 Kuna ST, Brennick MJ, Effects of pharyngeal muscle activation on area-pressure relationships. Am J Resp Crit care Med 2002;166:972-977 Bennett LS, Davies RJ. Stradling JR.Oral appliances for thefor the management of snoring and obstructive sleep apnea. Thorax, 1998:53 (suppl 2):558-64 Ryan CF, Love LL, Peat D. et.al. Mandibular advancement oral appliance therapyfor obstructive sleep apnea: effect on awake caliber of the velopharynx. Thorax 1999; 54:972-77 Liu Y, Zeng X, et.al. Effects of a mandibular positioner on obstructive sleep apnea. Am J orthod Dentofacial Orthop. 2000: 118:248-56 Drake R, Vogl W, Mitchell A. “Gray’s Anatomy for Students” ed3. 2014 London, Churchill Livingstone Sagl B, Schmid-Schwap M, Piehslinger E, Kundt M, Stavness I. A dynamic jaw model with a finite-element Temporomandibular Joint, Frontiers in Physiology; v10:2019, 1156-67

CHOOSINGappliances

Incorporating myTAP into Your Sleep Practice ®

by Jason Hui, DDS, MAGD, D.ABDSM

he myTAP appliance has significantly impacted my dental sleep medicine practice. When properly fitted, I view this appliance as a “semi-custom” alternative that performs just as effectively as a fully custom oral appliance. In fact, I frequently designate myTAP as the definitive appliance for some of my severe obstructive sleep apnea (OSA) patients, but I’ll save that story for another occasion. Before integrating myTAP, our treatment workflow resembled that of most dentists: assess the patient’s need for treatment, take impressions and a protrusive bite record, await medical insurance approval, await for the dental laboratory to fabricate the oral appliance, deliver the appliance to the patient, and conduct a few office visits for adjustments and follow-ups to evaluate the oral appliance effectiveness and patient’s compliance. When factoring additional delays

and patient scheduling conflicts, it wasn’t uncommon for patients to receive their oral appliance 2-3 months after their initial visit with me. This treatment delay consistently posed issues. For instance, consider a pilot, truck driver, or school bus operator struggling to stay alert due to excessive daytime sleepiness during work hours because of poor sleep quality and untreated obstructive sleep apnea. Imagine spouses constantly irritated at each other due to poor sleep from epically loud snoring; these couples usually are already sleeping in separate bedrooms, which negatively affects their relationship and intimacy. Many of my patients also want to get treatment sooner due to an upcoming trip with friends or family where it doesn’t make sense financially to get separate rooms. Lots of people have delayed treatment for many DentalSleepPractice.com 51

CHOOSINGappliances years until the symptoms were no longer tolerable or could be dismissed as somehow “normal.” Frequently, I will see a new patient struggling with a disease or symptom, and testing/treating for sleep apnea was the last consideration. These patients have seen several doctors, managing certain conditions unsuccessfully such as drug resistant hypertension, cardiac arrhythmias, chronic fatigue, depression, anxiety, insomnia, etc. Wouldn’t you prefer to address all their needs sooner? I certainly would, and myTAP enables me to do just that. myTAP often also serves as a diagnostic appliance, to see if it helps these

myTAP appliance

Jason Hui, DDS, MAGD, D.ABDSM, earned his bachelor’s degrees in biology and business administration from the University of Texas at Dallas. Before graduating from Baylor College of Dentistry with his Doctorate of Dental Surgery, Dr. Hui received the “General Dentistry Award” and “Implant Award” for outstanding performance in both these areas. Dr. Hui has received his Mastership in the Academy of General Dentistry and his Fellowship in the American Academy of Craniofacial Pain. Dr. Hui is also Board Certified with the American Board of Craniofacial Dental Sleep Medicine. Dr. Hui has found that Obstructive Sleep Apnea has been the link to many tooth problems such as cracked teeth, grinding, clenching, and often times frequent headaches or facial pain. Dr. Hui is currently an Adjunct Assistant Clinical Professor at Texas A&M/Baylor College of Dentistry. Dr. Hui is active in the American Academy of Dental Sleep Medicine, American Academy of Craniofacial Pain, American Dental Association, Academy of General Dentistry, Texas Dental Association, and the Dallas County Dental Society.

52 DSP | Winter 2023

patients, before moving forward. Many of us treating sleep disordered breathing with oral appliances have seen the improvement in quality of life for our patients. Treating their problems as soon as possible is often a priority for the patients I see. I have never encountered a patient that struggled with a problem who was excited to wait for treatment. Most dentists I talk to about myTAP usually ask me how it is billed. I bill it to the patient. The myTAP can be billed under CPT code E0485 which is for all prefabricated oral appliances used for the treatment of OSA. However, if E0485 is billed, the insurance carrier usually will not cover the custom fabricated oral appliance HCPCS code E0486. My treatment coordinator presents financials to the patient as a total treatment fee. The amount includes the myTAP and the estimated out of pocket cost for the custom oral appliance, after insurance support. Since incorporating myTAP into my dental practice, for diagnosed patients I can begin treatment at the initial visit. Upon the patient’s return for the second visit for fitting the custom oral appliance, we can evaluate the efficacy and compliance of oral appliance therapy for their OSA, given that the patient has worn a myTAP for several weeks. Typically, the patient has been self-adjusting the myTAP and has determined the therapeutic position. We replicate this position in the custom oral appliance fabricated by the lab. Subsequently, we return the patient to their sleep physician for a post-treatment sleep apnea test to verify the appliance’s effectiveness. The initial myTAP now becomes a backup oral appliance should anything happen to the custom-made one. Using myTAP at the initial visit translates to fewer follow-up visits, resulting in cost savings for patients in copays and chair time overhead for my practice. Moreover, fewer follow-up visits open more appointment times on my schedule for productive appointments and expedite new patient intake. Most cases, the treatment process involves just those two visits, with treatment beginning from the patient’s initial encounter. Patients and spouses are happy, and referring physicians are typically SHOCKED at how quickly the sleep apnea is resolved. I strongly encourage all dental sleep medicine practitioners to incorporate myTAP

CHOOSINGappliances appliances into their workflow. The inclusion of myTAP has brought the following benefits to my practice: 1. Enhanced patient care and satisfaction. 2. Reduced number of office visits to complete treatment, leading to quicker patient referrals back to referring physicians. 3. Increased word-of-mouth referrals. 4. Provision of a backup oral appliance once the patient obtains the custom oral appliance. 5. A more affordable treatment option compared to a custom oral appliance. This is particularly beneficial for patients who lack insurance coverage or those wanting to assess its effectiveness prior to committing to the custom oral appliance.

myTAP appliance with mouth shield (left) and myTAP appliance (right)

The best way to get started with myTAP is to call Airway Management, Inc. Their inhouse lab, Airway Labs, provides every new dentist with a complimentary myTAP when sending in the first case. Learn how to create an effective myTAP for yourself, your family, or your team members, and witness how myTAP can enhance the workflow in your dental sleep medicine practice!

FASTER, EFFECTIVE TREATMENT

WITH MYTAP

Immediate, precision-fit oral appliance

•

Begin treatment at initial visit

•

Affordable treatment option

•

Comfortable, customizable fit in 20 minutes

•

Fewer in-office visits

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Clinically validated

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Easy patient adjustment

DentalSleepPractice.com 53

EDUCATIONspotlight

Airway Palooza March 15-16, 2024

by Lauren Gueits, BS, RDH

f you are passionate about airway health, and enjoy the friendly atmosphere of experts sharing their best in a personal way, get ready for Airway Health Solutions 2024 Airway Palooza at The Ritz Carlton, New Orleans on March 15-16, 2024!

“Overall, well organized, great speakers! Loved speaking to the different collaborators and their passion for airway health. I can’t wait for next year!” – Courtney Guley

Airway Health Solutions founder Lauren Gueits hosts Airway Palooza to bring together healthcare professionals who are dedicated to exploring and integrating Airway Dentistry and Airway Health into reallife practices. The event offers top-notch education, crafted New Orleans food, open bars, and socials with music, all included in the registration fee. The inclusive setup fosters a sense of camaraderie and provides excellent networking opportunities. Last year’s Airway Palooza sold-out. This year, you will meet an even more robust lineup, in a great city, with global experts in dentistry, medicine, and myofunctional therapy. Let's take a closer look at the speakers and topics for each day:

Day One – Pediatric Airway Health

James Nestor & Lauren Gueits

“A fantastic and in-depth discussion of Air Way Dentistry with like-minded colleagues. I strongly encourage anyone with an interest to make the leap, you will not be disappointed!” – James Segulyev, DDS

54 DSP | White 2023

Morning Session • Keynote Speaker Dr. Kevin Boyd, a pediatric dentist, will kick off the event with his compelling research-based talk on "Why We Must Fix Before Six." • Dr. Ben Miraglia, an international educator and primary care dentist, will share impressive case studies on "Using Myofunctional Appliances for Children." • Brittny Sciarra Murphy will present "MiniMyo," focusing on the benefits of myofunctional therapy for children under six. • Dr. Bret Christensen, an Airway Orthodontist, will present his 30-year experience in orthodontics, focusing on "Expansive vs Retractive Orthodontics" and why he will never extract healthy teeth. Afternoon Session • Sharon Moore, a world-renowned speech language pathologist, will kick off the afternoon session with her presentation,

"From Sleep Wrecked to Well Slept in 3 Steps." • Dr. Shereen Lim's presentation, titled "Breathe, Sleep, Thrive, Pediatric Case Reviews," will provide an eye-opening look into pediatric airway health. • Dr. Susan Maples will close out the day with her energetic talk on the necessity of performing an "Airway Health Screening Every Day!"

Day Two – Adult Airway Health

Morning Session • Dr. Jeevanan Jehandran, a world-renowned ENT, will jump start the day demonstrating through compelling case reviews, "The Power of Collaboration." • Dr. Jerald Simmons, triple board certified in Sleep Medicine, Neurology, and Epilepsy, will break down the research and teach the "Connection between Bruxism and OSA." • Dr. Michael Gelb, a TMD Expert, and Dr. Layne Martin, a dually trained prosthodontist/orthodontist, will co-present on "TMD and Sleep Disorders – New Treatment Options." • Dr. Felix Liao, a holistic educator, will teach about Epigenetics and Adult Expansion. Afternoon Session • Dr. Scott Siegel, an oral surgeon, researcher, and national educator, will share his expertise on "Demystifying Adult Frenectomies." • Dr. Reza Movahed, an oral surgeon and MMA patient, will review his protocols and showcase jaw-dropping before and after case portfolios in his presentation on "When MMA Surgery is the Answer." • Dr. Dave McCarty, a board-certified specialist in Sleep Medicine and author of "Empowered Sleep Apnea," will help

EDUCATIONspotlight "Unpack the Complexities of Sleep Apnea" from the unique perspective of empowering the OSA patient. • Dr. Steve Carstensen, Chief Dental editor of Dental Sleep Practice and an avid champion of the ADA-backed Children’s Airway Screener Task Force, CAST, will inspire us to do our part in the airway health movement providing Updates in Airway Dentistry and Simple Actions Everyone Can (and Must) Do. To close out Airway Palooza we have two compelling presentations from Airway Dentists, Dr. Ratti Handa and Dr. George Rivera sharing their professional and personal growth since implementing airway dentistry into their practices. Whether you are a seasoned airway advocate or new to the field, Airway Palooza is a unique conference that promises an enriching experience. To learn more about each speaker and their topics, and to register for the event, visit www.airwayhealthsolutions. com/palooza or scan the QR code. Airway Palooza is an essential event, offering you a unique opportunity to learn from global experts, network with likeminded professionals, and gain valuable insights and knowledge from each speaker's

“Left the palooza with our minds and hearts full knowing that we are not alone, just the pioneers of Airway Health.” – Dr. Tamara Strouth expertise. Don't miss out on this incredible event at The Ritz Carlton, New Orleans in 2024. Register now and be a part of the Airway Palooza experience!

Use Coupon Code: AHSSLEEP for a $150 discount on live tickets

Lauren Gueits, BS, RDH, is a highly experienced dental professional with 30+ years of clinical and corporate dentistry experience. She is a leading advocate for disease prevention and airway health, and has received numerous awards for her commitment to making a difference in the field. Lauren is a published author, national speaker, and the founder of Airway Health Solutions (AHS), dedicated to improving patients’ breathing and overall well-being. She is also a guest faculty at New York University and serves on various dental advisory boards. You can find Lauren on Airway Health Solutions’ social media platforms and YouTube channel where she shares valuable insights on airway health.

DentalSleepPractice.com 55

SEEKandSLEEP

JUMBLE Unscramble key words from this issue.

sccely __ __ __ __ __ __ tmuims __ __ __ __ __ __ foolntiac __ __ __ __ __ __ __ __ __ bytmirodi __ __ __ __ __ __ __ __ __ arnoittuas __ __ __ __ __ __ __ __ __ __ noounfatdi __ __ __ __ __ __ __ __ __ __ typpehnose __ __ __ __ __ __ __ __ __ __ ananuoiprcft __ __ __ __ __ __ __ __ __ __ __ __ manoomcilesit __ __ __ __ __ __ __ __ __ __ __ __ __ gnomottaashcit __ __ __ __ __ __ __ __ __ __ __ __ __ __ kleelatluumcoss __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ naattipurroehioz __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ aaamundincorbilr __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ sesedneteccinontrn __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

For the solution, visit www.dentalsleeppractice.com.

56 DSP | Winter 2023

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Save the Date: ProSleep 2024, August 1-3. Registration coming soon!

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

94% of Mild & Moderate Patients Successfully Treated (ODI < 10) with Precision OAT (n=58)

Percentage of Patients Successfully Treated

A recent independent, prospective clinical study published in the Journal of Clinical Sleep Medicine1 reported: 100%

94% 81%

80%

Traditional OAT Mean Efficacy 68% ± 13%

60% 40%

Mild/Moderate OSA

20%

All Severities

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. 2 Sall E. Precision Oral Appliance Therapy: The Prime - Time Treatment for OSA. World Sleep Congress. Rome, Italy. Poster Abstract #289. March 2022. 3 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

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