The Sleep Magazine- 2nd Issue

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Ambulatory Sleep Studies in DSM: When and Why? Let’s answer the call to action and start Saving Lives!

By Dr. J.Brian Allman, DDS, DABDSM, DAAPM, FAGD, FAACP, FICCMO, FAAFO, FASGD, Senior Instructor IAO

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mbulatory sleep study instrumentation (ASSI) has become a necessary tool in the dental sleep physician’s armamentarium. Protocol though is often unclear regarding when to administer take home sleep tests for our OSA oral appliance therapy patients. Though space prevents a complete treatise on this subject, the following is a brief overview of ambulatory sleep study instrumentation protocol to help guide DSM physicians as to when and why.

ASSI has gained recent near explosive interest in sleep medicine due to Medicare’s favorable view of such diagnostic instrumentation for obstructive sleep apnea (OSA) screening and diagnosis in the hands of sleep specialists. While many dental sleep physicians were first to introduce such instrumentation to their communities, often preceding their sleep medicine colleagues, (as in the case of the author, by nearly a decade) now everybody’s got ‘em.

Several advantages exist when

PSG s Under Built Labs s Patient Waiting Lists s Evaluation Stagnation s Disability/Distance Barriers s Age & Emotional Stressors s Financial Burdens s PSG Phobia, Avoidance, Inability

ASSI s Inability to Stage Sleep s Data Dilution s Low End Insensitivity s Data Loss - Due to unsupervised lead application s Confounded Data Gathering s Study Interpretation While PSG and ASSI have their differences; ASSI - a newly recognized cost effective alternative to OSA screening and diagnosis, DENTAL SLEEP MEDICINE is vital to DSM.

comparing an ambulatory study to “big brother” polysomnography (PSG). Oftentimes, sleep labs are under built and patient waiting lists swell creating evaluation stagnation.

Patient disability and geographic distance can also be effective barriers to lab studies. Age and emotional stressors can further prevent those most in need of expert diagnosis form entering the overnight lab environment.

Finally, the expense of a technician-attended laboratory study can burden an individual financially prohibiting adequate and necessary testing. Other examples of PSG-phobia, PSG -avoidance, and PSG-inability abound shinning an encouraging spotlight on PSG’s newly recognized and cost effective alternative.

ASSI testing does however harbor several disadvantages. For example, most ambulatory equipment lacks the ability to stage sleep providing more accurate AHI and RDI calculations. Under reported RDI/AHI values are a by-product of data dilution as EEGs are not generally enlisted to measure brain waves and stage sleep (For those interested, the Embletta X100 does offer 12+ lead capability including EEG). Another criticism of ASSI has been low end insensitivity: Is it an AHI of 12 or 21? Data loss due to unsupervised lead application and inadvertent loss can also confound data gathering and subsequent study interpretation.

ASSI, though seemingly fraught with “nuisance factors”, is vital to DSM. Four examples of ASSI utility in DSM include: Patient screening - the screening ambulatory test performed on one’s existing patients recently identified by the dentist as a likely OSA sufferer. If the patient suffers from PDS (Patient Denial Syndrome), ASSI is an excellent screening tool to measure and demonstrate a patient’s sleep pathology. The author uses a “pass, and the test is free: fail, and you agree to see a sleep specialist” approach to effectively educate and motivate patients in denial.

Pre-OAT post-PSG screening - ASSI scenario recommends a baseline test prior to beginning OAT when the new sleep patient presents with an outdated PSG. Often the dental sleep physician will inherit patients “MD-referred” for OAT based upon the results of 2-plus year old PSG. It is prudent to establish an office protocol whereby patients with PSGs older than 6-12 months routinely have an ambulatory sleep study performed prior to OAT so as to establish a baseline evaluation later followed

by additional ambulatory tests as treatment progresses.

OAT titration update & maximum medical improvement re-evaluation - Often, patients will espouse that they feel better when, in fact, OSA persists. Placebo treatment effect can be tested by easily and affordably measuring the patient’s nocturnal condition with and without their appliance. When patient titration is completed, an MMI study should be performed and results communicated to the referring sleep specialist. This data, in the hands of the MD, will help him or her best direct re-evaluation diagnostics. The sleep specialist may determine that a follow-up PSG is unnecessary based upon your results and professional collaborative approach. Consider also how your referring sleep specialists value your level of OAT follow-up. Many sleep specialists have been burned by “drive-by” dentists wielding appliances that are unwilling or unable to follow-up with take home titration studies prior to turfing the unresolved mutual patient back to the referring MD; frustrating for the patient, the dentist and the sleep specialist.

Several brands of ASSI are available for use by dentists to monitor their OAT patients.

It is a good idea, prior to purchasing such instrumentation, to discuss which types of instruments your referring sleep specialists use. If the sleep centers you are going to work with use EMBLA equipment, for example, it might behoove you to also utilize EMBLA instrumentation (e.g., Embletta X100). Using data collection instrumentation or technology unfamiliar to your physician network does little to cultivate multidisciplinary confidence.

Making a few phone calls to your future sleep specialist referrers regarding recommended instrumentation can be a great icebreaker when establishing your necessary MD-DDS relationships.

OSA is no longer a simple case of oropharyngeal collapse. OSA, by definition, harbors co-morbid factors including several very serious and life threatening medical conditions. ASSI is a necessary and useful tool to help maximize OAT outcomes. Multiple PSGs used to follow patients’ progress is expensive and impractical. By incorporating ASSI into your dental sleep medicine practice, you will set a higher standard for your practice, your patients and your referring physicians.

SLEEP DISORDERS The Fastest Growing Dental Specialty

By Dr. Maurice Salama

p. 44-45

The Field of Dental Sleep Medicine is Growing ...................................................................... 2 Helping Keep People A.W.A.K.E. .............................................................................................. 3

Acoustic Pharyngometry

By Professor Fredberg

p. 37

Working With TAP3

By Dr. Dan Tache

What is Your OSA Story? ........................................................................................................... 4 OSA the Camouflaged Killer .................................................................................................... 5 Is Your Team Snoozing? ........................................................................................................... 8 Rhinometry Not An Option! ...................................................................................................... 8 An Orthodontist’s Perspective on Sleep Disordered Breathing ............................................ 10 Protocol For Snoring Problems Male Age 18 .......................................................................... 11 Oxygen is Under-Rated .......................................................................................................... 12 Dr. Lucia Interview ........................................................................................................ 18-19 No Thanks Mister! I’ll Take Vanilla ............................................................................. 20-22

p. 33-35

The Epworth Test .................................................................................................................. 20

Home Sleep Tests Helping Sleep Labs

SGS Sleep Seminar Schedule ..................................................................................... 25-28

By Randall Haupt, RPSGT

United Sleep Diagnostics ..................................................................................................... 24

Obstructive Sleep Apnea and CPAP ..................................................................................... 29 Genetic Orthodontics .................................................................................................. 30-31 Developing a Sleep Physician Team .................................................................................... 32 The Emergence and Explosive Growth of OSA ..................................................................... 36

p. 14

Sleeping Down Under ................................................................................................. 42-43

OSA and Eye Vision

Pneumodontics .......................................................................................................... 48-51

By Troy Bedinghaus

p. 56

tableofcontents

Internet Based Education

Introducing The Silent Sleep Trial Oral Appliance For Snoring And Sleep Apnea ............... 46

Raising the Level of Suspicion ................................................................................... 53-55

Change the way you practice dentistry for the health of your patients!

DISCLAIMER Dental Sleep Medicine Magazine, and all of the expert opinion herein, represents many years of dental sleep medicine practice. It is presented as a forum for the advancement of dental sleep medicine. The articles within this publication are the opinions/statements of the medical professionals featured. Sleep Group Solutions is a private medical equipment and education company producing and distributing medical equipment and services. SGS provides practitioners with appealing diagnostic and treatment alternatives and in no way offers medical advice in the sleep disorder industry.

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The Field of Dental Sleep Medicine is Growing Here at Sleep Group Solutions, we have accomplished a lot thanks to our wonderful clients, partners and affiliates.  by  Rani  Ben-­David,  President

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he  genesis  of  this  magazine  came  from  my  experience  over  the  past  few  years  in  WKH ¿HOG RI VOHHS GLVRUGHUV Doctors  always  asked  me  what  others  are  doing  and  I  never  had  all  the  answers.  Now,  thanks  to  Dr.  Allman,  Dr.  Rondeau,  Dr.  Tache,  and  all  the  other  great  doctors  that  offered  advise  and  suggestions,  we  now  have  the  Dental  Sleep  Magazine.  In  it  \RX ZLOO ¿QG WKH GRFWRUVœ stories  and  cases  from  their  own  personal  and  up  front  perspective.  I  would  like  to  thank  my  dear  friend  Dr.  Maurice  Salama  for  his  wonderful  article  about  the  importance  of  education.

add  more  all  over  the  world.   We  are  partnering  with  the  leading  doctors,  most  of  whom  are  AADSM  (American  Academy  Dental  Sleep  Medicine)  members  and  Diplomats  to  accomplish  this  lofty  goal.  Each  study  club  will  arrange  2  to  4  seminars  in  its  area  and  ZLOO DOVR KDYH LQ RI¿FH WUDLQLQJV DQG D consulting  team  to  coach  new  members.  This  will  help  educate  more  dentists  to  treat  the  millions  of  patients  suffering  from  Obstructive  Sleep  Apnea  and  Snoring.  In  the  future,  just  log  on  to  www.

VOHHSJV FRP WR ÂżQG D VWXG\ FOXE FORVH WR you.  Despite  our  rapid  growth,  there  are  VWLOO QRW HQRXJK GHQWLVWV WR PHHW SDWLHQWVÂś needs.  Even  if  all  the  170,000  dentists  in  the  United  States  educate  and  treat  TXDOLÂżHG SDWLHQWV WKH QHHG ZLOO QRW EH met.  We  recommend  that  you  join  us  and  EH D SDUW RI WKLV JURZLQJ ÂżHOG  It  would  be  our  pleasure  to  feature  all  applicable  articles  in  the  Dental  Sleep  Magazine.   If  “In my 6 years in the Dental Industry, I have developed and you  would  like  to  submit  continue to develop a lot of relationships with doctors. I am an  article,  please  send  it  to  often asked questions on companies and their products and us  at  info@sleepgs.com.  what my input is on them. Before SGS came along, although I  Thanks  for  reading  this  knew it was a good product, I had a hard time supporting the magazine  and  for  joining  Eccovision System, because of lack of long-term support and us  in  our  efforts  to  reach  empty promises. SGS has really turned this around and has all  those  patients  in  need  of  a great knowledgeable supporting cast that goes above and assistance  with  thier  sleep  beyond what’s expected of them. They have even helped mend disorders. relationships with older users that dealt with the previous company. I hold my relationships in high regard and would Sincerely, work with and refer doctors to SGS without hesitation.â€?

Rani  Ben-­David - Shane, BioResearch President Sleep  Group  Solutions  In  the  immediate  future,  we  plan  to  open  20  SGS  Sleep  Study  Clubs  around  the  country  and,  thereafter, Â

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DENTAL Â SLEEP Â MEDICINE

Tamir  Cohen CEO  -­  Sleep  Group  Solutions tamir@sleepgs.com

Rani  Ben-­David President ranibd@sleepgs.com Eldar  Adi General  Manager eldar@sleepgs.com Dr.  Brian  Allman Co-­Editor Dr.  Dan  Tache Co-­Editor Contributed  Articles Dr.  Brock  Rondeau Dr.  Chris  Hansen Dr.  Brian  Billard Dr.  Dawne  E.  Slabach Dr.  Michael  Pecenka Dr.  John  T.  Herald Dr.  Steven  J.  Scheer Dr.  Gy  Yatros Dr.  John  Farringer Dr.  Donald  E.  Frantz Dr.  Melody  A.  Barron Randall  L.  Haupt,  RPSGT Dr.  Michael  Lucia Dr.  John  C.  Jeppesen Dr.  Robert  L.  Horchover Dr.  Lisa  Matriste Dr.  Maurice  Salama Dr.  Jamison  R.  Spencer Donald  Burke Creative  Director Sleep  Group  Solutions 16830  Northeast  19th  Avenue North  Miami  Beach,  FL  33162 Toll-­Free  1.866.353.3936 Email:  info@sleepgs.com

Helping Keep People A.W.A.K.E. Alert, Well and Keeping Energetic.  By  Edward  Grandi,  Executive  Diretor  of  American  Sleep  Apnea  Association

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or  many  people,  doing  what  is  good  for  you  is  not  easy  –  like  exercising  several  times  a  week,  eating  foods  that  are  healthy  and  following  your  treatment  regime  for  your  chronic  disease.  Adherence  or  compliance  to  therapy  can  be  particularly  onerous  when  it  involves  using  a  device  like  continuous  positive  airway  pressure  (CPAP)  to  treat  obstructive  sleep  apnea.  The  mask,  the  hose,  the  air  blowing  in  \RXU IDFH FDQ EH GLI¿FXOW WR WDNH DOO QLJKW So  it  is  easy  to  understand  why  people  might  not  use  their  therapy  even  if  it  is  EHQH¿FLDO  The  American  Sleep  Apnea  Association  $6$$ LV WKH RQO\ QDWLRQDO QRQSUR¿W organization  dedicated  to  educating  the  public  about  sleep  apnea  and  enhancing  the  lives  of  those  affected  by  the  condition.  The  ASAA  sponsors  a  network  of  support  groups  around  the  United  States  under  the  name  A.W.A.K.E.  that  is  an  abbreviation  for  Alert,  Well  And  Keeping  Energetic.  The  A.W.A.K.E.  support  group  model  has  three  distinct  objectives:  mutual  support,  continuing  education  and  empowerment.  It  is  easy  to  think  when  faced  with  using  a  challenging  therapy  like  CPAP  that  you  are  the  only  person  in  the  world  having  to  endure  this  hardship.

 The  support  group  brings  together  people,  some  who  have  adapted  well  to  treatment  and  others  who  are  just  getting  started.  There  are  questions  the  doctors  can  answer  and  then  there  are  questions  that  when  answered  by  someone  living  with  the  condition  will  make  the  newcomer  feel  much  less  alone.  The  treatment  of  sleep  apnea  continues  to  evolve.  The  support  group  is  an  excellent  way  to  stay  up-­to-­date  on  new  and  alternative  therapies.  Expert  speakers  can  provide  information  on  how  to  address  certain  treatment  issues  and  to  showcase  improvements  in  the  masks  and  devices.  Continuing  education  about  sleep  apnea  helps  make  the  patient  an  informed  consumer  of  healthcare,  which  is  critical  for  maintaining  good  health.  An  apneic  who  feels  supported  in  the  treatment  and  is  informed  is  an  empowered  patient  –  this  is  the  ultimate  objective  of  the  support  group.  Not  only  is  he  or  she  adherent  to  their  chosen  therapy Â

An apneic who feels supported in the treatment and is informed is an empowered patient.

EHFDXVH WKH\ XQGHUVWDQG WKH EHQHÂżWV WKH\ can  also  “pay  it  forwardâ€?  by  helping  to  raise  awareness  about  a  serious  potentially  life  threatening  disease  and  to  help  others  who  may  be  facing  the  same  challenges  they  faced  before  they  found  support.  For  more  information  about  the  A.W.A.K.E.  Network  of  support  groups  DQG WR ÂżQG RQH LQ \RXU DUHD SOHDVH YLVLW our  web  site:  www.sleepapnea.org   Dentist  that  want  to  join  the  A.W.A.K.E  can  contact  Sleep  Group  Solutions  at  info@sleepgs.com  or  go  to  www.sleepgs. com.

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What Is Your O.S.A. Story?

Many people seem to have a story about how OSA has affected their life in some way.   by  John  Nadeau,  Vice  President,  Sleep  Group  Solutions

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hroughout  my  years  of  educating  dentists  and  physicians  how  to  identify,  diagnose  and  treat  OSA  in  their  SUDFWLFHV ,ÂśYH QRWLFHG D FRQVLVWHQW WUHQG 0DQ\ people  seem  to  have  a  story  about  how  OSA  has  affected  their  life  in  some  way.   Some  stories  refer  to  relationships  and  how  sleep  apnea  and  snoring  have  driven  a  husband  and  wife  to  sleep  in  separate  bedrooms.  Some  stories  are  health  related,  one  friend  of  mine  had  a  heart  attack  at  age  40  and  it  was  only  after  this  event  did  he  realize  that  apnea  was  the  underlying  cause.  +H ZDV IRUWXQDWH KH VXUYLYHG DQG LV QRZ EHLQJ WUHDWHG Many  others  have  not  been  as  lucky.  NFL  Hall  of  Fame  SOD\HU 5HJJLH :KLWHÂśV SUHPDWXUH GHDWK LQ KDV EHHQ widely  attributed  to  untreated  OSA.  Millions  of  others,  perhaps  even  one  of  your  friends  or  family  members  have  suffered  similar  fates  caused  by  OSA  without  a  diagnosis.  Did  you  know  that  70%  of  stroke  victims  have  sleep  apnea?  (Bassetti  et  al.  Sleep.  1999) 4XLFN ZKDWÂśV WKH QXPEHU RQH FDXVH RI DXWR DFFLGHQWV RQ 1RUWK $PHULFDÂśV URDGV HDFK \HDU" 'HVSLWH WKH ODFN of  attention,  what  is  statistically  more  dangerous  than  drunk  driving?  The  answer  is  tired  driving  and  OSA  is  a  huge  contributing  factor.  Sleep  apnea  deprives  people  of  the  clean  rejuvenating  sleep  they  need  and  replaces  it  ZLWK IUDJPHQWHG VOHHS ÂżOOHG ZLWK DURXVDOV KLJK EORRG pressure  and  heart  rate  increases.  As  a  result,  people  suffering  from  OSA  are  seven  to  twelve  times  more  likely  to  be  involved  in  an  auto  accident  because  of  their  excessive  sleepiness.  Did  you  know  that  sleeping  for  only  4  hours  results  in  equivalent  reaction  times  to  those  of  someone  with  a  blood  alcohol  content  of  .08%?  This  leads  me  to  one,  of  my  many,  OSA  stories.  On  January  6th,  2008  a  bus  load  of  skiers  was  traveling  back  from  a  Utah  ski  resort  to  my  hometown  of  Phoenix,  AZ.  My  father-­in-­law  along  with  a  few  of  his  friends  were  on  this  trip.   As  the  bus  passed  near  the  four  corners  area  with  hundreds  of  miles  of  mountain  and  desert  in  every  direction  its  speed  began  to  increase.  This Â

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DENTAL Â SLEEP Â MEDICINE

continued  prompting  one  passenger  to  yell  at  the  driver  to  slow  down.  A  while  later  the  speed  began  to  increase  again,  this  time  nobody   yelled  at  the  driver.  On  board  video  showed  passengers  bracing  for  impact  as  the  bus  approached  D FXUYH DW DOPRVW PSK WKH GULYHUÂśV expression  remained  unchanged  â&#x20AC;&#x201C;  he  was  sleeping!  The  bus  virtually  disintegrated  as  it  rolled  down  an  embankment  throwing  almost  every  passenger  out.  My  father-­in-­ ODZ ZDV IRUWXQDWH KH HVFDSHG ZLWK VHULRXV but  treatable  injuries.   9  people  died  that  night  including  2  of  his  friends.   Over  15  months  later,  in  April  2009,  the  NTSB  reported  that  the  driver  suffered  from  sleep  apnea  and  faulted  his  fatigue  as  the  cause  of  the  accident.  There  is  no  other  disease  or  disorder  as  deadly  as  OSA  that  is  undiagnosed  to  this  level.  If  you  are  not  already  screening  and  treating  patients  I  ask  that  you  take  a  course  and  get  started.  Preventing  heart  attacks  and  strokes  is  truly  rewarding.  Taking  a  tired  driver  off  the  road  could  change  the  lives  of  countless  others. :KDWÂśV \RXU 26$ VWRU\" <RX PD\ KDYH one  and  not  even  know  it.

2 6 $ 7KH &DPRXĂ DJHG Killer!

Dental Sleep Magazine - clinical articles to advance your dental sleep medicine education journey  by  J.  Brian  Allman,  DDS,  Co-­Editor  DSM  Magazine

T

hank  you  all  for  your  overwhelming  and  enthusiastic  response  to  our  inaugural  issue  of  Dental  Sleep  Medicine  Magazine  released  earlier  this  year.  Comments  have  been  unanimously  positive  prompting  SGS  founders,  Rani  Ben-­David  and  Tamir  Cohen,  to  publish  a  second  installment  with  an  even  broader  dental  scope  including  topics  related  not  only  to  dental  sleep  medicine,  but  to  advanced  dental  restorative  techniques  as  well.  Volume  2  uniquely  embodies  the  ¿UVW HGLWLRQ as  a  clinical  resource  offering  numerous  articles  from  seasoned  â&#x20AC;&#x153;wet-­ ÂżQJHUHG´ GHQWDO experts.  Dental  sleep  medicine  is  now  experiencing  explosive  demand  from  savvy  dental  consumers  seeking  CPAP  alternatives  as  well  as  dentists  eager  to  become  involved  in  providing  oral  appliances  for  snoring  and  OSA.   As  one  devoted  to  â&#x20AC;&#x153;spreading   WKH JRVSHO´ UHJDUGLQJ GHQWLVWU\ÂśV YLWDO role,  I  have  found  our  sleep  seminar  attendees  increasing  in  number,  level  of  sophistication  and  genuine  enthusiasm.  More  dentists  are  anxious  to  add  dental  sleep  medicine  to  their  practices  EHQHÂżWWLQJ WKH KHDOWK RI WKHLU SDWLHQWV communities  and  bottom  line.  Standing  on  the  sidelines  ignoring  our  responsibility  to  include  OSA  screening  of  our  patients  is  a  tragic  oversight  in  modern  dental  diagnosis  and,  in  my  opinion,  we  clearly Â

have  a  moral  obligation  to  screen  for  sleep  disordered  breathing  conditions.  It  is  time  to  also  include  examination  protocol  in  dental  school  education.  Shame  on  us  for  not  embracing  our  responsibility  to  upgrade  our  clinical  acumen  with  more  vigor!.   Obstructive  sleep  apnea  is  an  â&#x20AC;&#x153;insidious  and  treacherous  health  hazardâ&#x20AC;?  (Dr.  Keropian)  fueling  a  dramatic  rise  in  morbidity  and  mortality  statistics  under  the  cloak  of  heart  disease,  cerebrovascular  insult,  obesity  and  hormonal  dysfunction  conditions.  OSA  is  truly  an  under-­ diagnosed  and  FDPRXĂ&#x20AC;DJHG NLOOHU HYHQ WKRXJK SDWLHQWV can  be  easily  screened,  referred,  diagnosed  and  treated  via  a  multidisciplinary   collaborative  medical  model  which  does,  in  fact,  include  dental  therapeutics.  It  is  this  clinical  disconnect  that  dentistry  must   rectify  by  playing  a  vital,  if  not  primary,  role.  Not  tomorrow  morning,  but,  this  morning.  I  am  excited  to  be  involved  with  Dental  Sleep  Medicine  Magazine.  I  am  also  excited  to  incite  my  profession  to  become  involved  in  the  medical-­dental  sleep  medicine  model.  Please,  use  these  clinical  articles  as  a  reference  and  guide  to  advance  your  dental  sleep  medicine  HGXFDWLRQ MRXUQH\ /HDUQ IURP '60ÂśV contributors.  And  lastly,  continue  to  attend Â

lectures  and  seminars  to  further  your  NQRZOHGJH FRQ¿GHQFH DQG VNLOO :H QHHG many,many  more  dental  seep  medicine  physicians  out  there!  Enjoy  Volume  2!

J.  Brian  Allman,  DDS,  DABDSM,  DAPM,  FAGD,  FAACP,  FICCMO,  FIAO,  FASGD,  FAAFO Co-­editor  DSM  Magazine Awards s $IPLOMATE !CADEMY OF $ENTAL 3LEEP -EDICINE s $IPLOMATE !MERICAN !CADEMY OF 0AIN -ANANGEMENT s &ELLOW !MERICAN !CADEMY OF #RANIOFACIAL 0AIN s &ELLOW !CADEMY OF 'ENERAL $ENTISTRY s &ELLOW )NTERNATIONAL #OLLEGE OF #RANIOMANDIBULAR Orthopedics s &ELLOW !MERICAN !CADEMY OF &UNCTIONAL /RTHOPEDIC s &ELLOW !MERICAN 3OCIETY FOR 'ERIATRIC $ENTISTRY Memberships s !MERICAN !CADEMY OF 3LEEP -EDICINE s !MERICAN !CADEMY OF $ENTAL 3LEEP -EDICINE s !MERICAN !CADEMY OF #RANIOFACIAL 0AIN s !MERICAN !CADEMY OF /ROFACIAL 0AIN s )NTERNATIONAL #OLLEGE OF #RANIOMANDIBULAR /RTHOPEDICS s !MERICAN %QUILIBRATION 3OCIETY s )NTERNATIONAL !SSOCIATION FOR /RTHODONTICS s !MERICAN (EADACHE 3OCIETY s !MERICAN !CADEMY FOR &UNCTIONAL /RTHODONTICS s !MERICAN $ENTAL !SSOCIATION s .EVADA $ENTAL !SSOCIATION

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continuededucation 6

Is Your Team Snoozing?

Are you losing potential Sleep Apnea Patients?  by  Dawn  Patrick

W

ho  can  ignore  the  onslaught  of  information  about  Sleep  Apnea  Ă&#x20AC;RRGLQJ WKH GHQWDO ÂżHOG WRGD\" Long  time  suffers  of  Sleep  Apnea  are  now  being  inundated  with  information  about  an  alternative  to  the  dreaded  CPAP  machine.  This  media  blitz  has  patients  hitting  the  internet  hungry  for  information  and  wondering  if  they  too  can  exchange  the  traditional  ball  and  chain  for  a  more  conventional  method  of  treating  apnea.  This  certainly  is  the  new  wave  in  dentistry  and  an  incredible  opportunity  for  dentists  to  increase  their  bottom  line,  but  how?   7KH ÂżUVW VWHS WRZDUGV incorporating  Sleep  Apnea  alternatives  into  your  practice  repertoire  is  Â&#x2021; Education  -­  Just  as  potential  SDWLHQWV DUH EHLQJ Ă&#x20AC;RRGHG ZLWK information,  so  are  dentists.   You  ZRQÂśW KDYH WR ORRN KDUG WR ÂżQG numerous  seminars  at  various  levels.  It  is  important  to  educate  your  entire  team  about  Sleep  Apnea  Dentistry.   Think  about  LW Âą LW GHÂżQLWHO\ QHHGV WR EH D team  approach  to  be  successful!   Everyone  on  the  team  has  to  know  how  to  â&#x20AC;&#x153;walk  the  walkâ&#x20AC;?  and  â&#x20AC;&#x153;talk  the  talkâ&#x20AC;?.  Your  team  DENTAL  SLEEP  MEDICINE

should  be  familiar  with  basic  dental  sleep  WHUPLQRORJ\ WKH W\SHV RI RUDO GHQWDO appliances  used  to  treat  sleep  apnea,  and  be  comfortable  discussing  basic  sleep  apnea  questions.  Â

Â&#x2021; Basic  Systems  -­  Once  you  have  HGXFDWLRQ XQGHU \RXU WHDPÂśV EHOW LWÂśV WLPH to  establish  basic  systems  for  everyone  to  IROORZ ,W LV LPSRUWDQW WR HVWDEOLVK D Ă&#x20AC;RZ chart  for  your  team  to  follow  for  sleep  patients  which  includes  detailed  steps  of  the  appointment  process  beginning  with  the  initial  phone  call.  Your  system  should  detail  each  step  of  the  appointment  process  including  scripting  for  your  team  to  follow  in  regards  to  insurance  and  treatment  questions.  It  is  imperative  WR LQFOXGH VSHFLÂżF EXOOHW SRLQWV DERXW \RXU WHDPÂśV DSSURDFK WKDW FDQ EH XVHG to  differentiate  your  practice  from  the  JURZLQJ PDVVHV RI RIÂżFHV SURPRWLQJ WKHLU own  Sleep  Apnea  treatment  modalities.  6\VWHPV ZLOO YDU\ IURP RIÂżFH WR RIÂżFH but  the  key  is  to  write  the  process  down  so Â

that  everyone  is  clear  as  to  what  needs  to  be  done  and  who  is  responsible  for  each  step.  Â&#x2021; Role-­playing  -­  is  also  an  integral  part  to  ironing  out  any  obstacles,  glitches,  or  communication  GLIÂżFXOWLHV SULRU WR VHHLQJ \RXU ÂżUVW SDWLHQW Â&#x2021; Marketing  -­  You  GRQÂśW KDYH WR ORRN IDU WR begin  marketing  Sleep  Apnea  treatment.   By  adding  a  few  questions  to  your  medical  history  pertaining  to  Sleep  Apnea  or  adding  the  Epworth  Sleep  Test  to  your  new  patient  paperwork,  screenings  will  automatically  become  part  of  your  routine.   Your  educated  team  can  take  this  important  screening  information  and  discuss  alternatives  with  your  patient  before  you  even  enter  the  treatment  room  to  conduct  an  exam.  Chances  are  with  one  simple  question,  â&#x20AC;&#x153;Do  you  or  someone  you  know  snore?â&#x20AC;?  you  will  be  well  on  your  way  to  incorporating  Sleep  Apnea  alternatives  into  your  practice.   Dawn Patrick is the owner of In Office Coaching, a coaching company focusing on building exceptional teams, one system at a time. By focusing on teams oneon-one to develop customized systems, daily stress is reduced and the profitability of the practice is increased.

Dawn is also Practice Administrator for Fairlington Dental located in Arlington, Virginia.

For more information on In Office Coaching, visit www.InOfficeCoaching. com or contact Dawn Patrick directly at InOfficeCoaching@yahoo. com

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patientcase

RHINOMETRY: Not An Option!

Abandoning the old model of treating patients . . . and pursuing, cultivating and embracing a multi-disciplinary collaborative medical approach to treating this insidious deadly condition.

J.Brian  Allman,  DDS,  DABDSM,  DAAPM,  FAACP,  FAGD,  FICCMO,  FAFO,  FASGD

E

lectrodiagnostic   Nasal  patency,  as  revealed  in  current  instrumentation  has  catapulted  literature,  plays  a  vital  role  in  OSA  heath  care  diagnoses  therapy.  Research  shows  that  nasal  LQĂ&#x20AC;XHQFLQJ WUHDWPHQW SURWRFRO UDWKHU airway  resistance  (NAR)  can  positively  or  GUDPDWLFDOO\ GHQWDO VOHHS PHGLFLQH QHJDWLYHO\ LPSDFW WKH HIÂżFDF\ RI ERWK 3$3 is  no  different.  In  fact,  rhinometry  and  OA  therapies.  Higher  NAR  negatively  in  particular,  offers  essential  utility  LPSDFWV 2$ HIÂżFDF\ DQG ORZHU 1$5 when  screening  prospective  oral  LPSURYHV 2$ HIÂżFDF\ &OHDUO\ ZH PXVW appliance  therapy  patients. evaluate  nasal  patency  as  part  of  our  OA   Understanding  the  modern  screening  protocol. approach  to  treating  obstructive   Not  all  patients  referred  for  OAT  will  sleep  apnea  have  had  endoscopic  mandates  examination  to  rule  abandoning  the  out  the  possibility  old  model  of  of  nasal  blockage.  It  treating  patients  behooves  the  astute  in  a  near  vacuum  dental  sleep  medicine  and  pursuing,  physician  to  use  cultivating  rhinometry  to  easily,  and  embracing  quickly,  economically  a  multi-­ and  non-­invasively  disciplinary  evaluate  nasal  collaborative  patency  which  can  medical  GLUHFWO\ LQĂ&#x20AC;XHQFH approach  to  OAT  prognoses  treating  this  for  OSA  sufferers.  Figure 1 Barry C. lateral cephalogram insidious  and  Abnormal  test  results  deadly  pandemic  should  alert  the  condition.  This  medical-­dental  dentist  to  follow-­up  with  ENT  referral  for  model  involves  now   a  quartet  of  expert  paranasal  sinus  evaluation.  Close  modalities  used  both  synergistically  attention  to  this  narrowest  member  of  the  and  adjunctively.

OSA  therapy  quartet  will  increase  OA   A  four  pronged  approach  to  outcomes  and  put  the  ability  to  examine  treating  OSA  patients  leverages  the  initial  few  centimeters  of  our  airway  the  talents  and  expertise  of  aware  into  the  skilled  hands  of  our  dental  sleep  dentists,  ENTs,  allergists  and  colleagues.  sleep  specialists  providing  the   The  following  case  illustrates  the  best  outcomes.  The  four  pronged  utility  of  rhinometry  in  dental  sleep  approach  can  be  likened  to  four  medicine  practice  and  should  also  raise  VSKHUHV RI LQĂ&#x20AC;XHQFH HDFK concern  for  rhinometry  non-­users.  In  intersecting  one  another.  The  four  fact,  the  author  welcomes  all  collegial  VSKHUHV RI LQĂ&#x20AC;XHQFH LQFOXGH WKH discussion  regarding  the  use  of  rhinometry  following  disciplines  and  therapies:  (reno2thdoc@sbcglobal.net). positive  airway  pressure  (PAP),  %DUU\ & SUHVHQWHG WR RXU RIÂżFH UHIHUUHG surgery,  oral  appliance  therapy  and  by  a  physician  for  an  oral  appliance  to  nasal  patency  therapies.  While  the  treat  his  OSA.  Though  pre-­diagnosed  ¿UVW WKUHH DUH KLVWRULFDOO\ UHFRJQL]HG with  moderate  OSA  (AHI  =  27)  and  a  â&#x20AC;&#x153;playersâ&#x20AC;?,  the  fourth,  nasal  patency,  negative  lateral  cephalogram  (See  Figure  is  a  relative  newcomer.

1),  routine  pre-­OAT  rhinometry  did Â

8

DENTAL Â SLEEP Â MEDICINE

UHYHDO VLJQLÂżFDQW QDVDO EORFNDJH RI KLV right  paranasal  sinus  (See  Figure  2).  An  iCAT  scan  was  subsequently  obtained  DQG XSRQ H[DPLQDWLRQ D VLJQLÂżFDQW PDVV was  revealed  (See  Figure  3).  Immediate  referral  to  an  ENT  for  evaluation  was  recommended  prior  to  my  initiating  OAT.  (17 HYDOXDWLRQ FRQÂżUPHG D KXJH DQWUDO choanal  polyp  on  the  right  side  with  erosion  of  the  medial,  maxillary  sinus  wall.  Further,  diffuse  maxillary  and  frontal  sinus  infection  was  noted  on  WKH SDWLHQWÂśV right  side.  7KH VXUJHRQÂśV recommendation  was  for  bilateral  endoscopic  intranasal  total  ethmoidectomy,  left  endoscopic  intranasal  antrostomy  and  right  endoscopic  intranasal  antrostomy  Figure 2 Left and with  tissue  right rhinometric scans removal.  Due,  of Barry Câ&#x20AC;&#x2122;s paranasal in  part,  to  our  multidisciplinary  sinuses. medical-­dental  QHWZRUN %DUU\ÂśV surgery  was  performed  successfully  only  nine  days  after  ENT  referral.  Had  rhinometry  not  been  performed  as  routine  screening  protocol,  OAT  might  have  been  less  than  successful  despite  my  efforts  monitoring  OAT   titration  protocol  for  several  months.  My  delay  in  identifying  this  obvious  and  undiagnosed  nasal  patency  issue  might  have  yielded  much  more  dire  consequences  for  this  patient.  While  general  dentists  cannot Â

Sleep Group Solutions supports the American Sleep Apnea Association and is working in collaboration with there AWAKE program.

SGS Clients if you would like to be a speaker in the A.W.A.K.E program in your area please contact us at info@sleepgs.com and will put you in contact with your local AWAKE Group.

Figure 3: .OTE HUGE MASS OBLITERATING Barry’s right paranasal sinus. A substantial blockage of the paranasal sinuses is easily missed by the dental sleep physician without rhinometry. utilize endoscopic procedures, thank goodness for rhinometry!

Editorial note: In my opinion, electrodiagnostic equipment such as pharyngometry and rhinometry are not an option. .ONINVASIVE AND INEXPENSIVE TESTING OF A PATIENT S AIRWAY is basic to modern dental sleep medicine. Read about the utility of pharyngometry in our next DSM Magazine. Brian.

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9

An Orthodontistâ&#x20AC;&#x2122;s Perspective of Sleep Disordered Breathing Fifty years clinical experience and the evolution of the EMAÂŽ Appliance  By  Donald  E.  Frantz,  DDS

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y  wife  kicks  me  in  the  middle  of  the  night.   She  â&#x20AC;&#x153;claimsâ&#x20AC;?  it  is  to  PDNH PH VWDUW EUHDWKLQJ DJDLQ , suspect  otherwise.  How  many  times  have  we  heard  similar  stories  from  our  patients?   This  was  me  approximately  twenty  years  ago.  After  doing  some  research  I  knew  I  would  not  wear  the  CPAP.  The  Elastic  Mandibular  Advancement  (EMAÂŽ)  appliance  was  created  as  a  treatment  alternative.   The  primary  treatment  mechanism  of  opening  the  bite  and  gently  moving  the  mandible  forward  is  achieved  with  the  use  of  elastic  straps  that  offer  varying  degrees  of  mandibular  advancement.  To  increase  effectiveness,  button  hooks  and  elastic  straps  are  placed  in  the  cheek  area  encouraging  maximum  anterior  tongue  SODFHPHQW %LWH SDGV LQ WKH ÂżUVW PRODU DUHD dictate  vertical  opening.    To  be  patient  friendly,  it  had  to  be  as  small  and  as  noninvasive  as  possible.  The  elastic  straps  allow  unsurpassed  lateral  movement  and  overall  TMJ  comfort.  The  hard  base  of  the  EMAÂŽ  Custom  increases  the  tooth  anchorage,  stabilizing  the  teeth.      There  are  several  things  I  have  observed  during  my  years  of  clinical  experience  that  I  feel  are  important  to  keep  in  mind  when  treating  sleep  disordered  breathing:  ORAL CAVITY SIZE  -­  Orthodontists  have  focused  on  the  size  of  the  oral  cavity,  concerned  that  the  size  of  the  maxilla  and  mandible  is  large  enough  to  allow  straight  teeth  upright  over  basal  bone.    Why  does  oral  cavity  size  matter?      Tongues  have  not  gotten  smaller.   With  a  smaller  oral  cavity,  because  of  evolution,  diet  or  dentistry,  the  crowded  tongue  is  forced  posterior  blocking  the  oral  pharynx.    TOOTH MOVEMENT  -­  Is  a  change  LQ WKH SDWLHQWÂśV ELWH WRRWK PRYHPHQW RU

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DENTAL Â SLEEP Â MEDICINE

a  relocation  of  the  condoyle  in  the  fossa?  With  continual  night  time  mandibular  advancement,  both  are  to  be  considered.    To  discourage  tooth  movement,  orthodontists  must  increase  â&#x20AC;&#x153;tooth  anchorageâ&#x20AC;?.  It  is  easy  to  tip  teeth  with  appliances  constructed  with  soft  liners  and  clasps.  The  EMAÂŽ  appliance,  like  retainers,  is  made  out  of  hard  material  ¿UPO\ KROGLQJ HDFK WRRWK WR SUHYHQW tipping.    It  is  important  to  communicate  to  the  patient  information  about  relocation  of  the  condoyle.  Instruct  the  patient  to  chew  sugar  free  gum  after  removal  of  their  sleep  appliance  each  morning  to  help  recapture  the  condoyle.   SITE OF CLOSURE ADVANCEMENT VS. VERTICAL  'XULQJ D ÂśV VWXG\ (Henke,  Kuna  and  Frantz),  75%  of  the  subjects  tested  closed  at  or  above  the  velophaynx.  All  subjects  closing  below  the  velopharynx  treated  with  the  EMAÂŽ  appliance  had  AHI  reductions  to  less  than  six  events  per  hour.  This  was  achieved  through  mandibular  advancements  and  between  8  and  14  mm  of  vertical  opening  (anterior).   Our  best  responder,  (AHI  reduced  from  101  to  10  events  per  hour)  was  open  14mm.   It  is  believed  that  the  vertical  or  caudal  displacement  brings  the  soft  palate  forward  and  depresses  the  tongue  via  the  anterior  and  posterior  tonsillar  pillars.  I  have  recently  been  increasing  the  vertical  on  patients  with  great  success.   AVOIDING TMJ PAIN  -­  When Â

sleep  disordered  breathing  is  properly  treated,  TMJ  and  other  maladies  seem  to  remediate.  If  you  have  a  TMJ  pain  patient  with  sleep  disordered  breathing,  the  last  thing  you  want  to  do  is  to  lock  their  mandible  forward  in  one  position.    The  EMAÂŽ  appliance  allows  you  to  gradually  move  the  mandible  forward  with  straps  of  varying  lengths  and  degrees  of  ¿UPQHVV PDWFKLQJ WKH VWUDS ÂżUPQHVV to  the  musculature  of  the  patient.  The  elastic  straps  allow  unlimited  lateral  excursion.    Adjusting  the  bite  pads  (with  a  dental  bur)  is  also  important.  If  one  side  is  minutely  higher  than  the  other,  the  high  side  will  create  TMJ  pain.     PATIENT SELECTION  -­  Examination  of  the  oral  cavity  will  give  you  a  world  of  information: Â

s Wear facets on the molars and bicuspids s Scalloped lateral boarder of the genioglossus s Orthodontics and/or bicuspid extractions s Soft palate, short or long webbed shaped with inferior border very close to the posterior wall of oral pharynx s Uvula â&#x20AC;&#x201C; short and pink or long and red (from vibrating all night) s Range of mandibular advancement s Retrognathic s Neck size (18 or larger indicates breathing problem) and BMI (29 or greater is 9 -12 times more likely to have OSA)

 You  can  predict  the  success  of  an  oral  appliance  by  asking  the  patient  to  snore  while  in  a  supine  position.  In  the  middle  of  this  â&#x20AC;&#x153;snoreâ&#x20AC;?  have  them  advance  their  mandible.  If  they  cannot  snore  with  the  mandible  forward,  you  can  predict  success.  If  advancement  alone  does  not  completely  stop  snoring,  have  them  open  and  move  forward  at  the  same  time.  If  this  maneuver  stops  snoring,  this  will  show  the  amount  of  vertical  opening  needed  for  that  particular  patient.   PATIENT TREATMENT  -­  The  speed  with  which  mandibular  advancement  LV DFKLHYHG E\ SODFLQJ VKRUWHU RU ÂżUPHU straps  on  the  EMAÂŽ  Custom  appliance  depends  entirely  on  the  patient.  Pain  (or  lack  thereof)  can  dictate  the  forward  titration  of  the  mandible.  If  mandibular  advancement  is  not  achieving  treatment  goals,  add  vertical  displacement  to  the  mandible.  This  can  be  easily  accomplished  by  adding  orthodontic  acrylic  to  the  bite  pads  after  roughening  with  a  bur.  RELATIONSHIPS WITH SLEEP DOCS  -­  Patients  deserve  the  very  best  treatment  available  which  I  believe  is  achieved  via  a  team  approach  including  a  sleep  specialist  and  a  dentist.  My  expertise  and  interest  lies  in  the  oral  cavity  and  not  in  the  intricacies  of  scoring  polysomnograms.  The  EMAÂŽ  appliance  was  initially  created  to  treat  one  patient.  Over  the  years  it  has  grown  in  popularity  and  we  have  turned  over  worldwide  distribution  to  Myerson,  the  tooth  company.  Should  you  be  interested  in  additional  information,  their  website  is  myersontooth.com/ sleepbetter.  As  always,  feel  free  to  contact  me  through  our  website  at  openairway.com.  My  wife  still  kicks  me  at  night,  but  we  have  ruled  out  breathing  cessation  as  the  motivating  factor  .  .  .  EMAÂŽ  Custom  appliance.  EMAÂŽ  Custom  appliance  straps.  Showing  one  length  of  strap  in  each  of  IRXU ÂżUPQHVVHV (durometers).  Available  in  ¿YH OHQJWKV WRR

Protocol For Snoring Problems Male Age 18 An invaluable addition to appliances and treatment for sleep disordered patients.  By  Brock  Rondeau,  D.D.S.,  I.B.O.,  D.A.B.C.P. Â

W

hen  an  18  year  old  male  FRPHV WR \RXU RIÂżFH DV D new  patient,  what  is  your  protocol?   Are  you  concerned  about  his  weight,  the  size  of  his  neck,  or  the  size  of  his  airway?   When  we  went  to  dental  school,  we  learned  to  take  a  complete  medical  history  including  previous  diseases,  operations,  etc.   We  also  learned  how  to  do  a  periodontal  examination  to  check  for  periodontal  disease,  as  well  as  an  examination  of  the  hard  tissues  for  the  presence  of  dental  FDULHV :H LGHQWLÂżHG PLVVLQJ WHHWK and  considered  the  best  alternatives  to  replace  them.    Most  dental  schools  worldwide  do  not  educate  dentists  on  how  to  identify  patients  who  snore  and  have  obstructive  sleep  apnea.   This  seems  WR EH D VHULRXV GHÂżFLHQF\ LQ RXU eduction  when  you  realize  the  comorbid  factors  of  untreated  obstructive  sleep  apnea,  i.e.  cardiovascular  disease  including  high  blood  pressure,  heart  attacks,  hypercapnia,  cardiac  arrhythmias,  and  strokes.   Other  health  complications  include  type  2  diabetes  DQG JDVWURHVRSKDJHDO UHĂ&#x20AC;X[ *(5'

The  medical  profession,  in  my  opinion,  is  also  not  adequately  educating  medical  doctors  to  play  a  greater  role  in  the  diagnosis  and  treatment  of  these  patients.  Dr.  Wayne  Halstrom,  one  of  the  pioneers  of  obstructive  sleep  apnea  (OSA),   had  to  have  a  serious  motor  vehicle  accident  due  to  excessive  daytime  sleepiness,  before  he  was  sent  for  a  sleep  study,  where  he  was  subsequently  diagnosed  with  obstructive  sleep  apnea.   There  are  three  recommended  treatments  for  patients  who  snore  and  KDYH REVWUXFWLYH VOHHS DSQHD 7KH ¿UVW

treatment  recommended  by  the  medical  profession  is  the  CPAP  device.   I  do  recommend  this  form  of  treatment  for  patients  who  are  diagnosed  with  the  polysomnogram  and  have  severe  OSA.   The  problem  is  that  while  the  CPAP  is  successful  in  the  majority  of  obese  patients  with  severe  OSA,  the  compliance  rate  with  mild  to  moderate  OSA  patients  is  extremely  poor.   The  American  Academy  of  Sleep  Medicine  in  the  January  2006  issue  of  Sleep  made  the  statement  that  for  mild  to  moderate  OSA,  the  oral  appliance  is  WKH ¿UVW WUHDWPHQW RSWLRQ &HUWDLQO\ patient  compliance  is  much  higher  with  the  oral  appliance  which  is  extremely  comfortable.   The  key  to  success  is  to  eliminate  any  airway  obstructions  in  the  nasal,  oral  or  throat  areas  prior  to  the  fabrication  of  the  oral  appliance.  I  believe  that  the  compliance  rate  in  RXU RI¿FH LV RYHU ZLWK WKH RUDO appliance.    The  third  treatment  option  is  the  surgical  approach.   Most  patients  would  prefer  the  oral  appliance  rather  than  the  CPAP  or  surgery.   However,  some  patients  with  enlarged  tonsils  or  adenoids,  deviated  septums,  enlarged  turbinates,  polyps,  tumors  in  the  nasal  area,  enlarged  uvula,  or  low  soft  tissue  palatal  drape  do  require  surgery  for  resolution  of  these  problems.    With  regard  to  the  age  18,  overweight,  male  patient  who  comes  to  \RXU RI¿FH ZKDW ZRXOG \RXU WUHDWPHQW protocol  be  for  this  patient?   Would  you  give  him  an  Epworth  Sleepiness  Scale?   Would  you  measure  his  neck?   Would  you  be  suspicious  of  snoring  or  obstructive  sleep  apnea?   An  early  diagnosis  of  our  younger  patient  could  Continued  on  Page  47 WWW.SLEEPGS.COM

11

Oxygen Is Really Under-Rated!

It is a simple Truth

by Dr. Melody A. Barron

T

his is a common phrase I use LQ P\ RI¿FH ZLWK P\ SDWLHQWV on a daily basis. It gets my point across. The importance of it is emphasized when you consider how long you can go without food and water as compared to how long we can go without oxygen. We think about it on an airplane (you know the mask demonstration and all) or in the hospital.

Look at the havoc that it wreaks ZKHQ ZH GRQ¶W EUHDWK RU R[\JHQDWH HI¿FLHQWO\

Common Co-­Morbidities of SLEEP DISORDERED BREATHING:

s ()'( ",//$ 02%3352% s 342/+% s $)!"%4%3 s )-0/4%.#% s (%!24 $)3%!3% s /"%3)49 s 0!). s (%!$!#(%3 s '%2$ s /6!2)!. #9343 s !$($ s %8#%33)6% $!94)-% 3,%%0).%33 s $%02%33)/. s !.8)%49 s 4-* $)3/2$%2 s !4(%2/3#,%2/3)3

The list goes on and on!

It is a major health problem! The prevalence of the disorder may be underestimated due to fact that the disease is often undiagnosed, but WKH VHULRXVQHVV LV PDJQL¿HG E\ the multitude of health problems that often co-­exist. It is so often overlooked in a patient by physicians and dentists alike. The patient very often is taking one or several medications for one or many of the “symptoms,” but the presence of sleep disordered breathing was totally overlooked. This is one of those

12

DENTAL SLEEP MEDICINE

times when “guilty until proven innocent” by polysomnogram (PSG) is a good rule of thumb. Dentists are in the best position to recognize it if we remember what to look for. We treat patients and their families for years usually on a regular basis. We should keep our eyes and ears open. Are there noticeable changes in the patient and their health. We are doctors after all. It is not all about teeth. You will be the hero for that patient if “YOU” recognize the possibility of this health problem which has serious health implications.

To begin add these simple questions to your health history: 'R \RX JHW WR VOHHS HDVLO\" 'R \RX VWD\ DVOHHS DOO QLJKW" 'R \RX ZDNH UHVWHG" 'R \RX VQRUH"

Other things to look for (I call them my RED FLAGS): 'RHV WKH SDWLHQW WDNH VOHHS PHGLFDWLRQV regularly? (Prescription or OTC) 'R WKH\ IDOO DVOHHS LQ \RXU GHQWDO FKDLU" Are they tired “all the time”? &DQ WKH\ IDOO DVOHHS DQ\ZKHUH RU anytime? (This could be driving.)

When the patient has their mouth open can you see the oropharynx? Does their tongue seem to be everywhere? Does the tongue retract into the oropharynx when they open?

Can you see their uvula?

If there is evidence of bruxism, you should always suspect the presence of sleep disordered breathing. Remember “guilty until proven innocent,” they may destroy the beautiful dental work you just placed. Ask that patient have they ever had a sleep study.

You will be surprised how may have had a sleep study, been prescribed a CPAP and do not use it anymore. The patient will be pleasantly surprised that you recognized that possibility.

The patient can be female, male or a child.

'21¶7 $6680( WKDW D SHUVRQ GRHVQ¶W have sleep apnea to simply treat them for VQRULQJ $V D GHQWLVW ZH DUH QRW TXDOL¿HG E\ licensure to make this diagnosis. Assuming that the patient just snores, is making a

diagnosis! An accurate diagnosis is made by SRO\VRPQRJUDP 36* E\ D TXDOL¿HG VOHHS physician. If the sleep study is negative for the presence of sleep apnea, OK now you know! After this diagnosis is determined, then the process of determining the best method of treatment can be treatment planned. This can be Oral Appliance (OA) therapy, CPAP only or combination of both.

Training and experience in treating with oral appliance therapy along with a good interdisciplinary care relationship with a TXDOL¿HG VOHHS SK\VLFLDQV DUH NH\ WR VXFFHVV for the patient.

(YHQ LI \RX GRQ¶W WUHDW VOHHS DSQHD E\ oral appliance therapy, learn to recognize it DQG UHIHU WR D TXDOL¿HG GHQWLVW RU SK\VLFLDQ The AADSM can help to guide you toward a dentist in your area. You will be shocked that when you start looking at your patients LQ WKLV ZD\ ZKDW \RX ZLOO ¿QG 7KLV FRXOG EH a time when that recognition may save that SHUVRQ¶V OLIH RU VLJQL¿FDQWO\ LPSURYH WKHLU quality of life. Who knows, you could even be looking in the mirror!

Dr. Barron is a graduate of the University of Tennessee College of Dentistry, class of 1992. She graduated with honors, and received the American Association of 2UWKRGRQWLFV¶ DZDUG IRU LQWHUHVW LQ WKH growth and development of the craniofacial complex for that graduating class. Previous to attending UT College of Dentistry, Dr. %DUURQ UHFHLYHG KHU %DFKHORU¶V RI 6FLHQFH degree in Medical Technology and had a ten-­ year career in a hospital medical laboratory.

She has treated patients with general orthodontics since 1994. Dr. Barron has limited her practice to the treatment of Temporomandibular Joint Disorders and Sleep Disorders by Oral Appliance Therapy since 2006. She is owner and director of the TMJ and Sleep Therapy Centre of Memphis.

Dr. Barron holds memberships in the following: Academy of Dental Sleep Medicine(AADSM) American Academy of Sleep Medicine(AASM) International Association of Orthodontics/ American Academy of Functional Orthodontics(IAO,AAFO) American Academy of Craniofacial Pain(AACP) American Academy of Pain Management(AAPM)

90 million people in North America suffer from sleep disorders including insomnia, snoring and sleep apnea. Dentists need to become involved in helping these patients.

Brock Rondeau, D.D.S., I.B.O., D.A.B.C.P.

Diplomate International Board for Orthodontics Diplomate American Board of Craniofacial Pain Over 18,000 Dentists have attended his courses and study clubs Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 1/2008 to 2/28/2012

Oral Appliances to Treat Snoring and Sleep Apnea The Dentist’s Role in Snoring and Sleep Apnea Why You Should Take This Course The American Academy of Dental Sleep Medicine in the January 2006 issue of “Sleep” recommends the use of oral appliances as the first treatment option for patients with mild to moderate sleep apnea. This presents a tremendous opportunity for dentists to become involved in the ever increasing new field of sleep disorders.

Course Content Ƈ Sleep Apnea Symptoms and Causes Ƈ Sleep Examinations and Forms Ƈ Hospital Sleep Studies (Polysomnogram)

2009 -­ 2010 Course Locations

Toronto, ON August 28 & 29, 2009 San Francisco, CA December 12 & 13, 2009 Toronto, ON January 9 & 10, 2010 Chicago, IL April 24 & 25, 2010

Course Fee Doctors $995 / Staff $395 Course fee includes extensive 288 page course manual and article CD. Earn 14 CE Hours.

Ƈ Home Sleep Studies Ƈ Pharyngometer to Evaluate Pharyngeal Airway Ƈ Rhinometer to Evaluate Nasal Airway Ƈ Different Sleep Cycles Ƈ Summary of Sleep Disorders Ƈ CPAP -­ Continuous Positive Air Pressure Ƈ Surgical Solutions for Sleep Apnea Ƈ Comparison of Different Oral Appliances Ƈ References and Articles Ƈ Marketing Your Sleep Practice

WWW.SLEEPGS.COM

13

HSTreview

Home Sleep Testing; %HQHĂ&#x20AC;WLQJ 6OHHS &HQWHUV Sleep facilities cannot expand rapidly enough to meet the demand of patients who need a sleep study performed.  by  Randall  L.  Haupt,  RPSGT

I

n  March  of  2008,  home  sleep  testing  (HST)  was  approved  by  Medicare  to  diagnose  obstructive  sleep  apnea  (OSA).  While  sleep  centers  have  not  placed  much  impetus  on  using  HST  as  an  extension  of  their  practice,  instituting  this  service  can  greatly  EHQHÂżW WKHLU DELOLW\ WR FDSWXUH WKRVH patients  that  have  a  high  probability  for  OSA,  target  those  patients  unwilling  to  have  a  sleep  study,  make  inroads  to  those  that  remain  undiagnosed,  incorporate  HST  into  a  sedated  apnea  management  program,  and  ultimately  save  their  patients  money.  As  a  result,  sleep  center  revenue  is  maximized  with  the  increase  in  PAP  titration  referrals  received  on  the  back  end  of  portable  studies.    According  the  American  Academy  of  Sleep  Medicine,  the  estimated  backlog  of  sleep  centers  is  between  two  and  three  weeks.  Sleep  facilities  across  the  nation  simply  cannot  expand  rapidly  enough  to  meet  the  demand  of  patients  who  need  a  sleep  study  performed.  Furthermore,  sleep  centers,  in  particular  hospital-­ based  ones,  are  slow-­moving  or  resistant  to  increasing  bed  capacity  as  it  is  costly  and  can  even  involve  relocating  the  sleep  center  to  a  different  area  of  the  hospital.  Using  a  portable  sleep  system  like  the  EmblettaÂŽ  has  allowed  our  facility  to  rapidly  and  inexpensively  increase  the  number  of  patients  we  can  diagnose  with  OSA.  In  turn,  we  have  been  able  to  use  the  available  sleep  rooms  to  perform  CPAP  titrations.    Of  140  portable  studies,  80  of  the  104  with  an  AHI  greater  than  15  returned  for  CPAP  and  are  currently  on  therapy.   This  resulted  in  a  revenue  increase  of  over  $182,000 Â

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DENTAL Â SLEEP Â MEDICINE

for  the  2008  year.   HST  has  been  able  to  reduce  the  time  it  takes  a  patient  to  get  onto  treatment  by  two  weeks.  Many  will  argue  that  the  split  night  study  is  the  fastest  route  to  CPAP  therapy.   While  in  theory  this  may  sound  logical,  the  reality  is  that  no  national  standard  for  splitting  patients  exists  and  sleep  labs  have  set  their  own  criteria  for  initiating  CPAP  therapy.  This  increases  the  potential  that  the  patient  will  require  a  second  QLJKWÂśV VWD\ IRU WKH WLWUDWLRQ VWXG\  Great  successes  have  been  achieved  in  capturing  those  patients  who  are  unwilling  to  spend  the  initial  night  in  the  sleep  lab  due  to  various  reasons,  including  the  disbelief  that  they  have  sleep  apnea.   When  faced  with  the  facts  that  they  have  a  serious  condition  that  warrants  treatment,  patients  are  more  apt  to  spend  the  night  in  the  sleep  lab  for  treatment.  For  the  past  year,  we  have  used  the  EmblettaÂŽ  on  patients  who  have  cancelled  or  been  a  no  show  for  their  in-­lab  NPSG  twice.   They  are  referred  back  to  their  physician  and  an  HST  is  offered  on  the  same  day.   The  treating  physician  sends  them  to  the  sleep  center  as  a  walk-­in  and  the  patient  wears  the  portable  sleep  device  home  that  night.  Setting  up  the  patient  is  quick  and  easy  and  requires  approximately  20  PLQXWHV RI WKH VOHHS WHFKQRORJLVWÂśV WLPH The  EmblettaÂŽ  integrates  well  with  their  lab-­based  REMLogicâ&#x201E;˘  data  acquisition  system  making  downloading  data,  scoring  of  the  data,  and  report  generation  simple  DQG HIÂżFLHQW 7KH FRVW SHU KRPH VOHHS study  is  minimal  and  most  of  the  studies  have  yielded  good  data  to  interpret  and  make  a  diagnosis.  The  EmblettaÂŽ  is  well  put  together  and  breakage  has  not  been  an  LVVXH 3DWLHQWV ÂżQG LW YHU\ HDV\ WR SODFH WKH XQLW RQ WKHPVHOYHV DQG GR QRW ÂżQG WKH device  too  cumbersome.     The  vast  majority  of  patients  have  been  receptive  to  having  their  study  in  the  home.  The  attractiveness  of  price  and  convenience  has  made  it  popular.  The  EHQHÂżWV RI KRPH VOHHS WHVWLQJ DUH WKDW LW

is  cost  effective  and  easy  to  employ  into  the  sleep  center  practice.  The  patient  EHQH¿WV IURP WKH UHGXFHG FRVW DQG EHLQJ able  to  rest  comfortably  in  their  own  home.  Some  issues  do  exist  with  respects  to  data  collection  and  appropriate  apnea/ hypopnea  index  (AHI)  severity  scale  values,  equipment  loss,  and  the  potential  for  other  sleep  disorders  to  exist  in  light  of  a  thorough  consultation  with  a  sleep  VSHFLDOLVW +RZHYHU WKH EHQH¿WV RI +67 far  outweigh  the  negatives  and  potential  drawbacks.  Incorporating  home  sleep  testing  into  the  sleep  lab  can  make  your  organization  more  robust  by  increasing  the  ability  to  screen  those  patients  for  OSA  in  at-­risk  areas  such  as  those  patients  undergoing  surgery  under  anesthesia  which  can  help  tremendously  with  a  safe  post-­operative  recovery  plan.   As  sleep  medicine  and  polysomnography  evolves,  a  future  for  home  sleep  testing  is  ¿UPO\ HQWUHQFKHG LQ WKH IXWXUH DQG VOHHS centers  should  explore  HST  as  a  way  to  increase  referrals,  revenues,  and  new  patient  populations  in  a  simple  and  cost  effective  way.  As  sleep  professionals,  we  need  to  embrace  this  new  technology  and  exploit  its  potential  to  reach  everyone  that  so  desperately  needs  treatment  for  OSA. Randall L. Haupt, RPSGT $IRECTOR 3LEEP $ISORDERS AND .EURODIAGNOSTICS #ENTER Jennie Stuart Medical Center, Hopkinsville, Kentucky OFlCE s CELL Embletta is a registered trademark of Embla Systems, Inc. RemLogic is a trademark of Embla Systems, Inc.

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DENTAL SLEEP MEDICINE

Rondeau Seminars Jointly Offered With Sleep Group Solutions For More Information Call:

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MDInterview

Dr. Michael Lucia Triple board certified physician with both academic and private practice roots and strong ties to medical education. He is the Medical Director and lead physician at Sierra Pulmonary and Sleep Institute, a pulmonary function lab, comprehensive pulmonary rehabilitation facility, four bed AASM-accredited sleep lab, complete cardiopulmonary stress testing lab and allergy clinic.

I Â

sat  down  with  Dr.  Lucia  to  ask  him  a  few  questions  that  I  thought  ZRXOG UHDOO\ EHQH¿W WKH Dental  Sleep  Medicine  community  as  a  whole  and  here  are  his  answers.

DSM:   What  was  your  ¿UVW H[SHULHQFH ZLWK GHQWDO sleep  medicine?

'U /XFLD   My  fellowship  training  was  at  Wake  Forest,  which  had  a  dental  school  across  the  VWUHHW $IWHU WKH LQĂ&#x20AC;XHQFH with  the  dental  students  and  the  program,  I  had  a  high  level  of  interest  at  a  multidisciplinary  level.  At  an  annual  national  sleep  meeting,  I  enrolled  in  the  dental  lectures  and  spent  the  day  learning  about  oral  appliance  therapy  and  dental  sleep  medicine.  After  hearing  the  lectures,  I  decided  that  dentistry  was  an  important  facet  of  sleep  medicine DSM:   How  did  you  become  involved  with  Dr.  Allman,  a  dentist  in  Reno,  NV? 'U /XFLD   I  started  practice  in  Sparks  in  2000,  looking  for  individuals  that  ZRXOG EH D JRRG ³¿W´ for  referral  sources  and Â

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trusted  colleagues.  In  2005,  Dr.  Allman  contacted  me  as  he  was  developing  his  sleep  practice  and  I  decided  that  he  was  a  very  well  educated  dentist  that  I  would  feel  comfortable  referring  my  patients  to.  Eventually  we  developed  the  â&#x20AC;&#x153;Sierra  Sleep  Group,â&#x20AC;?  which  is  a  study  group  of  medical  professionals  of  many  ¿HOGV WKDW PHHWV PRQWKO\ WR GLVFXVV connections  and  advancements  in  our  ¿HOGV

best  way  for  a  dentist  to  initiate  a  relationship  with  a  sleep  specialist,  such  as  yourself?

'U /XFLD    Having  a  practice  representative  can  be  very  helpful,  you  can  have  them  drop  off  cards  and  or  letters  to  declare  intentions  ¿UVW 7KH\ FDQ VHW XS WKH PHHWLQJ IRU the  dentist  and  the  MD.   Your  staff  can  represent  you  very  well,  and  may  EH DEOH WR ³¿OWHU´ RXW GRFWRUV WKDW \RX DSM:   Tell  me  a  little  more  about  this  may  not  want  to  work  with  because  of  study  group;Íž  how  would  another  doctor  any  number  of  factors  such  as  staff,  or  dentist  go  about  starting  something  FOHDQOLQHVV RIÂżFH DWPRVSKHUH HWF 7KH\ similar? can  do  a  sort  of  â&#x20AC;&#x153;screeningâ&#x20AC;?  and  set  up  PHHWLQJV ZLWK TXDOLÂżHG GRFWRUV WKDW \RX 'U /XFLD   would  want  to  work  with.      +HUHÂśV ZKDW ZH GLG ZH VWDUWHG ZLWK $V WKH GHQWLVW GR \RXU KRPHZRUN ÂżUVW dentist,  sleep  specialist  and  an  ENT  and  sell  the  fact  that  you  are  a  resource.  physician  and  built  from  there.  It  is  Use  an  evidence  based  vs  retail  important  to  wait  for  the  right  people  to  DSSURDFK DQG GRQÂśW EH LQ WKLV EXVLQHVV EH LQYROYHG GRQÂśW EH LQ D KXUU\ WR EXLOG to  make  a  quick  buck,  you  will  not  get  the  group.  Hand  pick  people  that  you  referrals.   can  develop  a  professional  relationship   Try  not  to  â&#x20AC;&#x153;oversellâ&#x20AC;?  or  use  non  with  and  that  you  can  feel  comfortable  VFLHQWLÂżF EDVHG LQIRUPDWLRQ WR WDON WR sending  your  patients  to.  From  the  the  physician.  Use  data  that  can  back  up  network  that  is  built  between  the  what  you  do,  â&#x20AC;&#x153;no  wallet  biopsies.â&#x20AC;?  What  members,  you  can  effectively  refer  and  \RX GR LQ \RXU RIÂżFH DQG KRZ \RX WUHDW co-­treat  in  a  much  more  collegial  way.  \RXU SDWLHQWV UHĂ&#x20AC;HFWV RQ \RXU GHFLVLRQ Dentists  are  not  outliers,  they  should  making  ability.  Remember,  everything  be  an  integrated  part  of  the  healthcare  WKDW \RX GR UHĂ&#x20AC;HFWV RQ \RXU RIÂżFH team.  What  grows  from  the  study  group  No  â&#x20AC;&#x153;free  exams,â&#x20AC;?  cheap  interactions  LQWHUDFWLRQ LV SDWLHQW FRQÂżGHQFH DQG are  not  wanted  referral  sources.  It  is  DOVR FRQÂżGHQFH EHWZHHQ SK\VLFLDQV very  important  to  market  yourself  as  The  main  goal  was  to  create  interaction  a  professional   you  have  been  through  ZLWK FROOHJLDO ÂżHOGV WKDW GRQÂśW FURVV GHQWDO VFKRRO DQG \RX VKRXOG UHĂ&#x20AC;HFW LW paths  very  often.  We  meet  once  a  month,   Remember,  we  need  you  as  a  resource  DIWHU ZRUN PHHWLQJV DIWHU KRXUV DOORZ DV PXFK DV \RX QHHG XV 'RQÂśW EH for  communication  that  cannot  happen  apprehensive  about  meeting  your  sleep  during  the  day  with  patients. specialist,  even  if  the  relationship  does  not  develop  right  away,  be  patient.  If  DSM:   What  would  you  say  is  the  you  presented  yourself  well  and  made  a Â

solid  impression,  when  they  need  you,  (and  they  will)  your  name  will  be  on  the  top  of  their  list.  DSM:   How  do  you  feel  the  collaboration  between  dentists  and  MD  Sleep  Specialists  will  affect  the  OSA  population  as  a  whole?   'U /XFLD   Healing  for  all  is  affected  by  sleep.  Dental  disorders  are  worse  with  sleep  disorders,  poor  immune  function  is  also  associated  with  sleep  disorders.  Who  else  is  better  to  capture  more  patients  with  simple  screening  than  the  dentist?  More  patient  awareness  =  more  treatment  and  fewer  problems  as  a  whole.  Dentists  can  provide  great  input  as  a  trusted  advocate  for  that  patient.   Dentists  that  are  treating  OSA  without  an  MD  on  their  team  may  be  missing  huge  pieces  of  the  puzzle  that  we  are  more  equipped  to  deal  with.  As  a  sleep  center  we  have  the  ability  to  treat  any  co-­morbid  factors  that  the  patient  may  EH GHDOLQJ ZLWK DQG E\ GH¿QLWLRQ DOO OSA  is  accompanied  by  co-­morbid  factors.

DSM:   You  made  a  distinction  between  Sleep  Centers  and  Sleep  Labs.  can  you  tell  me  about  the  differences?   What  should  a  dentist  look  for?

standard  that  you  want  to  make  sure  that  you  look  at  is  either  JCAHO  (Joint  Commission  on  Accreditation  of  Healthcare  Organizations)  accreditation  or  AASM  (American  Academy  of  Sleep  Medicine)  accreditation.  JCAHO  does  not  have  clinical  standards.  They  check  for  HIPPA  compliance,  licensing  compliance,  health  and  safety  requirements  compliance,  etc.  They  are  a  hospital  accreditation  commission  that  GRHV QRW KDYH DQ\ VSHFL¿F VWDQGDUGV for  sleep  medicine.   For  AASM  accreditation,  the  center  has  to  meet  about  31  pages  of  criteria,  from  clinical  VSHFL¿FDWLRQV OLNH ZKR WHVWV ZKR UHDGV studies,  how  technicians  are  trained,  etc.  to  computer  monitor  size  and  a  gamete  of  other  criteria.  It  is  a  much  more  GLI¿FXOW SURFHVV DQG LV UHHYDOXDWHG RQ a  continuous  basis.  All  of  the  guideline  criteria  are  on  the  AASM  website,  should  anyone  want  to  see  them.   We  are  an  AASM  accredited  Sleep  Center,  so  we  meet  all  of  those  standards.

DSM:   Finally,  do  you  have  any  advice  for  dentists  who  are  establishing  their  relationships  with  sleep  specialists  and  starting  their  sleep  practice?

'U /XFLD   My  advice  would  be  to  jump  into  this,  wholeheartedly.  Do  your  research,  GHYHORS D TXDOLÂżHG PXOWLGLVFLSOLQDU\ team  and  go  for  it!  Standards  are  changing  and  medicare  is  helping  the  process.  The  accreditation  process  is  changing  and  evolving,  look  for  younger  doctors  who  are  fellowship  trained,  they  will  have   dental  sleep  medicine  education.   Home  studies  are  a  wave  of  the  future  and  they  are  coming  to  be  a  huge  part  of  this  market,  for  both  dentists  and  sleep  specialists,  home  studies  are  a  very  valuable  tool.  Also,  when  working  with  sleep Â

specialists,  follow  up  questions  are  important  to  ask,  if  they  do  follow  up  with  their  CPAP  patients,  they  will  need  you  because  of  non-­compliance.  Every  0' VKRXOG ZDQW WR VROYH SUREOHPV they  need  another  option,  and  they  will  eventually  try  Oral  Appliance  Therapy  once,  impress  them  from  the  beginning.    Look  at  CPAP  compliance  with  your  sleep  specialist,  use  numbers  that  show  how  much  the  patients  are  wearing  their  CPAP.  The  Medicare  requirement  is  4  hours  per  night,  4  or  more  nights  per  week  between  day  30  and  90.  You  can  ask  for  their  compliance  statistics  and  go  from  there  (They  should  have  at  least  an  estimate).   DME  companies  have  to  prove  that  the  patient  is  wearing  the  CPAP   also  the  sleep  specialist  must  see  the  patient  to  document  the  subjective  improvement  within  that  30-­90  days.  Labs  that  are  not  trained  in  these  requirements  will  suffer  because  they  ZLOO KDYH &3$3œV WDNHQ DZD\ GXH WR QRQ compliance.  Dentists  should  know  these  guidelines  and  practice  the  same  things  with  visit  protocol  and  follow  up.    The  changes  on  the  horizon  will  EHQH¿W GHQWLVWV LQ WKH VOHHS ¿HOG DQG you  should  be  there  when  it  is  time!

Thank  you  so  much  to  Dr.  Lucia  for  his  expertise  and  his  candid  answers.  We  hope  that  this  article  will  give  you  a  little  insight  as  to  what  the  sleep  specialist  in  your  area  is  thinking,  and  how  you  can  start  developing  your  multidisciplinary  team.

'U /XFLD  A  Sleep  Center  is  comprehensive,  there  PXVW EH D ERDUG FHUWLÂżHG SK\VLFLDQ running  the  center.  They  must  have  a  clinic  to  treat  all  types  of  sleep  disorders.  They  also  treat  both  adult  and  pediatric  patients.  A  Sleep  Lab  does  testing  on  adults  OR  children,  not  both.  They  do  not  have  a  full  clinic,  they  only  treat  airway  disorders.  This  means  no  treatment  of  things  like  Narcolepsy,  allergies,  cardiac  function  etc.  There  LV D ERDUG FHUWLÂżHG physician  reading  the  studies  at  both,  however,  at  the  sleep  center,  that  physician  can  actually  treat  anything  that  is  found.   I  would  recommend  a  Sleep  Center,  Dr. Michael Luciaâ&#x20AC;&#x2122;s new, custom designed, state-of-the-art facility Sierra Pulmonary Sleep Institute has nearly personally.   7,000 square feet of clinical space.  The  other  accreditation Â

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Dental Sleep Medicine

No, Thanks Mister, Iâ&#x20AC;&#x2122;ll Take Vanilla!

By  Dr.  Dan  TachÊ,  DDS

REWARD (love, respect and gratitude of your patient) for identifying the often-missed cause of these common dental PROBLEMS AND DO ./4 TELL ME ABOUT LEMON SUCKING OR EXCESsive intake of soda pop, or stress and please, oh please, for the love of everything that is holy, not loss of anterior guidance or malocclusion!

I

f  any  of  your  patients  look  like  these  and  tell  you  that  they  are  aware  of  clenching,  grinding,  headaches  in  the  morning,  sensitive  teeth,  excessive  daytime  sleepiness,  GERD,  sleep  poorly  and  snore,  then  you  owe  it  you  your  patients  (and  family  members  yet)  to  get  hold  of  some  of  the  concepts  in  this  brief  article  and  if  you  are  a  DENTAL  SPECIALIST  (yes,  YOU)  or  just  a  walking  down  the  street  general  dentist,  just  minding  your  own  business,  ditto-­you  have  to  know  this  stuff!  So,  for  all  of  you  out  there  who  are  doing  ok  without  the  hassle  of  having  to  learn  something  new  that  smacks  of  medicine,  perhaps  a  little  more  information  might  help.  Like  many  of  you,  I  too  am  a  general  dentist,  and  I  did  not  go  looking  for  this,  in  fact,  I  am  not  a  writer,  never  had  a  Journalism  course,  so  why  am  I  even  pounding  the  keys  and  doing  this?  I  am  editorializing  and  I  just  looked  that  word  up.  Well,  I  had  my  epiphany  and  got  religion  and  now  I  have  this  burden  to  inform  my  fellow  colleagues  that  in  fact,  ALL  of  us  are  staring  this  stuff  in  the  face  nearly  every  day  and  ALL  DAY  LONG  and  if  you  are  treating  the  effects  of  sleep  and  breathing  problems  and  unaware  of  LW 'LGQÂśW \RX HYHU DVN \RXUVHOI :+< or  HOW  it  is  that  people  wear  their  front  teeth  down  the  way  that  some  of  them  do.  Knocking  off  all  manner  of  enamel  and  then  our  veneers  and  crowns?   You  must  have  asked  yourself  that  question  an  LQÂżQLWH QXPEHU RI WLPHV :HOO , ZLOO WHOO you  what  a  lot  of  us  think  about  that  at  the Â

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DENTAL Â SLEEP Â MEDICINE

end  of  this  article  but  for  now,  just  a  little  more  background  information.    This  whole  Dental  Sleep  Medicine  WKLQJ KH\ ,œP D JHQHUDO 'HQWLVW ,œOO MXVW send  this  stuff  out  when  it  shows  up  in  P\ RI¿FH :KRD KROG RQ WKHUH ELJ JX\ not  so  easy.  Whether  you  realize  it  or  not,  \RX DUH DOUHDG\ LQ WKH ¿JKW EXW \RX FDQQRW ¿JKW \RXU ZD\ RXW RI WKLV\RX PXVW GHDO with  it!  Well  wait,  perhaps  I  am  being  a  bit  arrogant,  so  allow  me  impart  some  information,  perhaps  you  might  see  them  as  insights,  as  I  did  and  if  and  when  you  GET  IT,  you  may  get  a  little  excited  too.

3HUKDSV WKH ÂżUVW SRLQW WKDW , ZRXOG OLNH to  make  is  that  having  an  understanding  of  Dental  Sleep  Medicine  is  not  merely  for  the  few  who  are  willing  to  treat  people  with  sleep  apnea  who  cannot  tolerate  Continuous  Positive  Air  Pressure  (CPAP)  machines.  No,  it  is  far  more  basic  than  that.  Most  patients,  who  come  to  us,  do  so  because  they  oftentimes  have  complaints  about  the  effects  of  sleep  disordered  breathing  (SDB)  and  for  many  of  those  complaints,  a  patient  may  quite  often  seek  help  from  a  dentist  totally  unaware  that  these  problems  are  a  result  of  UNDIAGNOSED  SDB!  The  reason  that  the  patient  is  suffering  from  signs  and  V\PSWRPV LQ WKH ÂżUVW SODFH LV EHFDXVH QRW only  is  he  or  she  unaware  that  the  problem  exists  but  so  too  is  the  physician  and  dentist.   PREVALENCE   Sleep  disorders  are  a  very  common Â

problem  for  many  of  our  patients,  both  the  (very)  young  and  old.  Epidemiological  and  cohort  studies  conducted  in  Wisconsin,  Pennsylvania,  and  Spain  show  estimated  prevalence  of  obstructive  sleep  apnea  upwards  of  28%  in  adults1  and  as  high  as  18%  in  a  pediatric  populations2  and  that  does  not  account  for  the  prevalence  of  just  upper  airway  resistance  (aka:   benign  snoring)  that  in  some  studies  show  a  prevalence  of  38%3.  So,  why  all  of  the  interest  and  hoop-­la  about  this?  4XHVWLRQ   Sure,  I  feel  sorry  for  the  kids  and  adults  who  have  this  problem  but  honestly,  why  should  I  care  about  it?  I  have  so  much  information  to  keep  abreast  of  like  new  cements,  resin  systems,  the  ODWHVW HQGRGRQWLF ¿OHV WKH ODWHVW &(5(& software,  that  new  laser  I  need  (want)  and  the  list  goes  on.  $QVZHU   the  fact  is  that  some  or  many  common  dental  problems  are  clinical  manifestations  of  sleep  and  breathing  problems  and  if  you  are  treating  the  effects  but  ignoring  the  cause,  you  are  neglecting  to  recognize  that  SDB  can  be  life-­ threatening.  A  number  of  recent  articles  show  that  snorers  with  acute  myocardial  infarction  more  often  died  during  the  night  than  non-­snorers  and  that  smoking,  not  even  habitual  smoking  was  an  additional  ULVN IDFWRU IRU IDWDO ¿UVW WLPH P\RFDUGLDO infarction4.

BRUXISM: Â Â A Â RISK Â FACTOR Â FOR Â SLEEP Â DISORDERED Â BREATHING

As  the  above  photos  imply,  SLEEP  BRUXISM  is  a  fairly  common  manifestation  of  a  sleep  and  breathing  problem,  in  fact,  it  is  referred  to  as  a  parasomnia  of  sleep,  an  intrusion  into  normal  sleep,  like  sleep  walking  and  talking  etc.  In  fact,  it  is  cited  as  the  3rd  most  frequent  parasomnia  of  sleep.  Additionally,  often  reported  by  patients  who  brux  are  the  triumvirate  of  symptoms  ZKLFK VKRXOG EH D UHG Ă&#x20AC;DJ WKDW WKHUH LV more  going  on  than  the  need  for  a  free  gingival  graft  or  an  equilibration,  namely:    â&#x20AC;&#x153;â&#x20AC;Śsubjective  sense  of  choking  and  blocked  breathing  during  sleepâ&#x20AC;Śâ&#x20AC;?   â&#x20AC;&#x153;â&#x20AC;Śnocturnal  awakeningsâ&#x20AC;Śâ&#x20AC;?,  and   â&#x20AC;&#x153;â&#x20AC;Śmorning  headachesâ&#x20AC;Śâ&#x20AC;?  5    If  these  common  clinical  complaints  are  not  being  reported  by  your  patients,  you  are  either  working  on  a  Typodontâ&#x201E;˘  or  you  DUH VLPSO\ QRW VXIÂżFLHQWO\ DZDUH RI WKH magnitude  or  prevalence  of  the  problem.    At  the  2008   American  Academy  of  Sleep  Medicine  annual  meeting  in  Baltimore,  Md,  a  seminal  poster  presentation  was  made  by  a  fellow  dentist  out  of  Houston,  Texas,  Dr.  Ron  S.  Prehn Â

and  his  co-­author  and  researcher,  Jerald  H.  Simmons,  MD,  also  of  Houston.  In  my  view  and  that  of  many  who  attended  as  ZHOO LW ZDV WUXO\ D ODQGPDUN SUHVHQWDWLRQ the  culmination  of  a  work  well  done.   The  essence  of  their  research  was  summed  up  in  the  poster  which  you  can  see  below.  6      Wow,  does  this  do  for  you,  what  it  did  IRU PH" ,I QRW WKDWÂśV RN EXW DV D ORQJ WLPH clinician  trying  to  help  his  TMD  patients,  this  good  work,  well,  to  say  the  very  least,  rocked  my  world.  This  made  sense  to  me  and  explains  why  the  body  will  expend  so  much  energy  to  perform  such  a  seemingly  senseless  and  destructive  maneuver  .  .  .  getting  the  jaw  forward  and/or  side  to  side,  helps  to  stabilize  the  airway  so  that  we  can  EUHDWKH EHWWHU 7KDW ÂżQDOO\ H[SODLQHG WR PH why,  some  bruxers  might  brux.  As  you  become  more  aware  of  the  interface  between  the  medical  problem  of  SDB  and  dental  manifestation  because  of  this  â&#x20AC;&#x153;compensatoryâ&#x20AC;?  mechanism,  it  will  begin  to  clear  a  lot  of  things  up  for  you.  You  will  understand  that  we  play  a  bigger  role  in  the  overall  health  of  our  patients,  so  when  Mrs.  Jones  comes  in  and  she  you  see  changes  in  her  health  such  as  elevated  blood  pressure,  and  you  note  that  she  is  now  taking  SSRIs  and  alas  and  alack  you Â

1. Patient falls asleep.

2. Mandible falls back bringing the back of the tongue with it.

3. This triggers a series of events causing a reflexive attempt to open up the airway by increasing masseter tone.

This brings the mandible forward and in many patients improves respirations.

5. Unfortunately over time this can lead to anterior tooth wear and Symptoms of PAIN IN THE 4-* AND OTHER PROBLEMS SUCH AS !.4%2)/2 4//4( 7%!2 AND -/2.).' (%!$!#(%3 â&#x20AC;&#x153;We postulate that Sleep Bruxism (SB) is a compensatory mechanism of the upper airway to help overcome upper airway obstruction by activation of the clenching muscles which results in bringing the mandible, and therefore the tongue, forward.â&#x20AC;?

begin  to  see  the  erosions  and  attrition  and  recession  not  as  an  occlusal  problem  but  a  manifestation  of  a  survival  problem,  that  of  maintaining  or  regaining  an  airway.    It  may  be  unnecessary  to  add  that  the  rule  is  that  there  are  no  hard  rules  and  that  exceptions  are  the  norm,  and  certainly   stress  and  anxiety  are  common  risk  factors  for  sleep  bruxism  too  but  when  you  have  ruled  them  out,  remember  that  sleep  bruxism  and  the  gaggle  of  problems  and  symptoms  associated  with  it,  rarely  occurs  alone  and  research  has  shown  it  can  be  centrally  mediated  because  our  patients  are  in  survival  mode  when  SDB  is  the  reason  5,  7,  7,  8.  So  when  your  peri-­  or  post-­menopausal  happily  married  grandmother-­to-­be  female  patient9  or  obese  but  fat  and  sassy  unstressed  male  patient  comes  in  for  an  a  recall  visit  complaining  of  headaches  in  the  am  and  â&#x20AC;&#x153;TMJâ&#x20AC;?  and  you  notice  that  they  are  now  on  beta  blockers,  please,  ask  them  a  simple  question:   â&#x20AC;&#x153;Do  You  Snoreâ&#x20AC;?  and  if  either  one  of  them  says  yes,  well,  you  may  be  on  the  brink  of  a  breakthrough  that  may  impact  his  or  her  life  forever.   :KHQ \RX ÂżQDOO\ JHW RQH \RX PD\ want  to  get  them  in  front  of  a  dentist  who  has  some  credentials  in  Dental  Sleep  Medicine  or  refer  them  to  a  Medical  Sleep  Specialist.  However,  there  is  an  excellent  screening  protocol  (among  many)  which  has  been  shown  to  be  predictive  of  SDB  and  it  is  called  the  Adjusted  Neck  Circumference  screening  for  Obstructive  Sleep  Apnea10  .  I  am  attaching  a  copy  of  a  handout  made  from  that  article.   I  suggest  that  you  obtain  the  article  and  anything  written  by  Ward  Flemons,  MD.  It  can  be  obtained  from  the  New  England  Journal  of  Medicine  for  a  fee  but  it  is  available  all  over  the  Internet  for  free.  There  are  many  resources  for  growing  in  your  understanding  of  (Dental)  Sleep  Medicine.  The  world  we  live  in,  professionally,  cannot  remain  â&#x20AC;&#x153;vanillaâ&#x20AC;?  if  we  are  to  serve  our  patients.  Sure,  you  can  make  a  buck  living  with  vanilla  while  our  patients  struggle.  Hey,  make  mine  â&#x20AC;&#x153;Rocky  Roadâ&#x20AC;?,  the  Road  Less  Traveled.  I  am  up  for  the  challenge,  how  about  you?    Sleep  apnea  should  be  suspected  in  patients  who  are  obese,  hypertensive,  habitual  snorers,  with  excessive  daytime  sleepiness.    In  a  primary  care  setting,  patients  with  a Â

Continued  on  Page  22 WWW.SLEEPGS.COM

21

Dental Sleep Medicine EPWORTH SLEEP TEST

How  likely  are  you  to  doze  off  or  fall  asleep  in  the  following  situations,  in  contrast  to  just  feeling  tired?  Use  the  following  scale  to  choose  the  most  appropriate  number  for  each  situation:  0  -­  Would  never  doze 1  -­  Slight  chance  of  dozing 2  -­  Moderate  chance  of  dozing 3  -­  High  chance  of  dozing SITUATION:  CHANCE  OF  DOZING  1.  Sitting  and  reading          ___ 2.  Watching  television         ___ 3.  Sitting,  inactive  in  a  public  place      (i.e.  A  theater  or  a  meeting)        ___ 4.  As  a  passenger  in  a  car  for  an  hour      without  a  break          ___  5.  Lying  down  in  afternoon  when      circumstances  permit         ___  6.  Sitting  and  talking  to  someone         ___  7.  Sitting  quietly  after  lunch      without  alcohol          ___  8.  In  a  car,  while  stopped  for  a  IHZ PLQXWHV LQ WUDI¿F

BBB TOTAL EST SCORE: Â Â

Â

     ___ Â

 The  Epworth  Sleepiness  Test  is  a  tool,  not  a  diagnosis.  However,  if  your  ESS  score  is:  1-­6  Obstructive  Sleep  Apnea  is  Less  Likely   7-­8  Your  Score  is  Average   RU +LJKHU   Obstructive  Sleep  Apnea  is  More  Likely  and  You  Should  Seek  the  Advice  of  a  Sleep  Specialist  Â

$GYDQFHG 6OHHS 6HPLQDU 2FWREHU WK GWDFKH#XQLYHUVLW\ GHQWDO FRP 22

DENTAL Â SLEEP Â MEDICINE

No, Thanks Mister, Iâ&#x20AC;&#x2122;ll Take Vanilla!

By  Dr.  Dan  TachÊ,  DDS

Continued  from  Page  19 high  risk  of  sleep  apnea  were  those  who  met  two  of  the  following  three  criteria:  Â&#x2021; Snoring Â&#x2021; 3HUVLVWHQW GD\WLPH VOHHSLQHVV RU GURZVLQHVV   while  driving, Â&#x2021; 2EHVLW\ RU K\SHUWHQVLRQ.    Combinations  of  clinical  variables  such  as  neck  circumference  or  body-­mass  index,  snoring,  reports  of  nocturnal  breathing  disturbances,  and  hypertension  have  been  used  to  predict  which  patients  will  have  abnormal  results  on  sleep  tests.   The  sensitivity  of  this  approach  can  be Â

s

s

ANC* = NC + H(4) + S(3) + C/G(3) (H: Hypertension; S: Snoring; C/G: Choking/Gasping)

Less Than 43 Low Probability 43-48 Intermediate Probability Greater Than 38 High Probability * Adjusted Neck Circumference

KLJK WR SHUFHQW EXW WKH VSHFL¿FLW\ tends  to  be  low  (41  to  63  percent).    Neck  circumference  (measured  in  centimeters)  is  adjusted  if  the  patient  has  hypertension  (4  cm  is  added),  is  a  habitual  snorer  (3  cm  is  added),  or  is  reported  to  choke  or  gasp  most  nights  (3  cm  is  added).   A  low  clinical  probability  corresponds  to  an  adjusted  neck  circumference  of  less  than  43  cm,  an  intermediate  probability  (4  to  8  times  as  probable  as  a  low  probability)  to  a  neck  circumference  of  43  to  48  cm,  and  a  high  probability  (20  times  as  probable)  to  a  neck  circumference  of  more  than  48  cm.  Together  with  the  consideration  of  the  severity  of  symptoms,  the  clinical-­probability  estimate  helps  guide  management10.  To  hear  and  see  more  of  Dr.  Tache.

You  can  hear  him  in  one  of  the  seminars  www.sleepseminars.com  or  (see  page  31  from  old  magazine)  Dr.  Tache  has  an  In  2I¿FH BIBLIOGRAPHY s 1. Young T, Peppard PE, Gottlieb DJ. Epidemiology of

s

s

s

s

s

s

s

obstructive sleep apnea: A population health perspective. American journal of respiratory and critical care medicine.

2002;165:1217.

2. Gozal D. Sleep-disordered breathing and school performance in children.

0EDIATRICS 20.

3. Teculescu D, Benamghar L, Hannhart B, Montaut-Verient B, Michaely JP. Habitual snoring. prevalence and risk factors in a sample of the french male population. Rev -AL 2ESPIR *ANSZKY ) ,JUNG 2 2OHANI -

Hallqvist J. Heavy snoring is a risk factor for case fatality and poor short-term prognosis after a first acute myocardial infarction. Sleep.

2008;31:801.

5. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population*. Chest.

6. Prehn, R.S., Simmons, J.H. Sleep burxism: Poster presentation for the american academy of sleep medicine. 2008;Poster Presentation for the American Academy of Sleep Medicine.

7. Lindberg E, Janson C, Svardsudd K, Gislason T, Hetta J, Boman G. Increased mortality among sleepy snorers: A prospective population based study.

4HORAX ,AVIGNE '* (UYNH .

Kato T, et al. Genesis of sleep bruxism: Motor and autonomic-cardiac interactions. Arch Oral Biol.

5NRUH -, 2EDLINE 3 !N MW, et al. Subjective and objective sleep quality and aging in the sleep heart health study. J Am Geriatr Soc [Sleep Heart Health Study]. 2008;56:1218.

10. Flemons WW. Obstructive SLEEP APNEA . %NGL * -ED

WWW.SLEEPGS.COM

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FeaturedSleepLab 24

United Sleep Diagnostics

Comprehensive diagnostic sleep testing and treatment

U

nited  Sleep  Diagnostics,  Inc.  (USD)  is  a  Joint  Commission  accred-­ LWHG 0HGLFDUH FHUWL¿HG $$60 (American  Academy  of  Sleep  Medicine)  accred-­ ited  sleep  diagnostic  company.   USD  provides  comprehen-­ sive  diagnostic  sleep  testing  and  treatment  in  our  state-­of-­the-­art  sleep  laboratories,  WKH SDWLHQWœV KRPH RU hospital  environment.   Our  service  is  de-­ signed  to  ensure  high  quality,  cost  effec-­ tive  sleep  services  to  physicians  and  their  patients.  USD  also  serves  as  an  advisory  board  member  on  The  Joint  Commission.

OUR HISTORY: USD  is  a  direct  descendant  of  Ambulatory  Services  Of  Amer-­ ica,  Inc.  (ASA)  which  was  the  ¿UVW SURYLGHU RI DPEXODWRU\ channel  Polysomnography  (Sleep  Studies)  in  the  home  and  bedside  CCU  in  the  United  States.   ASA  was  founded  in  1991  and  grew  to  provide  over  6,000  sleep  studies  per  year  in  both  patient  homes  and  in  20  hospital  based  sleep  labs.   In  1999,  ASA  was  sold  to  a  publicly  traded  company.   $6$œV SULQFLSDO SDUWQHU IRUPHG a  new  company  in  South  Florida  and  United  Sleep  Diagnostics,  Inc.  was  born.   Together  with  %RDUG &HUWL¿HG 6OHHS 3K\VLFLDQV Registered  Polysomnographic  Technologists  and  a  professional  administrative  staff,  USD  has  DENTAL  SLEEP  MEDICINE

over  25  years  experience  in  providing  quality  sleep  diagnostics  and  treatment.

SERVICES All  tests  performed  for  the  diagnosis  of  sleep  disorders  are  in  accordance  with Â

the  parameters  outlined  in  the  American  Academy  of  Sleep  Medicine  as  well  as  Medicare  guidelines.  6OHHS $SQHD (YDOXDWLRQ  (Polysom-­ nography).  A  one  night  nocturnal  poly-­ somnogram  (NPSG)  allows  visually  aided  FRPSXWHU DQDO\VLV RI HDFK SDWLHQWÂśV VOHHS period,  by  the  accepted  method  of  evaluat-­ ing  the  EEG,  EOG  and  EMG.  In  addition,  WKH SUHVHQFH RU DEVHQFH RI DLUĂ&#x20AC;RZ DW WKH nose  and  mouth  is  determined,  respira-­ tory  belts  monitor  abdominal  and  thoracic  respiratory  efforts,  continuous  non-­inva-­ sive  evaluation  of  arterial  blood  oxygen  saturation,  recording  of  electro-­cardiogram  (ECG)  to  diagnose  intermittent  rhythm  abnormalities,  recording  of  body  position  for  nocturnal  breathing  abnormalities,  recording  of  continuous  leg  movements  and  several  other  parameters.   0XOWLSOH 6OHHS /DWHQF\ 7HVW (MSLT).  The  accepted  diagnosis  tool  for  assess-­ ment  of  excessive  daytime  sleepiness Â

DQG IRU D GH¿QLWLYH GLDJQRVLV RI 1DUFR-­ lepsy.   6OHHS $SQHD 7LWUDWLRQ.  A  second  nocturnal  polysomnogram  (NPSG)  is  performed  with  the  aid  of  Continuous  Positive  Air  Pres-­ VXUH PDFKLQH WR WUHDW FRQ¿UPHG presence  of  apnea.

OUR FUTURE:  USD  is  poised  to  be-­ come  the  leading  force  in  sleep  in  the  South  Florida  Region.   USD  currently  operates  full  service  sleep  centers  as  well  as  providing  complete  in-­ home  Polysomnography  and  CPAP  titration  throughout  the  tri-­county  area.   USD  has  been  fortunate  to  be  recognized  as  a  quality  provider  and  has  won  many  managed  care  contracts  as  well  as  working  with  some  of  the  top  physician  groups  in  South  Florida.   USD  looks  forward  to  expand-­ ing  our  sleep  centers,  partnering  with  physician  groups,  hospitals,  contracting  with  new  managed  care  organizations  and  participating  in  research  grants  as  well  as  improving  the  awareness  and  education  of  sleep  disorders  in  the  South  Florida  region.  USD  is  well  contracted  with  all  the  major  carriers.  United  Sleep  Diagnostics  now  runs  7  Hospital  based  facilities  and  3  free-­standing  facilities.  USD  covers  Dade,  Broward,  and  Palm  Beach  Counties. *OE 3OLLECITO 2 . %-4 0 6ICE 0RESIDENT Director of Marketing and Business Development /FlCE #ELL

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DENTAL SLEEP MEDICINE

WWW.SLEEPGS.COM

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As a Diplomate of the AADSM, I can honestly say, this is the best course I have ever taken.

If I were you, I would sign up today .

-Dr. Gerald Kushner

I learned more in these two days than in the years of continuing education I have had, combined!

This is the most beneficial course I have ever taken.

-Dr. Bruce Roman

Register Today!

1-866-353-3936 Visit Our Website: www.sleepseminars.com for further details and registration

16830 Northeast 19th Ave., North Miami Beach, FL 33162 1-866-353-3936 • 1-305-830-0327

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DENTAL SLEEP MEDICINE

Obstructive Sleep Apnea and CPAP

DME selection can influence long term therapeutic success.

By  James  P.  Reichmann,  MBA  American  Home  Patient,  Senior  Vice  President  of  Sales  and  Marketing

I

NTRODUCTION  -­  Obstructive  sleep  apnea  (OSA)  is  a  common  condition  characterized  by  partial  closures  (hypopneas)  and  complete  closures  (apneas)  of  the  airway  while  sleeping.   These  cause  blood  oxygen  saturation  levels  to  decrease  markedly  resulting  in  frequent  arousals.  $GGLWLRQDOO\ WKHVH DURXVDOV VLJQLI\ D ÂżJKW RU Ă&#x20AC;LJKW UHDFWLRQ LQ WKH ERG\ DQG WKHUHIRUH OSA  is  associated  with  an  ever  increasing  list  of  both  dangerous  and  inconvenient  co-­ morbidities.  A  partial  list  of  the  clinical  and  social  problems  associated  with  OSA  that  are  demonstrated  by  medical  evidence  and  well  accepted  include  obesity,  vehicular  accidents,  hypertension,  type  2  diabetes,  stroke,  cardiac  complications  such  as  CAD  and  CVD,  recurrent  DWULDO ÂżEULOODWLRQ DQG erectile  dysfunction.  Perhaps  few  medical  professionals  could  envision  how  common  OSA  would  become  ZKHQ LW ZDV ÂżUVW described  in  a  prominent  medical  journal  in  1976.  It  is  estimated  in  the  United  States  that  9%  of  women  and  24%  of  men  between  the  ages  of  30  and  60  have  at  least  mild  OSA.  Awareness  outside  the  area  of  sleep  medicine  has  been  very  slow  to  develop  despite  the  fact  that  OSA  was  described  so  long  ago,  evidenced  by  estimates  that  less  than  25%  of  the  patients  with  the  condition  have  been  diagnosed.  The  fact  that  OSA  is  closely  linked  to  the  growing  problem  of  obesity  means  that  the  cases  of  OSA  are  likely  to  increase  as  well.   Patients  generally  present  with  symptoms  of  daytime  sleepiness,  high  blood  pressure,  reports  of  snoring  with  arousals,  large  neck  circumference,  sleep  complaints,  and  problems  with  focus  or  concentration.  Most  people  visit  the  dentist  far  more  often  than  their  primary  care  physicians,  which  puts  the  dentist  in  a  unique  position  to  empirically  diagnose  OSA Â

patients  so  suspicions  can  be  objectively  FRQ¿UPHG DQG WUHDWHG WKHUHIRUH DYRLGLQJ WKH dangerous  co-­morbidities  associated  with  the  condition.

DIAGNOSIS  -­  The  apnea-­hypopnea  index  (AHI)  is  equal  to  the  number  of  apneas  and  hypopneas  per  hour.   The  severity  of  WKH 26$ LV GHÂżQHG E\ WKH $+, $Q $+, of  >5  to  10  is  termed  mild  OSA,  >  10  to Â

15  is  moderate,  and  >  15  is  described  as  severe.  Selection  of  appropriate  diagnostic  tests  should  consider  the  estimated  pretest  probability  of  the  patient  having  OSA,  availability  of  various  diagnostic  methods,  and  local  skill  to  allow  for  test  interpretation.  Polysomnography  is  the  universally  accepted  standard  of  care  in  diagnosing  OSA.  Home  Sleep  Testing  (HST)  has  recently  been  approved  as  an  option  to  qualify  a  patient  for  insurance  coverage  and  may  be  performed  RQO\ XQGHU WKH GLUHFWLRQ RI D ERDUG FHUWL¿HG sleep  medicine  physician.

TREATMENT  -­  Treatment  options  for  OSA  fall  into  three  categories,  namely  surgical  intervention,  positive  airway  pressure  and  oral  appliances.  The  American  Academy  of  Sleep  Medicine  (AASM),  after Â

a  thorough  review  of  the  available  published  peer  reviewed  medical  evidence,  declared  that  oral  appliances  should  be  considered  the  ¿UVW OLQH RI WUHDWPHQW IRU PLOG WR PRGHUDWH OSA.  The  AASM  also  states  that  oral  appliances  are  indicated  for  patients  who  do  not  respond  to  CPAP,  are  not  deemed  good  candidates  for  CPAP,  or  simply  fail  to  use  their  CPAP.  A  recent  meta-­analysis  found  that  oral  appliances  should  not  be  used  as  D ¿UVW OLQH WKHUDS\ IRU OSA  patients  with  an  AHI  >15  or  described  as  severe.  Oral  appliances  are  however  an  excellent  alternative  therapy  for  patients  that  can  not  tolerate  the  use  of  CPAP.  The  oral  appliances  lack  WKH HI¿FDF\ RI &3$3 therapy  but  oral  devices  are  sometimes  the  patient  preference  which  may  improve  adherence  to  therapy  and  therefore  improve  health  outcomes.

6LQFH LW ZDV ÂżUVW described  in  the  medical  literature  in  1981  Continuous  Positive  Airway  Pressure  (CPAP)  has  been  the  cornerstone  of  treatment  of  patients  suffering  with  obstructive  sleep  apnea.   CPAP  is  the  most  effective  treatment  for  OSA  and  is  the  treatment  of  choice  for  severe  obstructive  sleep  apnea.   Therapeutic  effectiveness  of  CPAP  therapy  is  unfortunately  plagued  by  the  high  non-­compliance  rate.  CPAP  compliance  LV FRPPRQO\ GHÂżQHG DV XVLQJ WKH GHYLFH 70%  of  nights  for  at  least  4  hours  and  this  is  the  least  amount  of  use  it  is  believed  WR UHFHLYH FOLQLFDO EHQHÂżW $V WKH IRUPHU surgeon  general  C.  Everett  Koop  MD  once  VDLG Âł'UXJV GRQÂśW ZRUN LI SHRSOH GRQÂśW take  them!â&#x20AC;?  and  the  same  can  be  said  for  &3$3 XVH 'HVSLWH WKH HIÂżFDF\ RI &3$3 in  reversing  sleep  apnea  and  the  attendant  co-­morbidities  studies  indicate  between Â

Continued  on  Page  48 WWW.SLEEPGS.COM

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patientcase

Genetic OrthodonticsÂŽ A True Paradigm Shift.

By  Dr.  John  C.  Jeppesen,  DMD

S

to  sending  an  intermittent,  cyclic,  leep  Group  Solutions  is  vibratory  signal  to  the  periodontium,  proud  to  announce  its  which  contains  mechanoreceptors.   These  acquisition  of  Checkmate  mechanoreceptors  in  turn  send  signals  to  Holding  Company,  LLC,  from  WKH SDWLHQWœV JHQRPH WR UHVWDUW FUDQLRIDFLDO Dr.  John  C.  Jeppesen,  DMD.    development  in  Checkmate  is  *HQHWLF 2UWKRGRQWLFVŽ the  adult  patient  the  owner  of  via  a  mechanism  two  important  called  Genome  patent  Positioning  applications  SystemŽ  (GPS).   (PCT   The  theory  application  Other components of the craniofacial system, such as the of  Genetic  number  PCT/ mandible and tongue, are induced to follow the maxillary OrthodonticsŽ  US08/78032  correction until a new position of stability i.e. craniofacial teaches  that  all  and  U.S.  homeostasis is reached. craniofacial  Design  structures  such  Application  as  teeth,  bone,  number  and  soft  tissue  29/325,146),  are  encoded,  which  relate  to  before  birth,  a  new  method  for  positioning  in  3-­D  space  as  of  treating  orthodontic  patients.  measured  by  x.y.z  coordinates.  One  This  method  is  referred  to  as  reason  why  malocclusions  develop  and  Genetic  OrthodonticsŽ. underdevelopment   For  the  Ž of  various  layperson,  *HQHWLF )DFHOLIW craniofacial  PCT  is  an  WITH NIGHT MOVES structures  occurs  acronym  is  through  for  Patent  adverse  gene-­ Cooperation  environmental  Treaty.  interactions,  This  PCT  which  suppress  or  application  is  Before Mid-Treatment After inhibit  the  natural  WKH ¿UVW VWHS genetic  switches  in  procuring  *HQHWLF )DFHOLIWŽ from  carrying  out  a  series  of  their  intended  worldwide  functions.  patents  for  a  The  objective  technology.  of  Genetic  The  worldwide  OrthodonticsŽ  art  search  is  to  turn  on  has  been  these  switches  completed  and  Facial Appearance with no Fixed Appliances or Elastics Courtesy of Dr. Franklin Del Rio - Academy of Pneumodontics so  that  they  can  ALL  claims  carry  out  their  were  found  to  be  valid  and  non-­obvious.  The  key  encoded  mission.  When  the  technique  is  performed  correctly,  using  the  right  claim  staked  out  by  Checkmate  technologies,  the  result  is  a  Genetic  Holding  Company,  LLC,  relates  Ž

ÂŽ

30

DENTAL Â SLEEP Â MEDICINE

FaceliftÂŽ.  Not  only  do  teeth  naturally  straighten  but  also  new  bone  will  grow  in  a  bilaterally  symmetrical  pattern  resulting  in  craniofacial  homeostasis.   Beauty,  function,  and  health  are  the  obvious  signs  of  a  successful  outcome  for  the  patient.  Proof  that  this  phenomenon  called  Genetic  OrthodonticsÂŽ  is  real  comes  from  a  historic  biopsy  of  alveolar  bone  performed  by  Dr.  Neal  Murphy.   In  treatment  using  GeneticOrthoÂŽ  techniques  applied  to  the  LINGUAL  surfaces  of  the  maxillary  teeth,  Dr.  Murphy  demonstrated  an  unprecedented  result:  Stem  Cell  induced  WOVEN  BONE  (slide  B,  below)  on  the  BUCCAL  side  of  the Â

(A; top) Routine hematoxylin and eosin histological section at buccal aspect of tooth #5, labial palatal alveolus DEVELOPMENT USING A 'ENETIC/RTHOÂ&#x161; APPLIANCE .OTE absence of a â&#x20AC;&#x153;lamellarâ&#x20AC;? pattern that is characteristic of mature bone. Panel B (bottom) is a polarized light section OF SPECIMEN .OTE hWOVEN BONEv PATTERN CHARACTERISTIC OF immature bone.

alveolus!   Previously,  woven  bone  was  known  to  exist  ONLY  in  EMBRYOS.   New  embryonic  WOVEN  BONE  was  genetically  induced  in  the  adult  patient.   Increased Airway Volume

Another extremely valuable property of Genetic OrthodonticsÂŽ is the ability to increase upper airway VOLUME. This functional property has the potential to either decrease and/or eliminate issues such as Sleep Disordered Breathing (SDB). Bigger airways are better than smaller ones.

This is indeed a paradigm shift.

As they say, there are several ways to skin a cat. The same is true with Genetic Orthodontics®. This technique can be SHUIRUPHG XVLQJ ¿[HG RU UHPRYDEOH appliances or a combination of both. The key, though, is still the application of an intermittent, cyclic, vibratory signal to the

bone continues throughout the day.

The Night Moves® appliance is composed of two saggital substrate

/RZHU 1LJKW 0RYHV®

1LJKW 0RYHV® 8SSHU 1LJKW 0RYHV® What was achieved?

s -ALOCCLUSION #ORRECTED s 4-$ 3YMPTOMS 2ELIEVED s #HANGE IN 4ONGUE 0OSITION !LLEVIATES !IRWAY Compromise

periodontium. Static biomechanical forces used in traditional orthodontic treatment do not appear to be capable of activating the Genome Positioning System® (GPS).

Rather the INTERMITTENT nature of the signaling to the mechanoreceptors within the periodontium appears to be necessary for this technique to work.

The Night Moves Appliance Better Looking Every Day™ ®

sections, which can be displaced from each other via a controlled mechanism, such as a jackscrew. Alternatively, the substrate may be composed of wire alone and a mid-­line spring can be used to transmit intermittent vibratory signals thereby guiding induction of new bone. The appliance can be designed with or without acrylic overlays on the posterior teeth depending on the vertical dimension of occlusion (VDO) that the patient presents with. All anterior teeth have uniquely designed Genosprings®, which incorporate a unique 3-­D axial design. These springs are made from a special material called Smart Wire®.

*HQRVSULQJ ZLWK 6PDUW:LUH® during the night as the patient swallows and/or bruxes. As the patient swallows, the jaws come together and kinetic energy is transferred and stored in the Smart Wire®.

The energy stored in the wire is translated to the lingual surfaces of the anterior teeth, which then activate the mechanoreceptors, thereby inducing the Genome Positioning System® to grow new bone. Typically, the system works to create Sutural Homeostasis. As the craniofacial sutures are genetically activated to produce new bone, remodeling of this bone occurs, resulting in certain hard and soft tissue growth that results in correction of malocclusion and ultimately the Genetic Facelift®.

*HQHWLF )DFHOLIW®

*HQHWLF )DFHOLIW®

Pre-Treatment

Post-Treatment

*HQHWLF )DFHOLIW®

The two most important properties of Smart Wire® are its ability to store kinetic energy and its ability to transmit a vibratory signal to the periodontium.

As the name suggests, the Night Moves® appliance is a removable appliance that need only be worn at night. After removal of the appliance in the morning, the osteogenic process of developing new

These springs are lightly applied to cover the entire lingual surface of the anterior teeth. The design and the alloy of the Genospring® SHUPLWV D VLJQL¿FDQW vibratory signal to be imparted to the teeth WWW.SLEEPGS.COM

31

Developing A Sleep Physician Team Working with a medical sleep team can be rewarding, educational and profitable. The Key is . . .

By Gy Yatros, DMD

A

s most dentists who are involved in WKH ¿HOG RI GHQWDO VOHHS PHGLFLQH know, working with your local sleep physicians, ENTs, hospitals and other MDs FDQ EH D UHZDUGLQJ DQG PXWXDOO\ EHQH¿FLDO experience. If both the sleep dentist and the medical team have the same vision of successful treatment for all Obstructive Sleep Apnea (OSA) patients then a symbiotic relationship will naturally develop among the team members. The most effect will vary depending on the individual, so it is important to develop a protocol with your team members for the different indications for Oral Appliances, CPAP or surgery. Realize that this protocol will be continually dynamic and even possibly different depending on the origin of the patient referral. As you develop closer relationships with your local physicians they may become more educated on indications for oral appliances. Likewise by working with sleep MDs and ENTs you can gain a large amount of knowledge as to which patients are best treated by their particular modality of treatment.

In my particular situation these UHODWLRQVKLSV KDYH ÀRXULVKHG WR WKH SRLQW that two of our referring physician groups XUJHG XV WR RSHQ XS VDWHOOLWH RI¿FHV LQ FORVH proximity to their sleep facilities. To better serve one particular sleep group we were able to place a dental sleep facility in the sleep lab itself. This has been a wonderful arrangement because I have been able to spend time with my physician team and we can communicate RQ D SHUVRQDO EDVLV DERXW VSHFL¿F FDVHV and treatment goals. The second facility is adjacent to a major hospital with a large educational sleep program. I am presently on the volunteer staff for the university and helping educate the Sleep Fellowship physicians with their training.

Similar to location in real estate, the

32

DENTAL SLEEP MEDICINE

key to developing these relationships is communication, communication, communication. It is best to take every opportunity that becomes available to communicate with your physicians. From the initial contact to the request for an orthotic PSG, these are all important opportunities to communicate either by letters, phone or in person. In particular I believe it is of critical importance to contact any physician that you have not worked with in the past if you are going to see a mutual patient.

I will usually begin with a phone conversation explaining why I am seeing their patient and how I believe I may or may not be able to help them. It is then advisable to ask the physician what their treatment goals for the patient might be and to assure them that you will keep them LQIRUPHG RI WKH SDWLHQW¶V progress. I usually follow this up with an invitation WR YLVLW RXU RI¿FH RU DVN IRU VRPH WLPH LQ WKHLU RI¿FH WR meet with them personally to go over the treatment success once our treatment has completed. Keep in mind it is important to be well educated before you begin this process.

Once the communication has begun with the physician it is important to never quit.

As a dentist I have known specialists that were “gung ho” ZKHQ ZH ¿UVW PHW EXW after a while the communication waned.

Resultantly so did my referrals to them. It is important to keep the communicating constant with letters, phone calls, and personal visits either personally or by a member of the dental team. Through constant interaction the physician referral stream will UHPDLQ ÀXLG DQG JURZ Lastly it is important to realize that this is a two way street. All patients are

not best suited for oral appliance therapy and these individuals should be referred WR WKH DSSURSULDWH SK\VLFLDQ , ¿QG LW YHU\ rewarding to educate our patients on all of their treatment alternatives. As dentists we are used to educating our patients and my experience is that by spending the time to go over all treatment options (not just oral appliances) you build much closer relationships with these patients as well as immeasurably increase your credibility.

Often times I will hear comments like “no one has ever taken the time to explain it that way” or “I didn’t know that there were other alternatives” 6RPHWLPHV SDWLHQWV GRQ¶W even have the basic understanding of their disorder. Once the alternatives are discussed it may be apparent that an oral device is the appropriate treatment. This situation should never be looked at as negative. Conversely this can be a very positive opportunity to further build relationships with your sleep physicians and ENTs. Also remember there are many, many patients in your dental practice that have undiagnosed obstructive sleep apnea. Once you have a good screening procedure these patients will need a diagnosis from a physician which is another prime opportunity to nurture your relationships by the appropriate referral.

Working with a medical sleep team can be rewarding, HGXFDWLRQDO DQG SUR¿WDEOH 7KH NH\ LV communication and perseverance. With proper training in sleep medicine and an ethical vision of optimal treatment for obstructive sleep apnea patients these UHODWLRQVKLSV ZLOO UDSLGO\ JURZ DQG ÀRXULVK Gy Yatros, D.M.D. Island Dental Spa , Anna Maria Island, Florida Member of ADSM Member of AGD Member of ADA Email: dryatros@islanddentalspa.com Website: www.islanddentalspa.com /FlCE s #ELL

Working With The TAP 3 Mandibular Advancement Devices Alteration of the Advancement Mechanism When You Have More Titration to Accomplish.

By  Dan  Tache  DDS,  D,ABDSM

O

bstructive  Sleep  Apnea  Syndrome  (OSAS)  is  a  disorder  with  high  prevalence  and  it  is  associated  with  substantial  morbidity  and  increased  PRUWDOLW\ LI LQVXI¿FLHQWO\ PDQDJHG 7KH Gold  Standard  for  the  management  of  OSAS  is  continuous  positive  airway  SUHVVXUH &3$3 'HVSLWH KLJK HI¿FDF\ long-­term  compliance  with  CPAP  therapy  has  been  estimated  at  between  25-­50%  of  patients.1   Oral  appliances  (OA)  have  been  shown  to  be  effective  in  a  subset  of  patients  with  OSAS  who  are  CPAP-­ intolerant.2   Typically,  these  patients  who  are  responsive  to  OA  therapy  have  mild-­ moderate  supine-­dependent  sleep  apneas  OSAS.1,  3   'HVSLWH ORZHU HI¿FDF\ VRPH VWXGLHV have  shown  OAs  to  have  a  relatively  robust  compliance  rate  ranging  between  64.1%  and  93.7%.4,5  Often,  in  the  course  of  titration  of  any  of  the  adjustable  MADs,  additional  advancement  is  required  but  the  advancement  mechanism  has  been  completely  advanced.  This  may  be  the  result  NOT  of  MAD  design  weakness  EXW RQH RI LQVXI¿FLHQW UHSRVLWLRQLQJ RI the  mandible  at  the  time  of  fabrication  of  the  appliance  when  cranio-­mandibular  records  are  taken.  Certainly,  this  problem  is  also  encountered  when  patients  of  record  return  for  their  annual  OSA  recall  visit,  particularly  if  there  has  been  weight  gain  or  the  patient  has  begun  to  take  opioid  medication  at  bedtime.  This  frequently  encountered  challenge  highlights  the  need  for  continued  vigilance  with  the  OSAS  patient  not  to  mention  the  fact  that  annual  recall  of  these  patients  is  a  requirement  of  the  Practice  Parameters  for  the  Treatment  of  Snoring  and  Obstructive  Sleep  Apnea  with  Oral  Appliances  2005.2  Effectiveness  of  MADs  requires  VXI¿FLHQW DGYDQFHPHQW RI WKH PDQGLEOH LQ

order  to  adequately  stabilize  the  airway.  6XIÂżFLHQW UHSRVLWLRQLQJ PD\ DSSURDFK RI 80%  of  maximum  protrusive  range.  This  may  require  protrusion  ranging  between  6  and  8  mm  6  which  exceeds  the  adjustability  of  most  MADs.   Many  clinicians  out  of  fear  of  inducing  symptoms  will  elect  a  more  conservative  starting  point,  usually  â&#x20AC;&#x153;end  to  endâ&#x20AC;?  only  to  discover  that  the  device  is  fully  advanced  before  the  airway  has  been  VXIÂżFLHQWO\ VWDELOL]HG  When  a  clinician  is  confronted  with  this  dilemma  and  has  to  return  the  MAD  to  the  lab  for  alteration,  it  can  mean  a  considerable  problem  for  the  patient  was  well.  Often,  the  OSA  patient  has  relinquished  his  or  her  PAP  device  and  is  dependent  upon  the  MAD  for  control The  TAP  3  is  an  excellent  device  because  of  its  simplicity  of  design  and  heartiness  of  articulating  advancement  mechanism.   It  was  designed  by  Dr.  Keith  Thornton  (http:// www.airwaylabs.com/)  whose  intent  was  to  make  the  process  as  user  and  clinician-­ friendly  as  possible  which  would  imply  HDVH RI UHSDLU PRGLÂżFDWLRQ ZLWKRXW the  need  for  returning  the  device  to  the  laboratory.   7KLV DUWLFOH EULHĂ&#x20AC;\ GHVFULEHV D VLPSOH method  of  moving  the  advancement  mechanism  of  the  TAP  3  MAD  when  this  problem  is  encountered.   I  will  use  a  recently  treated  OSA  patient  to  illustrate  the  technique.

CC: â&#x20AC;&#x153;I am soon to be deployed to Iraq and I used a CPAP but there will not be any electricity where I to be stationedâ&#x20AC;?

PMH: s Past history of elevated blood pressure which had been managed with medication s Elevated BP has been more recently controlled with management of his OSAS using CPAP s Diagnosed in 1998 with obstructive sleep apnea s Not currently under the care of a physician for medical problems HPI: s Has been very successfully using CPAP since 1996 s Most recently, he learned that he was to be deployed to Iraq s He is concerned that he may not have access to electricity to run his

CPAP s s

s

TV was provided with a TAP3 and we began the titration process The process had to be accelerated because we had only two weeks to accomplish optimization of the efficacy of his appliance Given that he had a severe level of disease, advancement was near maximum

Continued  on  Page  32 This is TV, a 43 y.o. male who was diagnosed with severe obstructive sleep apnea in 1996.

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33

Working With The TAP 3 Mandibular Advancement Devices Continued from Page 31

LABORATORY PROCEDURE LABORATORY PROCEDURE FOR MOVING THE AM

PORTABLE MONITOR (PM) 6800$5< 6+2:,1* 6/((3 INDICES OF CURRENT MANDIBULAR POSITION

FOR MOVING THE AM

s s

s pAHI pRDI Baseline Oxygen Saturation Lowest Oxygen Saturation Oxygen Saturation <90%

42.0 52.8 93% 89% 3.1

s

s s s

34

We will advance 3mm after freeing the AM from the acrylic base on both sides and front surfaces only.

Keep the acrylic “rear wall” intact as a reference point.

DENTAL SLEEP MEDICINE

s

s s

The AM is freed.

It will be repositioned 3mm anterior to the posterior fence (black line).

s

The AM is positioned 3mm anteriorly to posterior fence (black line).

I will tack the AM in place with Super Glue.

We will use a Robinson Bristle Brush to “evaporate” the acrylic from over the wings of he AM. We will also remove the anterior acrylic “fence” as well while leaving the posterior “fence” in place to guide our advancement.

Even at low speed, the acrylic is easily removed.

Using a brush, you will not damage the AM.

The anterior and lateral acrylic is removed.

The posterior acrylic (black line) is preserved.

s

ers MH. Ballard RD. Magalang UJ. Medical therapy for obstructive sleep apnea: A review by the medical therapy for obstructive sleep apnea task force for the standards of practice committee of the american academy of sleep medicine. SLEEP [Medical Thereapy for Obstructive Sleep !PNEA 4ASK &ORCE= !VAILABLE FROM http://www.journalsleep.org/.

2. Kushida CA. Morgenthaler TI. Littner MD. Alessai, CA. Bailey, D., Coleman J. Friedman, L. Hisrhkowitz M.

s

Kapen S. Kramer M., Lee-Chiong T. Owens J., Pancer

The AM is secured with a acrylic on all four sides preserving just the amount of advancement desired.

J. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appiances: An update for 2005. SLEEP [Practice Parameters Oral Appliances].

pAHI pRDI Baseline Oxygen Saturation Lowest Oxygen Saturation Oxygen Saturation <90%

12.0 12.8 93% 89% 0.1

!VAILABLE FROM HTTP WWW AASMNET ORG !CCESSED -AY

3. Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring* tolerability and predictors

s s s

All done.

We will turn back the AM and return to the patient.

We will continue the titration process and re-test.

 We  have  completed  the  procedure  and  the  MAD  titration  process  is  continued.

We  have  just  a  few  days  remaining  before  our  patient  leaves  for  Iraq.  Below,  is  the  last  PM  study  performed  EHIRUH KH OHIW ,QGHHG DOWKRXJK HI¿FDF\ of  PMs  have  been  repeatedly  demonstrated  7  in  keeping  with  AASM  Guidelines,  when  TV  returns,  he  will  be  referred  back  to  his  sleep  specialist  for  a  follow-­up  7LWUDWLRQ 36* WR DVVHVV WKH HI¿FDF\ RI KLV

MAD  if  he  plans  on  continuing  to  use  it.     So,  what  is  our  goal  of  MAD  therapy?   We  are  looking  for  a  reducing  in  AHI  by  50%  and  <10.   Although  we  have  not  ac-­ complished  that  by  the  time  our  patient  is  deployed,  a  closer  look  at  the  details  of  the  result  of  our  MAD  therapy  (to  date)  shows  remarkable  improvement  in  SpO2  <90%.   That  value  changed  from  3.1  to  1.0%  of  7RWDO 6OHHS WLPH DQG LV D YHU\ VLJQLÂżFDQW improvement.   Additionally,  our  patient  reports  subjectively  that  he  feels  quite  refreshed  upon  awakening  and  is  very  encouraged.  Â

OF TREATMENT SUCCESS #HEST DE !LMEIDA &2 ,OWE !!

4SUIKI 3 ET AL ,ONG TERM compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea SYNDROME * #LIN 3LEEP -ED 5. Hoekema A, Stegenga B, Wijkstra PJ, van der Hoeven JH, Meinesz AF, de Bont LGM. Obstructive sleep apnea therapy. Journal of Dental Research. 2008;87:882-7.

6. Dort L, Hadjuk E, Remmers J. Mandibular advancement and obstructive sleep apnoea: A method for determining effective mandibular protrusion. European Respiratory *OURNAL #OLLOP . %PSTEIN , %NTERING THE AGE OF PORTABLE MONITORING * #LIN 3LEEP -ED n Available from: http://www.pubmedcentral.nih.gov.ez-

6RPH ¿QDO WKRXJKWV +\EULG 7KHUDS\ PROXY LIBRARY TUFTS EDU ARTICLERENDER FCGI ARTID Even  though  he  has  been  very  successful  with  his  CPAP,  it  may  be  interesting  and  very  productive  to  consider  combination  or  Hybrid  Therapy,  utilizing  BOTH  his  MAD  and  his  CPAP,  concurrently.   Often,  this  combination  is  a  very  syn-­ h-Y EXPERIENCE WITH 3LEEP 'ROUP 3OLUTIONS HAS BEEN ergistic  blending  of  strategies.   With  exceptional from both an academic and customer service standpoint. SGS has provided assistance the  MAD  worn  in  concert  with  the  in marketing and promoting the courses I give CPAP,  often  the  pressures  required  for  the  CPAP  to  stabilize  the  airway  THROUGHOUT .ORTH !MERICA !T MY COURSES THE 3'3 representatives are professional and helpful in DUH VLJQL¿FDQWO\ UHGXFHG WKHUHE\ educating my students about the dental treatment further  improving  comfort.   of sleep apnea. SGS provides a great training program for all offices that purchase equipment and Dan  TachÊ,  DMD,  D,ABDSM the feedback from my students has been positive.

SGS is a reliable and honest organization and I recommend their services to my colleagues.â&#x20AC;?

BIBLIOGRAPHY â&#x20AC;&#x201C; Dr. Brock Rondeau 1. Veasey SC. Guilleminault C. Strohl KP. SandWWW.SLEEPGS.COM

35

The Emergence And Explosive Growth Of OSA OSA Dental evolution is increasingly interfacing medicine with dentistry.  By  Dr.  Robert  L.  Horchover,  DDS

M

r.  Jones  described  the  past  two  development  until  today  implants  are  an  and  why   â&#x20AC;&#x153;professional  opinionsâ&#x20AC;?  and  weeks  of  his  life  as  having  LQWHJUDO SDUW RI GHQWDO FDUH ,ÂśYH REVHUYHG â&#x20AC;&#x153;judgmentâ&#x20AC;?  span  those  gaps.  The  more  amazing  energy,  sudden  Obstructive  Sleep  Apnea  (OSA)  go  measuring  and  experience,  the  shorter  optimism,  a  rediscovery  of  his  family,  WKURXJK VLPLODU VWDJHV EXW ZKDWÂśV 9(5< the  gap.  My  outcomes  have  always  been  severe  head  pain  gone,  and  no  snoring!   DIFFERENT  is  the  OSA  Dental  evolution  better  when  I  could  apply  my  tools  with  Sleep  Apnea  patient?   Not  according  is  increasingly  as  much  tape  to  his  chief  complaint,  diagnosis  and  interfacing  measure  treatment.  Yes,  only  by  coincidence.  His  Medicine  with  involvement  chief  complaint  on  arrival  were  his  years  Dentistry  in  as  possible  of  constant  headaches  and  many  doctors  profound  ways  and  OSA  and  many  but  minimally  effective  strong  WKDW EHQHÂżW treatment  drugs.  He  was  describing  how  his  lower  all  those  outcomes  are  orthotic  freed  him  of  the  pain  and  fog  and  involved. no  different.  gave  him  his  family  and  life  back!   His   My  It  is  simply  snoring  comment  was  interesting,  but  not  exclusive  a  different  WKH ÂżUVW WLPH ,ÂśG KHDUG LW , VDLG ÂłZKDW D dental  sleep  metric  bonusâ&#x20AC;?.  No  surprise  to  me  was  the  changes  medicine  application.

Pharyngometer Interface. the  orthotic  had  brought  into  his  life,  but  practice   I  have  ,ÂśG QHYHU KHDUG RI VOHHS DSQHD WKHQ ,W ZDV started  developed  a  1979.  â&#x20AC;&#x153;from  scratchâ&#x20AC;?  15+  years  ago  following  system  over  some  seven  years  that  has  had   The  emergence  and  explosive  growth  27  wonderful  years  of  general  practice.  D VLJQLÂżFDQW LPSDFW RQ P\ 26$ SUDFWLFH of  Obstructive  Sleep  Apnea  (OSA)  shares  I  quickly  discovered  there  were  Its  evolution  was  mostly  frustration-­ a  commonality  with  dental  implants.  comparatively  few  guidelines  or  literature  LQVSLUHG ,W KDV EHHQ DSSOLHG PRGLÂżHG It  started  with  a  few,  was  not  user  and  many  diverse  opinions.  The  sleep  reapplied,  etc.  It  provides  a  repeatable  friendly,  had  high  failure  rates  and  was  medicine  community  was  somewhat  metric  for  airway  measurement,  jaw  controversial.  There  were  pioneer  gurus,  skeptical  and  early  generation  devices  positioning  and  recording  for  start  and  a  competing  systems,  mailers  assuring  the  shared  some  common  design  features  target  position  for  optimum  airway.  It  is  practitioners  that  a  weekend  course  would  that  limited  their  success.  I  could  not  simple,  fast,  packaged  for  quick  access  make  them  instant  experts.  Many  of  those  ¿QG D VDWLVIDFWRU\ UHSHDWDEOH SURWRFRO IRU and  storage,  and  color-­coded  for  cold  â&#x20AC;&#x153;week-­end  warriorsâ&#x20AC;?  learned  through  diagnosis,  prognosis  and  treatment  that  VWHULOL]DWLRQ ÂżOLQJ DQG PDQDJHPHQW ,W LV failures  and  patient  disappointment  that  educated  the  patient  from  the  start  through  easy  for  staff  to  learn  and  the  enhanced  a  little  knowledge  could  be  â&#x20AC;&#x153;dangerousâ&#x20AC;?.  their  treatment.  I  was  both  humbled  and  patient  education  almost  creates  their  The  ultimate  good  emerged  as  many  inspired  by  how  a  simple  oral  device  could  desire  for  treatment  from  the  start.  It  is  dentists  profoundly  universally  applicable  for  any  device  and  dropped  improve  the  works  with  or  without  Pharyngometry.  It  â&#x20AC;&#x153;I  was  both  humbled  and  inspired  out  or  got  lifestyles   of  can  accelerate  learning  for  the  beginner  comprehensive  by  how  a  simple  oral  device  could  the  patient  and  simplify  the  protocol  for  the  training.  It  and  their  H[SHULHQFHG ,WÂśV VLPSO\ D ZD\ WR PHDVXUH profoundly  improve  the  lifestyles   of  started  slowly  the  patient  and  their  family.â&#x20AC;? family.

It  is  Airway  Metrics.  The  photos  are  only  in  isolated   a  sneak  preview  and  speak  for  themselves.    cells  but  There  is  no  Robert  L.  Horchover,  D.D.S.                                          it  soon  inspired  research,  professional  VXEVWLWXWH IRU ÂżUVW KDQG H[SHULHQFH +RZ AIRWAYMETRICS.COM  and  public  education  and  private  sector  much  can  be  measured  has  limitations Â

36

DENTAL Â SLEEP Â MEDICINE

By  Jeffrey  J.  Fredberg,  Professor,  Harvard  School  of  Public  Health

A

coustic  Pharyngometry  has  become  widely  employed  to  help  in  the  diagnosis  and  treatment  of  obstructive  sleep  apnea,  and  to  investigate  the  pathophysiology  of  the  upper  airway.   But  in  the  beginning,  when  this  technology  was  ¿UVW LQYHQWHG WKHVH issues  were  not  at  all  on  our  radar  screen.  Instead,  in  1973  when  , ÂżUVW FRQFHLYHG RI this  idea,  the  goal  was  to  develop  an  acoustic  technology  that  could  be  used  to  probe  lung  function  in  infants  and  young  children,  the  idea  being  that  we  needed  a  lung  function  test  that  could  be  used  in  the  uncooperative  subject.  We  were  fortunate  to  be  able  to  secure  generous  funding  from  the  NIH,  and  over  the  next  decade  the  technology  was  developed  and  matured.  Â

 At  that  time  the  upper  airway  was  simply  an  obstacle  that  needed  to  be  traversed  in  order  to  probe  the  deeper  structures  of  interest,  which  included  larynx,  trachea,  bronchi,  and  small  airways.  But  as  the  technology  improved,  and  as  the  test  became  simpler  to  accomplish,  we  began  to  appreciate  that  the  upper  airway  was  not  an  obstacle,  but  rather  an  important  structure  in  its  own  right,  and  one  deserving  of  greater  scrutiny.  Acoustic  Pharyngometry  was  born.  Today  Acoustic  Pharyngometry  is  used  in  children  as  well  as  adults  to  study  the  size,  structure,  and  collapsibility  of  the  upper  airway.  It  is  used  as  well  to  titrate  mandibular  advancement  devices  for Â

the  treatment  of  obstructive  sleep  apnea,  and  it  is  used  to  study  the  effect  of  weight  reduction  on  upper  airway  patency.   The  test  is  fast  and  noninvasive,  it  is  inexpensive  and  uses  no  ionizing  radiation.  0RUHRYHU LW LV FRPSDFW DQG ¿WV conveniently  in  any  examination  room.

appliancereview

Acoustic Pharyngometry

h-Y 0HARYNGOMETER IS AN INDISPENSABLE TOOL FOR MY sleep practice. I use it in my consultation appointment, and in variably when they see on the screen what my appliance can potentially do they accept treatment.

Then when I start treatment, it helps guide me as far as adjustments. Great for diagnosis, case presentation, and TREATMENT #AN T ASK FOR MUCH MORE v n 3COTT % 7EST $ $ 3 & ! ' $

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DENTAL SLEEP MEDICINE

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Sleeping Down Under The Aussie legends of sleep medicine!  by  Dr.  Lisa  Matriste,  BDSc  Hons  (Uni  of  Queensland),   AACNEM CNN.   There  have  been  many  Australians  who  have  been  awarded  the  prestigious  Nobel  Prize  for  their  contribution  to  major  VFLHQWLÂżF UHVHDUFK ,Q IDFW $XVWUDOLD LV one  of  the  leading  Nobel  Prize  winning  FRXQWULHV LQ SHU FDSLWD WHUPV UHĂ&#x20AC;HFWLQJ WKH QDWLRQÂśV VWURQJ UHFRUG RI LQQRYDWLRQ DQG VFLHQWLÂżF DFKLHYHPHQW Some  examples  are  Howard  Walter  Florey  who  is  often  overlooked  nspite  of  its  relatively  small  population  for  his  collaborative  role  with  Alexander  Fleming  (22  million),  Australia  boasts  its  fair  in  the  discovery  of  share  of  iconic  legends  in  dramatic  Penicillin  and  its  curative  DUWV PXVLF VSRUWV ÂżQDQFH PHGLD DQG effect  of  many  infectious  WKH VFLHQFHV 7KH Âł:KRÂśV :KR /LVW´ LV diseases  (Nobel  Prize  quite  impressive  including  actors   Hugh  for  Medicine  1945)  Jackman,  Russell  Crowe  and  Nicole  DQG PRUH UHFHQWO\ 'UÂśV Kidman.   The  Aussie  rockband  AC  DC  Barry  Marshall  and  endures  equally  with  the  â&#x20AC;&#x153;Greaseâ&#x20AC;?  starlet  Robin  Warren  (Nobel  Olivia  Newton  John.  Greg  Norman  still  Prize  for  Medicine  2005)  KDV DQ LPSUHVVLYH VZLQJ DQG ÂżQH JROI form  and  Geoff  Ogilvy  is  currently  ranked  who  used  antibiotics  to  cure  infections  of   #4  on  the  PGA  circuit.  Our  tennis  stars  Helicobacter  Pylori  include  Rod  Laver  who  won  the  Grand  causing  gastric  and  Slam  and  more  recent  winners  of  the  US  duodenal  ulcers.  This  Open  have  been  Pat  Rafter  and   Lleyton  discovery  has  led  to  Hewitt.   Last  year  the  Aussie  Olympic  VLJQLÂżFDQW UHGXFWLRQ RI Swimming  Dream  Team  managed  to  gastric  cancer  especially  steal  some  records  from  Michael  Phelps.  in  Japan.

Lauren  Jackson  who  plays  for  the  Seattle   So,  it  is  with  much  Storms  has  been  described  as  one  of  the  pride  that  I  draw  to  greatest  basketballers  of  all  times. your  attention  to  the   In  the  business  world,  Frank  Lowry  Aussie  Legends  in  Sleep  who  immigrated  to  Melbourne,  Australia,  Medicine.   The  obvious  comes  in  at  #174  by  Forbes  Richest  BIG  4  being   Colin  Billionaire  list  for  having  founded  the  Sullivan  who  invented  :HVW¿HOG 6KRSSLQJ 0DOOV PDNLQJ KLP the  CPAP  machine  and  the  owner  of  the  most  shopping  centres  continues  a  teaching  in  the  world.  He  was  instrumental  in  the  and  research  career  at  the  University  of  rebuilding  of  the  World  Trade  Centre  Sydney.  Dr  Murray   Johns  is  another  after  9/11.  Of  course  #109  ranked  Forbes  pioneer  who  developed  the  Epworth  Billionaire,  Rupert  Murdoch,  deserves  Sleepiness  Scale  in  1990  which  is  now  a  a  mention.  The  Australian  born  media  ZRUOG VWDQGDUG LQ PHDVXULQJ D VXEMHFWœV PRJXO VWLOO FRQWUROV D VLJQL¿FDQW VOLFH general  level  of  sleepiness  in  daily  life.   of   USA  newspapers  and  television.   He  was  also  involved  in  the  development  1HZVFRUS DQG )R[ ULYDO 7HG 7XUQHUœV

of  diagnostic  sleep  equipment  with  Compumedics.  For  more  than  30  years,  Dr  Johns  remains  a  OHDGLQJ UHVHDUFKHU LQ WKH ÂżHOG RI sleep  medicine,  now  focusing  on  'URZVLQHVV DQG )DWLJXH +RZÂśV that  for  an  oxymoron?)  Prof  Peter  Cistulli  who  is  based Â

I

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DENTAL Â SLEEP Â MEDICINE

at  the  University  of  Sydney,  received  the  Pierre  Robin  Award  from  the  AADSM  in  2006.  Whilst  being  a  Respiratory  and  Sleep  Physician,  his  research  has  focused  on  the  orofacial  aspects  of  OSA  pathophysiology   and Â

evaluating  oral  appliances  for  reducing  the  symptoms  of  OSA.  More  recently  he  is  investigating  the  effectiveness  of  orthodontic   rapid  maxillary  expansion  for  the  treatment  of  obstructive  sleep  apnoea  syndrome.  Prof  Cistulli  remains  a  champion  of  dental  sleep  medicine  as  his  research  validates  that  oral  appliances  are  indeed  a  valid  therapeutic  option  to  CPAP  especially  for  mild  and  moderate  OSA  sufferers.

2QH RI WKH ZRUOGÂśV PRVW SRSXODU RUDO appliances,  SomnoDent  was  designed  by  an  Australian  orthodontist,  Dr  Richard  Palmisano.  SomnoMed  was  formed  in  2004  to  commercialize  the  mandibular  advancement  splint  and  within  5  years  has  established  global  marketing  and  distribution  channels  for  its  patented,  pretty  pink  device.  7KHUH LV GHÂżQLWHO\ D JURZLQJ WUHQG for  dentists  incorporating  dental  sleep  medicine  into  their  clinical  practices.   Australian  memberships  in  representative  organizations  are  increasing  each  year.   For  example  there  are  now  62  dentists  registered  with  the  Australian  Sleep  Association  and  of  these  17  have  joined  the  AADSM.  Unfortunately,  the  learning  SDWKZD\ LQ WKLV ÂżHOG IRU $XVWUDOLDQ GHQWLVWV is  not  very  structured  and  is  only  regulated  in  one  State  which  obliges  dentists  who  wish  to  use  oral  appliances  for  their  patients,  to  follow  the  Guidelines  of  the  AADSM.  It  remains  to  be  seen  whether  this  policy  of  the  Dental  Board  of  Victoria  will  be  abandoned  or  introduced  nationally  when  the  National  Professional  Register  is  formed.  All  the  current  Regulatory  Health  State  Boards  will  be  merged  into  one  administrative  entity  under  the  Health  Insurance  Commission.  Furthermore,  there  is  no  recognized  specialty  of  Dental/ Oral  Sleep  Medicine  even  if  one  was  to  complete  the  2-­3  year  Masters  programme  of  Science  of  Sleep  Medicine  offered  at  the  University  of  Sydney  under  Prof  Colin  Sullivan.  There  have  been  some  visits  from  our  learned  American  colleagues,  Drs  Ed  Spiegal,  Jamieson  Spencer  and  Steve  Olmos  to  teach  Aussie  dentists  about  Dental  Sleep  Medicine.  The  soon-­to-­be  released  internet  courses  of  Dr.  Brock  Rondeau  will  provide  another  educational  option  on  this  subject.  On  the   home  front,  lecturers  Dr.  Derek  Mahoney   (Orthodontist)  and  Dr.  Harry  Ball  have Â

also  conducted  courses  on  Snoring  and  OSA.    Dentists  in  Australia  have  quite  a  range  of  MAS  appliances  to  utilize  with  the  most  popular  options  being:  SomnoDent,  Silent  Nite,  Silencer,  Tap  II/III,  Oasys,  EMA  and  the  only  registered  Australian  designed  appliance  â&#x20AC;&#x201C;  MDSA.   Last  year  saw  the  inaugural  Australian  â&#x20AC;&#x153;Oral  Sleep  Medicineâ&#x20AC;?  course  in  Adelaide.   This  initiative  is  a  collaboration  of  the  University  of  Adelaide  Dental  School,  the  Australian  Sleep  Association  and  the  Australian  Dental  Association.  These  organizations  have  made  an  annual  commitment  to  provide  continuous,  non-­commercial  educational  courses  for  dentists  providing   both  introductory  DQG DGYDQFHG SURJUDPPHV 7KLV \HDUÂśV venue  for  the  â&#x20AC;&#x153;Visions  of  the  Nightâ&#x20AC;?  Sleep  Conference  is  in  Melbourne  (October  8-­10).  It  will  be  springtime  downunder  where  the  air  is  warm  and  the  US  dollar  is  worth  a  fortune!  So  make  the  trip,  book  QANTAS.  Remember  to  pack  the  Melatonin.  Come  and  sleep  under  the  Southern  Cross  (our  famous  stellar  constellation)  and  wake  up  refreshed.

PERSONAL & PROFESSIONAL INSIGHTS  Submitting  to  family  pressures,  Lisa  reluctantly  commenced  her  dental  studies  at  the  University  of  Queensland,  Brisbane,  Australia  in  1982.  Graduating  with  Honours  in  Bachelor  of  Dental  Science  in  1986,  Lisa  travelled  to  North  Queensland  WR IXOÂżO KHU XQGHUJUDGXDWH VFKRODUVKLS with  the  Queensland  Government  Department  of  Health  completing  two  years  in  the  School  Dental  Service.  Enjoying  coastal  living,  Lisa  then  moved  WR &DLUQV DQG ERXJKW KHU ÂżUVW JHQHUDO dental  practice  at  the  tender  age  of  25years.  She  has  always  worked  full-­ time  in  spite  of  her  raising  three  children  with  the  last  twelve  years  being  as  a  sole  parent.  /LVD PRYHG WR 0HOERXUQH ÂżYH \HDUV ago  and  has  been  developing  her  new  dental  company  which  is  evolving  into  a  HOLISTIC  WELLNESS  CENTRE,  incorporating  dentistry,  beauty  and  laser  clinics  and  a  detox  spa.  There  coexists  a  vision  to  develop  a  teaching  institute  and  Foundation.  Motivated  by  the  premature  deaths  of Â

her  parents  -­  her  mother  dying  of  cancer  and  her  father  suffering  a  fatal  heart  attack,  Lisa  has  focussed  her  career  on  integrating  dental  medicine  into  the  day-­ to-­day  care  of  her  patients.  She  describes  her  practice  as  being  holistic  or  integrative  as  well  as  environmentally  responsible.  Lisa  continually  is  developing  clinical  protocols  where  she  as  a  dentist  can  offer  VROXWLRQV WKDW PDNH VLJQLÂżFDQW LPSDFW LQWR KHU SDWLHQWVÂś JHQHUDO KHDOWK DQG ZHOO EHLQJ EH\RQG WKH FRQYHQWLRQDO ÂłGULOO ÂżOO DQG billâ&#x20AC;?  methods.   Lisa  embraces  the  technological  advances  in  dentistry  such  as  lasers,  ozone,  photodynamic  therapy,  (FFRYLVLRQ DFRXVWLF UHĂ&#x20AC;HFWLRQ %LR3DN for  neuromuscular/TMJ  analysis,  digital  radiography  and  computer  networks  plus   screens  all  dental  materials  to  ensure  only  biocompatible  products  are  used  thus  making  DENTIQUE  a  mercury  and  Ă&#x20AC;XRULGH IUHH FOLQLF +HU VWXGLHV WDNH KHU WR North  America  several  times  a  year  where  she  updates  her  knowledge  and  skills  in  toxicology,  nutrition  and  environmental  medicine,  craniofacial  pain,  dentofacial  orthopaedics,  orthodontics  and  sleep  medicine.  Having  survived  twenty  plus  years  in  the  profession,  Lisa  genuinely  confesses  that  â&#x20AC;&#x153;Mother  did  know  bestâ&#x20AC;?  and  is  more  enthusiastic  about  her  career  now  than  she  ever  was,  because  Dentistry  is  the  medium  by  which  she  heals  people  and  can  transform  their  lives.

MEMBERSHIPS s !5342!,)!. $%.4!, !33/#)!4)/. s !#!$%-9 /& '%.%2!, $%.4)3429 s ).4%2.!4)/.!, !#!$%-9 /& /2!, -%$)#).% !.$ TOXICOLOGY s ).4%2.!4)/.!, !#!$%-9 /& ")/,/')#!, $%.4)3429 !.$ -%$)#).% s !5342!,!3)!. 3/#)%49 /& /2!, -%$)#).% !.$ TOXICOLOGY s !5342!,!3)!. #/,,%'% /& .542)4)/.!, !.$ %.6)2/.-%.4!, -%$)#).% s !5342!,!3)!. ).4%'2!4)6% -%$)#).% !33/#)!4)/. s !-%2)#!. !#!$%-9 /& #2!.)/&!#)!, 0!). s ).4%2.!4)/.!, !33/#)!4)/. /& /24(/$/.4)#3 s !#!$%-9 /& ,!3%2 $%.4)343 s !5342!,!3)!. !33/#)!4)/. /& ,!3%2 $%.4)3429 s 7%34). ! 02)#% &/5.$!4)/. s !-%2)#!. !#!$%-9 /& $%.4!, 3,%%0 -%$)#).% s 6)#4/2)!. 7/-%. 3 $%.4!, !33/#)!4)/. s ).4%2.!4)/.!, !33/#)!4)/. (/-/4/8)#/,/'9 s ).4%2.!4)/.!, 0(/4/$9.!-)# !33/#)!4)/. s !5342!,)!. 3/#)%49 /& 0%2)/$/.4/,/'9 s !5342!,!3)!. !#!$%-9 /& !.4) !').' -%$)#).%

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Internet-Based Dental Education A vast array of global experts showcasing their collective acumen making this type of specific dental information available in a timely manner.  by  Dr.  Maurice  Salama

D

ental  knowledge  today,  as  with  most  everything,  is  no  longer  expanding  along  a  linear  curve  -­  but  rather  exponentially.   Innovative  new  products,  as  well  as  constantly  evolving  WHFKQLTXHV QHHG WR PHHW WRGD\ÂśV GHQWLVW face  to  face  in  a  more  timely  manner.   7R UHPDLQ FXUUHQW WRGD\ÂśV SUDFWLFLQJ clinician  scans  a  plethora  of  Journals  and  advertising  driven  dental  tabloids,  attends  ongoing  study  clubs,  academy,  and  institute  meetings  (many  sponsored  by  dental  companies),  and  then  all  too  often  comes  away  with  new  ideas,  concepts,  and  philosophies  but  little  real  education  on  the  actual  â&#x20AC;&#x153;how  toâ&#x20AC;?  of  any  technique  or  the  intricacies  in  the  use  of  new  products.   As  traditional  dental  education,  even  rapid-­turn-­ around  print  media,  struggles  to  meet  this  demand,  dental  education  is  forced  to  meet  this  challenge  by  combining  traditional  learning  methods  with  new  internet-­based  technologies.    While  conventional  print  media  and  meetings  remain  effective  at  apprizing  them  of  a  concept,  an  internet  based  site  with  streaming  video  would  allow  a  dentist,  who  may  have  learned  of  a  new  process,  to  review  it  in  depth  on  their  computer  in  their  own  time  or  literally  before  doing  a  particular  procedure.   New  products  and  technologies  have  become  exceedingly Â

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technique  sensitive.   Information  on  these  products  and  technologies,  whether  it  is  the  sequences  and  timing  of  dentin  bonding,  subtleties  of  a  suturing  technique  system  or  the  nuances  of  a  innovative  grafting  process,  can  all  be  similarly  available  to  a  clinician  anywhere  in  the  world,  at  any  time,  on  an  internet-­based  teaching  site.   Developing  internet  based  educational  sites  are  all  too  often  industry  sponsored  but,  sites  such  as  DentalXP  available  at  www.dentalxp.com  bring  together  a  vast  array  of  global  experts  showcasing  their  collective  acumen  and  PDNLQJ WKLV YHU\ W\SH RI VSHFLÂżF GHQWDO information  available  in  a  timely  manner.   As  a  multi-­disciplinary,  cross-­disciplinary Â

non-­corporate  based  site,  it  is  a  veritable  resource  for  both  new  and  old  information  IRU WRGD\ÂśV FOLQLFLDQ LUUHVSHFWLYH RI WKH PDQXIDFWXUHU 7KH EHQHÂżW RI WKLV technology  is  evident  in  being  able  to  GHÂżQLWLYHO\ DFFHVV RQO\ D OLPLWHG DVSHFW RI D YHU\ VSHFLÂżF SURFHGXUH UDSLGO\ DQG easily.   The  format  is  similarly  particularly Â

versatile  ranging  from  presentations,  using  digital  images  similar  to  PowerPoint  or  Keynote,  animations  to  elucidate  on  the  UH¿QHPHQWV RI D WHFKQLTXH RU VWUHDPLQJ video  to  show  a  sequential  aspect  of  literally  any  process.    Combine  all  this  with  downloadable  3') ¿OHV RI UHOHYDQW UHODWHG DUWLFOHV detailed  instructions  and  information  on  associated  instrumentation  or  products,  and  DentalXP  becomes  a  one  stop  readily  available  site  for  any  procedure  technique,  technology,  or  product.   Today  DentalXP  is  becoming  an  essential  supportive  adjunct  to  peer  reviewed  journals  of  unbiased  educational  material.  Today,  DentalXP  has  over  16,000  members  in  over  160  countries  around  the  world  and  growing  rapidly.   The  heightened  interest  from  these  registrants  have  led  DentalXP.com  to  initiate  Hands-­On-­Training  (HOT)  programs  beginning  this  year.   Combining  on-­line  dental  education  with  HOT  modules  is  the  future  of  dental  education.

Biography Maurice Albert Salama, DMD Dr. Maurice A. Salama completed his undergraduate studies at the State University of New York at Binghamton in 1985, where he received his B.S. in Biology. Dr. Salama received his D.M.D. from the University of Pennsylvania School of Dental Medicine where he later also received his dual-specialty certification in Orthodontics and Periodontics, as well as implant training at the Brånemark Center at Penn. He is currently on the Faculty of the University of Pennsylvania and the Medical College of Georgia as Clinical Assistant Professor of Periodontics, and is visiting Professor of Periodontics at Nova Southeastern University in Florida.

Dr. Salama has completed an ADA accredited hospital based General Practice Residency at Maimonides Medical Center in New York City. He has had the opportunity to further

broaden his clinical horizons through externships at Hadassah Hospital, Hebrew University in Jerusalem and Beth Israel Hospital in New York City, in 1988 and has been a contributor to the dental literature. His very unique background includes specialized training in Orthodontics, Periodontal Surgery, and Implant Dentistry.

Dr. Salama is a partner in the Atlanta Esthetic Dental Practice known as “Team Atlanta”. His partners include Dr. David Garber, Dr. Ronald Goldstein and his brother, Dr. Henry Salama.

This group has an international reputation for interdisciplinary care, dental education and has published hundreds of articles and several text books.

Expert for Channel 5 Fox TV in Atlanta. He is an active member in the American Association of Orthodontists, the American Academy of Periodontics, the Academy of Osseointegration, the American Academy of Esthetic Dentistry, and the American Academy of Implant Dentistry. Recently, Dr. Salama has been a speaker at programs for the Academy of Osseointegration, the American Association of Orthodontists, the American Academy of Periodontology, the American Academy of Esthetic Dentistry, the Interdisciplinary Care Conference presented by five Academies, the American Academy of Cosmetic Dentistry, Alpha Omega International, and the Chicago Dental Society.

Dr. Salama is a featured Xpert content provider and member of the Scientific Committee of the leading web-based dental education site www.DentalXP. com.

In private practice at: Goldstein, Garber, & Salama, LLC 600 Galleria Parkway, suite 800 Atlanta, GA 30339 www.goldsteingarber.com

Dr. Salama served as the Dental

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appliancereview

Introducing The Silent Sleep Trial Oral Appliance For Snoring And Sleep Apnea

An invaluable addition to appliances and treatment for sleep disordered patients.

By  Dr.  Jamison  R.  Spencer,  DMD,  MS

W

e  all  know  that  boil  and  bite  appliances  currently  on  the  market  are  great  for  certain  patients,  but  we  also  know  that  they  can  sometimes  be  frustrating  to  use.   A  little  over  a  year  ago  I  set  out  to  develop  a  new  type  of  non-­custom  appliance.   After  months  of  development,  prototypes,  and  trials,  I  developed  what  I  believe  to  be  an  excellent  non-­custom  oral  appliance.   I  have  named  it  the  â&#x20AC;&#x153;Silent  Sleep.â&#x20AC;?

In  creating  the  Silent  Sleep  I  tried  to  develop  a  pre-­fabricated,  customizable  appliance  that:

s (AD MAXIMUM TONGUE SPACE AND WASN T OVERLY BULKY s 7AS COMFORTABLE FOR THE PATIENT TO WEAR s 7AS EASY TO lT AND DIDN T REQUIRE BOILING s 7AS EASY FOR THE DENTIST TO ADJUST s 7OULD LAST A REASONABLE AMOUNT OF TIME WITH PROPER CARE 7KH 6LOHQW 6OHHS LV ÂżW XVLQJ vinyl  polysiloxane  denture  reline  material  (GC  Soft  Reline).   This  makes  the  appliance  much  easier  WR ÂżW WKDQ ÂłERLO DQG ELWH´ W\SH appliances.   In  addition,  unlike  boil  and  bite  appliances,  the  Silent  6OHHS PD\ EH DGMXVWHG RU UH ÂżW DV many  times  as  needed.   The  Silent Â

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DENTAL Â SLEEP Â MEDICINE

Sleep  is  also  unique  in  that  it  uses  only  the  sleep  disordered  breathing  patients.   It  is  my  hope  that  use  of  the  Silent  Sleep  posterior  teeth  for  support  and  retention.   As  such,  the  appliance  allows  for  excellent  ZLOO VLJQL¿FDQWO\ LQFUHDVH WKH QXPEHU RI patients  that  you  are  able  to  help  in  your  WRQJXH VSDFH DQG LV VLJQL¿FDQWO\ OHVV FRPPXQLW\ DQG bulky  than  other  as  you  improve  non-­custom  Possible uses for: the  health  of  appliances.

THE SILENT SLEEP your  patients,   The  Silent  improve  the  Sleep  is  easy  to  ¿QDQFLDO KHDOWK use,  inexpensive,  s ! TEMPORARY APPLIANCE WHILE A of  your  practice  comfortable  custom made appliance is fabricated. as  well.   and  effective.    For  further  Whether  you  s ! SPARE APPLIANCE FOR TRAVEL OR CAMPING information,  have  been  please  contact  treating  patients  s ! TRIAL APPLIANCE FOR PATIENTS WHO ARE me  directly  with  sleep  uncertain about oral appliance therapy. via  email  at  disordered  Jamison@ breathing  for  s !N IMMEDIATE lT APPLIANCE IN THE SLEEP mysilentsleep. years,  or  you  lab for patients who are found during the com,  or  contact  are  just  getting  CPAP titration to be CPAP intolerant.

McMullin  Labs  started,  the  at  1-­888-­872-­ Silent  Sleep  s ! LOWER COST ALTERNATIVE TO CUSTOM 8538  for  sales  will  allow  you  made appliances when treating patients inquiries.    We  WR VLJQLÂżFDQWO\ who have been diagnosed by their DUH LQ WKH ÂżQDO increase  the  physician as â&#x20AC;&#x153;primary snorersâ&#x20AC;? and have stages  of  FDA  number  of  no insurance coverage, or otherwise approval  and  patients  that  you  have limited financial resources. will  soon  offer  are  able  to  help. the  Silent  Sleep   The  Silent  s ! TEMPORARY BRUXISM APPLIANCE OR to  U.S.  dentists.   Sleep  is  not  protective appliance in veneer cases.

To  ensure  that  intended  to  be  you  are  among  a  replacement  s !N APPLIANCE FOR PATIENTS TO USE WHILE WKH ÂżUVW GHQWLVWV for  custom  undergoing orthodontic therapy. to  offer  the  appliances,  but  Silent  Sleep,  rather  another  please  contact  tool  to  help  McMullin  Labs  to  place  an  order  today. you  in  the  treatment  of  patients  with  snoring  and  sleep  apnea.   I  believe  that  the  Jamison  R.  Spencer,  DMD,  MS Silent  Sleep  will  become  an  invaluable  Diplomate,  American  Academy  of  addition  to  your  armamentarium  of  Craniofacial  Pain custom  appliances,  CPAP/oral  appliance  Diplomate,  American  Academy  of  Dental  combination  appliances,  and  other  Sleep  Medicine treatments  that  you  are  providing  to  your Â

Protocol For Snoring Problems Male Age 18 Continued  from  Page  11

save  his  life  with  appropriate  treatment!  Justin  is  this  18  year  old  patient  ZKR FDPH WR P\ RI¿FH +H ZHLJKHG 230  pounds  and  his  neck  measured  20  inches.   Clinically,  I  have  found  that  any  male  with  a  neck  circumference  greater  than  17  inches  is  susceptible  to  OSA.   I  recommend  that  these  patients  be  scheduled  for  a  consultation  appointment  with  your  dental  assistant  who  is  knowledgeable  in  sleep  disorder  dentistry.     You  must  train  someone  on  your  staff  to  educate  these  patients  regarding  the  serious  health  consequences  of  failure  to  treat  OSA.   Our  protocol  is  as  follows: 1. TMJ Health Questionnaire 2. Epworth Sleepiness Scale 3. Rhinometer to check for nasal obstructions 0HARYNGOMETER TO CHECK FOR THE COLLAPSIBILITY OF THE pharyngeal airway when the patient exhales.

5. Sample Oral Appliances

The  patient  is  shown  samples  of  two  possible  oral  appliances  that  are  titratable  antero-­posteriorly  as  well  as  vertically.   Do  not  confuse  the  patient  by  showing  them  too  many  oral  appliances.  The  sleep  assistant  will  educate  the  patient  as  to  the  importance  of  diagnosing  and  treating  these  problems.   This  appointment  lasts  approximately  thirty  minutes,  and  then  I  arrive  and  meet  the  QHZ SDWLHQW ,Q -XVWLQœV FDVH , UHYLHZHG the  data  collected  by  the  assistant  and  explained  it  to  him: 1. TMJ Health Questionnaire This form revealed that he snored at night but he never had a sleep study done at a sleep clinic (hospital), and he was never diagnosed with sleep apnea.

2. Epworth Sleepiness ScaleTotal 15 This indicates a serious problem with daytime sleepiness which is one of the main symptoms of OSA. 3. Rhinometer Test This revealed that there were no nasal obstructions.

4. Pharyngometer Test This revealed that his airway collapsed to .76 cm2

when he exhaled (normal airway is 2.0 cm2).

Based  on  his  Epworth  Sleepiness  Scale  of  15,  the  collapsed  airway  and  severe  snoring  problem,  I  recommended  an  appointment  for  a  complete  set  of  records  including  an  evaluation  of  his  nasal,  oral  and  pharyngeal  airway.  The  records  appointment  involves  the  following: 1. Sleep Screening Questionnaire This form will identify all the problem areas with a history of the signs of OSA including frequent heavy snoring which affects the sleep of others. The patient had been told that he stops breathing when sleeping, gasps for air when waking up and had nighttime choking spells. These forms may be obtained from .IERMAN 0RACTICE -ANAGEMENT These forms further revealed that Justin had a history of asthma, chronic sinus problem, heartburn or sour taste in his mouth at night, insomnia, nighttime sweating, memory loss, and inability to concentrate.

This Sleep Screening Questionnaire also revealed that his father had been treated for a sleep disorder and had a history of heart disease, high blood pressure and diabetes. Obviously, Justin who has a BMI of 36 (normal male BMI is 30) is predisposed to cardiovascular disease, type 2 diabetes and already has gastroesphageal reflux (GERD).

2. Pharyngometer Test The sleep assistant will attempt to find a position where the collapsed airway increases in size when the jaw is put in different positions. Different wax bite registrations are taken in order to find the best position to fabricate the oral appliance. The best registered reading WAS WHEN THE MANDIBLE WAS ADVANCED MM AND THE VERTICAL WAS INCREASED MM CM 4HIS WAS less than the original reading of .76 cm2. If the airway does not increase in size with the pharyngometer test when the mandible is moved forward, then this usually indicates that the oral appliance may not be successful unless the cause of the airway obstruction is resolved.

3. Oral Examination 4HIS REVEALED ENLARGED GRADE TONSILS AND AN enlarged uvula obstructing the airway.

4. Overnight Sleep Study We use the Embletta 100 home sleep study as an initial screening device, and also to help titrate the oral appliance before referring them back to the sleep clinic for confirmation that the oral appliance helped reduce the snoring and sleep apnea. The patient is able to sleep in their own bed and the results are available the next day. Justinâ&#x20AC;&#x2122;s results were: 2$)

3EVERE /3! !()

3EVERE /3!

5. Polysomnogram The patient is referred to a sleep clinic for a polysomnogram test. The diagnosis of OSA must be made by a sleep specialist. Justinâ&#x20AC;&#x2122;s test result was:

!()

3EVERE /3!

The diagnosis by the sleep specialist was severe OSA. The sleep specialist recommended another sleep study with the CPAP device. Justin is age 18 and he did not want to wear the CPAP. I had informed him previously that if he had snoring and mild to moderate OSA, I would be willing to fabricate an oral appliance. I recommended the surgical removal of his enlarged tonsils and uvula. Once the severe airway obstructions were eliminated, another sleep study would be done to evaluate the severity of the OSA. 6. E.N.T. Specialist 4HE PATIENT IS REFERRED TO AN % . 4 SPECIALIST FOR THE removal of his enlarged tonsils and enlarged uvula.

7. Overnight Sleep Study (post surgical) After Justinâ&#x20AC;&#x2122;s tonsils and uvula were removed, the result was: RDI 12 Mild OSA 8. Consultation with Parent Due to the fact that Justin now had mild OSA, still snored slightly, had acid reflux and a family history of heart attacks and diabetes, it was decided to proceed with the oral appliance.

9. Overnight Sleep Study with Oral Appliance The result with the sleep study wearing an oral appliance was: 2$)

.ORMAL

 We  were  able  to  lower  the  RDI  from  42  (polysomnogram)  to  an  RDI  of  6  by  the  surgical  removal  of  the  enlarged  tonsils  and  uvula,  and  the  oral  appliance  which  moved  his  lower  jaw  slightly  forward  and  protected  his  airway  by  preventing  the  mandible  from  collapsing  his  airway  at  night  when  he  slept  on  his  back.    If  you  follow  the  protocol  as  I  have  discussed  above,  I  think  you  will  achieve  a  high  level  of  success  with  your  oral  appliances.   I  must  stress  the  fact  that  you  need  to  work  closely  with  your  medical  colleagues  in  your  area.   You  need  the  sleep  specialist  to  do  the  polysomnogram  to  diagnose  obstructive  sleep  apnea.   If  there  is  an  obstruction  in  the  nasal  pharyngeal  or  oropharyngeal  airway,  you  need  the  cooperation  of  an  E.N.T.  specialist  to  surgically  correct  the  problem.  This  case  was  successful  because  I  worked  closely  with  two  of  my  medical  colleagues  to  help  my  young  18  year  old  patient.   I  feel  that  I  prolonged  his  life  expectancy  not  to  mention  the  fact  that  by  relieving  his  serious  snoring  problem  (70  decibels),  I  am  certain  that  will  help  improve  his  overall  health  as  well  as  his  love  life.  WWW.SLEEPGS.COM

47

PneumodonticsÂŽ The Evolution of a new sub-specialty in dentistry.

By  Dr.  John  C.  Jeppesen,  DMD

A

s  a  result  of  my  own  journey  to  correct  my  snoring  and  sleep  apnea  problem,  I  became  absolutely  fascinated  with  the  practice  of  sleep  medicine.  Besides  my  wife  Brenda,  the  great  inspiration  for  me  was  my  personal  mentor,  the  late,  great  Dr.  Jim  Garry.  It  was  in  1996,  after  turning  40,  that  I  began  my  quest  to  solve  my  own  GLOHPPD 2QFH ÂżUPO\ LQWR PLGGOH DJH , began  to  notice  the  frequent  absence  of  my  wife  upon  awakening  in  the  morning.   The  answer  as  to  why  this  event  kept  occurring  became  crystal  clear  when  Brenda  played  me  an  audio  tape  of  the  sounds  I  was  evidently  capable  of  making  at  night.  After  hearing  the  recording,  P\ ÂżUVW WKRXJKW was  that  Brenda  had  taped  a  Harley  Davidson  commercial.  Certainly  no  human  could  make  that  much  noise.  Turning  to  my  then  six-­year-­old  son,  I  asked,  â&#x20AC;&#x153;Is  this  really  me?â&#x20AC;?  Without  hesitation,  my  son  FRQFXUUHG WKDW Âł<HV 'DG WKDWÂśV \RX ´ , ZDV KRUULÂżHG EXW DFFHSWLQJ RI WKH SUREOHP I  was  creating  in  my  household.    So  for  the  next  year  I  agreed  to  sleep  out  in  the  living  room  so  that  my  wife  and  son  could  get  their  well-­deserved  rest.  During  that  period  of  time  Brenda,  an  internet  neophyte,  found  a  Space  Maintainers  sponsored  course  on  snoring  and  insisted  that  I  take  the  course  ASAP.  The  course  was  taught  by  a  couple  of  orthodontists  who  demonstrated  a  dual  arch,  boil  DQG ELWH Âż[HG SRVLWLRQ 0DQGLEXODU Advancement  Device  (MAD).  Most  of  the  dentists  at  that  meeting  had  this  appliance  made  for  them.  I  recall  being  very  excited  about  this  area  of  practice  that  I  literally  knew  nothing  about.  But  I Â

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DENTAL Â SLEEP Â MEDICINE

do  remember  a  painful  look  on  one  RI WKH RUWKRGRQWLF LQVWUXFWRUÂśV IDFHV when  asked  how  far  to  advance  the  lower  jaw.  With  a  mild  cringe,  the  orthodontist  said  he  recommended  NOT  to  advance  beyond  â&#x20AC;&#x153;end-­to-­end.â&#x20AC;?  So  WKDWÂśV ZKHUH P\ RULJLQDO 0$' ZDV PDGH for  me.   I  took  it  home  and  it  seemed  to  ZRUN PLUDFXORXVO\ DW ÂżUVW LQ TXLHWLQJ down  the  Harley.  My  wife  was  now  back  in  my  bed  when  I  woke  up  in  the  morning.   I  thought,  â&#x20AC;&#x153;Gee,  that  was  easy.â&#x20AC;?  I  became  excited  that  this  was  a  new  area  of  practice  I  had  never  considered  before.  Fast  forward  about  4  months  later Â

and  Brenda  informed  me  that  my  snoring  had  returned.  7KDWÂśV ZKHQ I  reviewed  the  Space  Maintainers  literature  references  way  in  the  back  of  the  document  entitled  â&#x20AC;&#x153;Recommended  Reading  References.â&#x20AC;?  This  is  where  I  found  the  reference  to  a  couple  of  documents  authored  by  Dr.  Jim  Garry.  I  bought  these  publications  and  soon  thereafter  I  signed  up  for  his  two-­day  course  in  October  of  1996.  Jim  introduced  me  to  the  concept  of  â&#x20AC;&#x153;adjustableâ&#x20AC;?  MAD  devices.

1RW ORQJ DIWHU -LPÂśV FRXUVH , VZLWFKHG to  another  MAD  that  was  at  least  semi-­ adjustable.  To  correct  my  snoring  this  time,  I  had  to  advance  my  mandible Â

beyond  edge-­to-­edge.  I  noticed  a  bit  of  tenderness  in  my  TMJs  and  teeth,  but  it  ZDVQÂśW ÂłWKDW EDG´ DQG %UHQGD DVVXUHG me  that  the  snoring  was  again  mitigated  VXIÂżFLHQWO\ )DVW IRUZDUG WR P\ ÂżUVW PHHWLQJ RI WKH ADSM  (June  2000-­Las  Vegas)  and  I  was  introduced  to  several  different  devices.  I  was  excited  about  the  Thornton  Adjustable  Positioner  (TAPÂŽ)  as  it  was  adjustable  down  to  a  quarter  millimeter.  The  other  device  that  fascinated  me  was  the  OPAPÂŽ.   I  knew  nothing  about  positive  airway  pressure  in  2000  and  bought  myself  a  TAPÂŽ  kit.  I  fabricated  the  TAPÂŽ  and  the  adjustability  of  the  device  made  sense  to  me.  If  my  snoring  returned,  I  simply  turned  the  advancement  knob  and  I  again  was  quiet  at  night.  Most  importantly,  Brenda  was  happy.  When  I  started  my  treatment  with  the  TAPÂŽ  I  had  a  near  perfect  Class  I  occlusion.  I  always  took  this  for  granted.   I  could  chew  the  steaks  I  loved  so  much  and  the  MAD  was  only  being  used  at  night,  so  I  thought  that  the  early  morning  advancement  RI P\ PDQGLEOH ZKLFK DW ÂżUVW ZDV temporary  when  used  with  the  â&#x20AC;&#x153;Leaf  Gauges,â&#x20AC;?  was  still  acceptable.   However,  after  approximately  13-­14  months  into  treatment  with  the  TAPÂŽ,  I  noticed  that  , FRXOGQÂśW JHW P\ ORZHU MDZ EDFN LQWR maximal  intercuspation,  i.e.,  Class  I  position.  To  my  dismay,  I  noticed  that  my  occlusion  was  fairly  rapidly  progressing  from  a  near  perfect  Class  I  relationship  to  a  mild  Class  III.  I  began  to  have  trouble  chewing  my  beloved  steaks  and  also Â

noticed  that  making  my  â&#x20AC;&#x153;sâ&#x20AC;?  sounds  during  VSHHFK ZDV EHFRPLQJ PRUH GLIÂżFXOW Nevertheless,  I  continued  using  the  device.  However,  as  the  months  rolled  on,  Brenda  would  periodically  inform  me  that  I  needed  to  advance  further  to  maintain  the  control  of  my  snoring  problem.  Not  wanting  to  end  up  back  on  the  couch  and  not  at  all  sure  that  I  was  ready  for  CPAP,  I  continued  to  advance  the  TAPÂŽ  for  the  next  several  years.   Referring  to  my  original  pre-­treatment  casts  (2000)  in  early  2003,  I  noticed  that  I  had  a  permanent  advancement  of  my  mandible  equal  to  approximately  6mm.  I  even  made  a  reverse  TAPÂŽ  as  a  morning  repositioner  to  help  clear  prognathia  back  as  far  as  I  could.  This  approach  was  clearly  not  working  and  now  I  began  to  encounter  fracture  of  some  posterior  teeth  as  my  bite,  on  most  all  teeth,  was  cusp  on  cusp  and  edge-­to-­edge.  Also  I  noticed  that  I  had  developed  an  obvious  anterior  open  bite  precluding  incisal  mastication  such  that  to  eat  my  beloved  steak,  I  had  to  bite  on  my  premolars.  From  2000  to  mid-­2003  I  continued  to  treat  my  own  patients  with  MAD.   However,  now  some  of  my  patients  were  reporting  similar  permanent  advancement  issues.  Then  the  straw  that  broke  my  FDPHOÂśV EDFN ZDV WKH SUHOLPLQDU\ data  presented  by  the  esteemed  Dr.  Alan  Lowe  (ADSM-­Chicago-­2003)  indicating  that  at  least  70%  of  Class  I  occlusions  were  at  risk  of  becoming  Class  III  occlusions  due  to  the  MAD  DSSURDFK 'U /RZHÂśV GDWD DV , UHFDOO ZDV derived  from  study  of  his  own  Kleerway  appliance.  To  say  the  least,  this  really  VKRRN PH XS 7KH ÂżUVW UXOH LQ PHGLFLQH LV to  â&#x20AC;&#x153;do  no  harm.â&#x20AC;?  And  clearly,  I  was  doing  harm,  or  at  least  producing  unreasonable  ULVN IRU P\ RZQ SDWLHQWV 7KDWÂśV ZKHQ , made  the  decision  to  stop  recommending  mandibular  advancement  to  as  many  patients  as  I  could.

 Rolling  back  to  2000,  I  had  also  started  to  treat  my  patients  with  moderate  to  severe  OSAS  using  the  OPAPÂŽ  device.   Using  this  device,  I  was  able  to  treat  very  high  RDIs  successfully.  Between  2000  and  2005,  I  had  now  surpassed  Dr.  Richard  Moore  as  the  doctor  who  had  made  the  most  OPAPÂŽ  devices  in  the  world.  Along  the  way  I  learned  a  couple  of  things.   One,  oral  positive  airway  pressure  had  its  place.  It  worked  particularly  well  for  patients  with  extreme  nasal  impatency.   Second,  I  attempted  to  treat  one  patient  with  a  history  of  TMD  and  advanced  her  mandible  a  mere  2mm  and  she  had  D PDMRU Ă&#x20AC;DUH XS of  TMD  and  left  my  practice  never  to  return  again.  For  some  reason,  I  thought  it  was  in  fact  necessary  to  advance  mandibles  even  when  using  PAP.  I Â

was  thoroughly  brainwashed  into  thinking  that  all  sleep  apnea  dental  treatments  must  include  mandibular  advancement,  regardless  of  whether  the  power  of  positive  airway  pressure  was  really  doing  all  the  work  of  correcting  OSAS.  Regarding  OPAPÂŽ,  I  also  learned  along  the  way  that  case  selection  was  extremely  important  because  my  rate  of  positive  outcome  was  60%  to  70%  at  best.  As  an  anal-­retentive  dentist,  this  was  not  acceptable  to  me.  I  needed  a  new  solution.   Because  I  was  an  inventor  before  I  became Â

a  dentist,  solving  problems  creatively  was  very  natural  for  me.    So  again,  I  proceeded  with  my  journey  to  create  a  better,  more  powerful  and  consistent  solution  to  treating  OSAS  patients,  which  was  now  all  I  did  in  P\ SUDFWLFH , UHDOO\ ZDVQÂśW D GHQWLVW DQ\PRUH , GLGQÂśW WUHDW DQ\ SUREOHPV with  teeth  or  gums,  and  I  certainly  was  at  least  a  mild  neophyte  as  concerns  the  treatment  of  TMD.  I  never  went  through  DQ LQWHUQVKLS DQG UHVLGHQF\ WKHUHIRUH , ZDV QRW D SK\VLFLDQ 6R LI , ZDVQÂśW D GHQWLVW DQG ZDVQÂśW D SK\VLFLDQ DQG P\ practice  was  limited  to  treating  a  medical  condition,  sleep-­disordered  breathing,  now  usually  with  CPAP  and  BiPAP,  what  was  I?  I  have  also  always  been  uncomfortable  with  the  term  â&#x20AC;&#x153;Dental  Sleep  Medicine.â&#x20AC;?   :H DOO NQRZ WKDW WHHWK GRQÂśW VOHHS $QG the  physicians  who  were  involved  in  sleep  PHGLFLQH GLGQÂśW FDOO WKHPVHOYHV 0HGLFDO Sleep  Medicine  specialists.  I  concluded  that  there  was  only  sleep  medicine  going  on  here.  But  sleep  medicine  itself  includes  a  very  large  number  of  other  esoteric  sleep  disorders  that  were  not  the  focus  of  my  practice.  My  focus  was  simple.  My  practice  was  all  about  helping  patients  WR EUHDWKH 7KDWÂśV when  I  realized  that  I  really  was  a  PneumodontistÂŽ.  /LNH WKH ÂżUVW orthodontist,  endodontist,  periodontist,  prosthodontist,  and  pedodontist,  I  was  WKH ZRUOGÂśV ÂżUVW PneumodontistÂŽ KHQFH WKH GHYHORSPHQW of  a  brand  new  subspecialty  in  dentistry  which  I  entitled  PneumodonticsÂŽ.  All  I  did  all  day  long  in  my  practice  now  was  to  treat  SDB  patients  with  various  forms  of  positive  airway  pressure.  I  also  realized  that  advancing  the  mandible  was  not  necessary  and  in  fact  introduced  unreasonable  risk  to  my  SDB  patients.  I  also  realized  that  God  designed  our  human  Continued  on  Page  46

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Pneumodontics

ÂŽ

Continued  from  Page  45 respiratory  tracts  to  preferably  breathe  nasally.    Another  exciting  development  was  occurring  in  the  engineering  of  CPAP  machines.  I  learned  of  AutoCPAP  and  C-­FLEX  (expiratory  relief).  C-­FLEX  is  the  best  thing  to  happen  to  CPAP  since  its  invention  by  Sullivan  because  it  makes  exhaling  against  the  incoming  PAP  really  easy  for  most  patients.  Therefore,  this  notion  that  we  need  to  advance  mandibles  to  lower  therapeutic  pressure  was  completely  false.    My  SDB  practice  was  built  on  other  SK\VLFLDQVÂś IDLOXUHV WR SURGXFH SRVLWLYH RXWFRPHV /RFDO ERDUG FHUWLÂżHG VOHHS physicians  who  could  not  get  their  patients  well  began  to  send  me  their  so-­called  â&#x20AC;&#x153;CPAP  intolerantâ&#x20AC;?  or  â&#x20AC;&#x153;CPAP  failureâ&#x20AC;?  patients.  I  soon  learned  that  these  archaic  terms,  â&#x20AC;&#x153;intoleranceâ&#x20AC;?  and  â&#x20AC;&#x153;failureâ&#x20AC;?  were  in  fact  misnomers.  3DWLHQWV UDUHO\ IDLO &3$3 rather  these  patients  were  simply  not  given  an  opportunity  to  succeed.  There  is  a  difference.  In  my  quest  to  create  a  better  solution  for  patients  who  could  not  tolerate  STANDARD  therapy,  I  had  to  learn  what  the  major  issues  were  regarding  failure  of  STANDARD  therapy.  The  chief  complaints  were: A -ASK DISCOMFORT B -ASK LEAKAGE C #LAUSTROPHOBIA D )NADVERTENT MASK REMOVAL E -OUTH VENTING OF 0!0 f) Difficulty in tolerating high therapeutic pressures.  The  answer  was  to  individualize/ customize  the  pressure-­based  cases.   Realizing  that  most  STANDARD  masks  were  made  on  manikin  heads  on  mass-­ production  lines  in  China,  it  was  no  wonder  that  at  least  50%  of  my  patients  were  having  CPAP  interface  problems.  Â

50

DENTAL Â SLEEP Â MEDICINE

The  medical  technology  industry  was  using  a  cookie  cutter  approach.  Cookie  cutters  are  great  for  making  cookies  but  not  really  effective  in  applying  this  principle  to  treating  humans,  where  their  molds  are  ALL  different.  And  as  they  say,  the  mold  is  broken  (by  God)  after  the  human  is  made.  So  by  approaching  each  case  individually  and  like  a  detective,  IHUUHWLQJ RXW HDFK SDWLHQWÂśV PDMRU complaints  with  STANDARD  therapy,  it  was  possible  to  successfully  treat  most  SDB  patients  with  the  gold  standard:   CPAP  therapy.  Using  this  (customizing)  approach,  I  was  able  to  take  more  than  42  consecutive  so-­called  failures  of  STANDARD  CPAP  therapy  and  make Â

them  CPAP  champions.   Again,  these  patients  were  not  intolerant  of  CPAP  nor  KDG WKH\ IDLOHG &3$3 WKH\ MXVW ZHUH not  given  the  opportunity  to  succeed.   CPAP,  when  utilized  correctly,  is  a  very  attractive  therapy  because  it  is  inherently  safe,  requires  no  surgery  or  drugs,  and  is  purely  homeopathic  as  it  utilizes  room  air  to  create  a  pneumatic  splint.  CPAP  is,  in  fact,  a  very  elegant  solution  if  the  clinician  knows  how  to  make  it  work  for  the  patient.  Inventing,  as  Thomas  Edison  once  said,  is  1%  inspiration  and  99%  perspiration.   Inventing  requires  hard  work,  attention  to  detail,  and  stubborn  persistence,  with Â

revisions  and  constant  prototyping.  The  other  very  important  fact  to  understand  about  inventing  is  that  there  are  NO  PERFECT  SOLUTIONS.  This  is  particularly  true  in  medicine,  as  every  time  we  address  the  chief  complaint  of  the  patient  successfully,  we  invariably  FUHDWH D QHZ SUREOHP WKDW OLNHO\ GLGQÂśW exist  before.  This  is  an  extremely  important  message  to  translate  to  your  SDWLHQWV VR WKDW WKH\ GRQÂśW KDYH XQUHDOLVWLF expectations.  Statistically,  in  my  practice,  I  can  get  about  90%  of  all  SDB  patients  onto  PAP  regardless  of  the  size  of  the  patient,  the  severity  of  the  index,  or  the  type  of  SDB,  i.e.,  obstructive,  central,  or  complex.  When  I  treat  a  SDB  patient,  I  need  to  know  two  facts  to  start.  First:   Is  the  type  of  CPAP  machine  that  they  were  introduced  to  appropriate  for  the  patient?   Second:  Can  they  utilize  a  STANDARD  interface/mask?  Typically,  the  so-­called  failure  of  STANDARD  CPAP  arrives  at  my  RIÂżFH EHLQJ FXUUHQWO\ WUHDWHG XVLQJ SINGLE  PRESSURE  THEORY.  Single  Pressure  Theory  (SPT)  has  VRPH EDVLF SUREOHPV WKDW MXVW GRQÂśW make  common  sense.  SPT  is  based  on  a  faulty  assumption  which  is  that  the  upper  airway  dynamics  of  the  patient  remain  a  constant  as  if  the  upper  airway  is  made  from  a  rigid  material  like  PVC.  Nothing  could  be  further  from  the  truth.  Upper  airways  are  dynamic  structures  that  change  continuously  throughout  the  night  and  vary  in  their  rigidity  every  single  night.  Therefore,  attempting  to  treat  a  patient  with  a  single  pressure  does  not  make  much  common  sense.  SPT  is  determined  in  the  sleep  lab  using  a  supposed  worst  case  scenario.  The  single  pressure  determined  in  the  sleep  lab  via  PSG  is,  at  best,  a  snapshot  in  time.   The  patient  is  supine  and  in  REM,  and  during  this  examination  whatever  pressure  reduces  the  AHI/RDI  on  that  night  in  the Â

lab  is  assumed  to  be  correct  for  the  next  night.  Hard  evidence  suggests/proves  that  no  patient  should  ever  be  treated  using  a  single  pressure.  Therapeutic  pressure  requirements  vary  from  night-­to-­ night  for  all  patients.  Correct  pneumatic  splinting  requires  delivering  just  the  right  pressure  at  any  given  moment,  i.e.,  not  too  much,  not  too  little.  I  call  this  the  therapeutic  window,  and  again,  this  therapeutic  window  changes  with  every  patient  from  night  to  night.  This  is  why  most  of  my  patients  are  treated  using  an  AUTOCPAP  machine.  This  AUTOCPAP  machine  delivers  the  right  amount  of  pressure  minute-­to-­minute,  night-­to-­night.  In  fact,  because  the  optimal  amount  of  REM  sleep  is  about  25%  of  TST  (Total  Sleep  Time),  setting  a  single  pressure  for  this  patient  will  often  result  in  over  pressurization  75%  of  the  time.  Over  pressurization  will  often  create  abnormal  respiratory  events  and  resultant  brain  arousals.    Automatic  (CPAP)  algorithms  used  by  single,  bi-­level  S,  bi-­ level  ST,  and  servo-­ ventilators  require  correct  feedback  to  the  machine  for  it  to  work  effectively.   Correct  feedback  assumes  perfect  pneumatics,  i.e.,  control  of  leaks.  Without  control  of  the  leaks,  the  automatic  adjusting  machines  will  typically  overcorrect/over-­ventilate.   Therefore,  the  objective  with  the  interface,  be  it  STANDARD  or  CUSTOM,  is  to  create  excellent  pneumatic  control  of  untoward  leaks.  This  is  the  key.

 When  a  patient  cannot  tolerate  a  STANDARD  interface  or  the  pneumatics  are  not  excellent,  I  advance  the  patient  to  a  custom  interface.  This  could  be  an  OPAPŽ,  but  what  I  utilize  most  often  is  trademarked  as  the  JPAPŽ  Obturator.   JPAPŽ  is  an  acronym  that  stands  for  Jeppesen  Positive  Airway  Pressure.   Hallmark  features  of  the  JPAPŽ  Obturator  are: s $UAL ARCH ORTHOTIC WHICH IS BUILT WITHOUT PROTRUSION of the mandible in a neutral centric position. This is an orthopedically sound (patented) position that is kind to the TMJs. Typically this neutral centric position will be where TMJ specialists record their

neutral centric position is up to the clinician and may include TENS, Energex, Phonetic techniques, etc. s 4HIS DUAL ARCH ORTHOTIC SHOULD HAVE A COMFORTABLE snap-fit to position and hold the maxilla and mandible together, without lateral movement, to prevent mouth venting of PAP. s 4HE *0!0Â&#x161; HAS NO MASK STRAPS OR HEADGEAR s 4HE *0!0Â&#x161; FRONT END NASAL APPLICATION 0,!4&/2device sits upon a cylindrical slide which is mounted to the anterior surface of the orthotic positioned at the nasal midline. s %ACH 0,!4&/2- IS CUSTOM DRILLED AND TAPPED FOR proper NASAL ANGULATION. s %ACH SIDE OF THE pressure tubing has RIGID TUBES that are milled with spiral threads to permit precise adjustment to the left and right nares of the patientâ&#x20AC;&#x2122;s nose. s 3ITTING ON TOP OF THE RIGID SPIRAL THREADED TUBES are SWIVEL PILLOWSÂŽ. These swivels are composed of ball and socket joints which permit 360 degree rotation at a 30 degree compound angle.

This permits precise angulation into the nares. s 4HE 0,!4&/2- PERMITS AP adjustment closer to the face or further away

bite registrations to treat TMJ Dysfunction. If the TMJ patient requires a daytime orthotic/splint, this neutral centric position for the JPAPÂŽ will be almost identical to the splint position. The only difference would be to make sure the patient has an appropriate vertical dimension of occlusion (VDO) to allow for adequate tongue volume. The method of finding this

from the face depending on the length of the nose itself. s #OUNTER CLOCKWISE OR CLOCKWISE ROTATION OF THE entire PLATFORM permits equalization of the nasal pillow compression for comfort into each nare.

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Obstructive Sleep Apnea and CPAP

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29%  and  83%  of  patients  did  not  adhere  to  therapy.   Fortunately  there  is  an  extensive  body  of  evidence  that  supports  three  low  cost  interventions  proven  to  improve  acceptance,  adherence  and  compliance.   The  three  proven  interventions  are  heated  KXPLGLÂżFDWLRQ DW LQLWLDWLRQ RI WKHUDS\ PDVN VHOHFWLRQ DQG ÂżW DQG ODVWO\ SDWLHQW HGXFDWLRQ and  follow  up.  Lifetime  follow  up  may  be  one  of  the  most  important,  yet  almost  always  overlooked,  aspects  of  successful  CPAP  treatment.  Durable  medical  equipment  (DME)  dealers  are  normally  the  companies  that  set  up  patients  on  CPAP  under  the  direction  of  a  medical  professional.  Long  term  follow  up  with  CPAP  patients  falls  into  5  types  and  over  time  companies  may  progress  in  their  follow  up  regimen.   The  least  effective  follow  up  is  termed  â&#x20AC;&#x153;set Â

â&#x20AC;&#x2DC;em  and  forget  â&#x20AC;&#x2DC;emâ&#x20AC;?.  This  is  the  company  WKDW SURÂżWV IURP WKH LQLWLDO VDOH DQG DQ\ additional  contact  with  the  patient  that  goes  un-­reimbursed  simply  adds  cost  and  GHWUDFWV IURP WKH SURÂżWDELOLW\ RI WKH RULJLQDO sale.  The  second  stage  is  when  the  DME,  somtimes  reluctantly,  sells  supplies  to  a  walk-­in  patient.  This  takes  time  from  the  respiratory  therapist  and  costs  more  than  the  SURÂżW IURP WKH VDOH RI &3$3 VXSSOLHV 7KH next  evolution  involves  outbound  calls  to  patients  from  a  small  local  branch  or  single  unit  DME  dealer  and  then  mailing  supplies  to  the  patient.  Unfortunately  the  urgent  takes  precedent  over  the  vital,  and  COPD  patients  requiring  supplemental  oxygen  are  handled  before  making  proactive  follow  up  calls  to  CPAP  patients.  The  fourth  stage  involves  centralizing  those  calls  in  one  location  to  avoid  day  to  day  operational  and  FOLQLFDO LQWHUUXSWLRQV 7KH ÂżQDO VWHS LQ WKH evolution  of  long  term  or  lifetime  follow  up  for  CPAP  patients  is  the  development  of  a  CPAP  compliance  call  center.  The  optimal  call  center  should  have  highly  trained  CPAP  specialists  that  can  assist  CPAP  patients  with  all  of  their  equipment  and  supply  needs.  Additionally,  the  CPAP  specialists  should  have  a  simple  CPAP  troubleshooting  algorithm  that  allows  them  to  handle  simple  problems  and  help  maintain  CPAP  compliance.   The  call  center  software Â

must  trigger  the  quarterly  calls  to  every  patient  and  have  ready  access  to  the  CPAP  supply  purchase  pattern  so  that  the  agent  can  HQVXUH WKDW HYHQ WKH VHHPLQJO\ LQVLJQLÂżFDQW supplies  necessary  to  improve  the  patient  H[SHULHQFH VXFK DV ÂżOWHUV DQG KHDGJHDU FDQ easily  be  ordered.  It  is  necessary  for  the  DME  to  have  a  prescription  as  well  as  a  copy  of  the  sleep  study  to  bill  Medicare  and  most  insurance  companies.  The  sleep  study  must  indicate  severe  OSA  (>  15  AHI  or  >5  AHI  with  symptoms)  or  else  third  party  payers  will  not  cover  CPAP  therapy.  The  call  center  must  have  availability  of  a  trained  respiratory  therapist  and  also  be  comfortable  reporting  non-­compliance  to  the  treating  medical  professional.   CPAP  failure  rates  can  be  lowered  by  selecting  a  DME  supplier  who  specializes  in  sleep  therapy,  performs  all  three  low  cost  interventions  proven  to  increase  compliance,  and  operates  a  â&#x20AC;&#x153;state  of  the  artâ&#x20AC;?  CPAP  call  center  for  a  lifetime  of  health  coaching  and  follow  up.  Even  with  the  addition  of  all  the  evidence  based  interventions,  some  severe  OSA  patients  are  simply  unable  to  tolerate  CPAP  therapy.  An  oral  appliance  serves  as  an  excellent  rescue  option  for  patients  that  are  unable  or  unwilling  to  utilize  CPAP  therapy  so  they  can  receive  some  relief  from  a  condition  that  carries  such  devastating  co-­ morbidities.

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DENTAL Â SLEEP Â MEDICINE

Raising the Level of Suspicion PSG may lack sufficient sensitivity and that in some cases, there may be a much higher level of OSA. By  Dan  Tache  DDS,  D,ABDSM

I

n  epidemiology,  the  validity  of  any  where  there  is  an  exaggeration  of  sleep  Mandibular  Repositioning  Device  (MRD).   VFLHQWLÂżF VWXG\ UHTXLUHV YLJLODQFH IRU GLIÂżFXOWLHV RU SDUDGR[LFDOO\ D 5HYHUVH It  is  generally  agreed  that  such  treatment  control  of  random  error,  bias,  and  First  Night  Effect  (RFNE)  where  obtained  is  governed  by  the  Guidelines  established  confounding.   These  three  phenomena  sleep  data  represents  a  better-­than-­normal  by  The  American  Academy  of  Sleep  are  considered  alternative  explanations  sleep  than  that  normally  experienced  Medicine  (AASM).   when  assessing  the  outcome  measure  of  while  sleeping  at  home.   The  Reverse  First   The  American  Academy  of  Sleep  a  study.   Random  error  is  the  probability  Night  Effect  (RFNE),  is  characterized  by  Medicine  (AASM)  has  developed  that  the  observed  result  is  due  to  chance.   longer  rapid  eye  movement  (REM)  sleep  evidence-­based  â&#x20AC;&#x153;Practice  Parametersâ&#x20AC;?  Bias  is  a  systematic  error  committed  by  latency  (p  <  0.05),  increased  wakefulness  which  provide  clinicians  with  clear  the  investigator  during  the  course  of  a  (p  <  0.01)  and  total  sleep  time  (p  <  0.02)  recommendations  for  the  evaluation  study,  while  confounding  is  not  the  fault  DQG GHFUHDVHG VOHHS HIÂżFLHQF\ S and  management  of  patients  with  sleep  RI WKH LQYHVWLJDWRU EXW D UHĂ&#x20AC;HFWLRQ RI 0.01).3  The  RFNE  should  be  viewed  as  a  disorders.  These  parameters  are  based  on  the  inescapable  fact  that  all  research  is  potentially  more  serious  confounder  than  a  FXUUHQW VFLHQWLÂżF HYLGHQFH LQ WKH PHGLFDO involves  free-­living  human  beings.1   It  RFE  because  the  net  result  is  a  modest  to  literature.  The  â&#x20AC;&#x153;Guidelinesâ&#x20AC;?  which  govern  might  be  helpful  to  view  the  behavior  or  the  Dental  confounding  as  a  mixing  Sleep  clinician  are  clearly  of  the  effects  between  the  delineated  in  the  publication:   3.1 Diagnosis subject(s)  being  studied  and  â&#x20AC;&#x153;The  Practice  Parameters  for  3.1.1 The presence or absence of OSA must be other  extraneous  factors.   The  the  Treatment  of  Snoring  and  determined before initiating treatment with oral validity  of  epidemiologic  Obstructive  Sleep  Apnea  with  appliances to identify those patients at risk due to studies  also  requires  that  the  Oral  Appliances:  An  Update  complications of sleep apnea and to provide a baseline study  be  conducted  over  a  for  2005â&#x20AC;?  6.   The  â&#x20AC;&#x153;Guidelinesâ&#x20AC;?  particular  risk  period.  2 to establish the effectiveness of subsequent treatment. are  explicit  that  the  PSG  should   The  Polysomnogram  have  been  obtained  prior  to  the  Detailed diagnostic criteria for OSA are available and (PSG)  is  viewed  as  the  Gold  fabrication  of  an  oral  device  and  include clinical signs, symptoms and the findings Standard  in  the  objective  implicit  in  that  recommendation  identified by polysomnnography. The severity of sleep evaluation  of  sleep  and  is  that  this  necessary  diagnostic  related respiratory problems must be established in as  such,  should  be  held  to  aid  is  an  accurate  representation  order to make an appropriate treatment decision. {{320 the  highest  standards  for  of  the  level  of  disease  with  validity,  much  as  we  expect  which  the  patient  presents  to  us  Kushida, CA 2006}} of  epidemiologists  when  for  treatment.   gathering  data  in  the  search   Unlike  the  split-­night  for  central  themes  or  hypotheses  in  severe  underestimation  of  the  severity  of  study  with  CPAP-­application,  when  the  matter  of  public  health.   The  PSG  obstructive  sleep  apnea.   application  and  titration  is  completed  in  does  have  shortcomings  because  it  is   Because  of  these  shortcomings,  the  PSG  one  night,  the  process  of  MRD  Titration  expensive  and  as  a  consequence  of  the  LV QRW FRQVLGHUHG WR EH ÂżUVW OLQH GLDJQRVWLF to  achieve  airway  stabilization  may  cost,  the  â&#x20AC;&#x153;risk  periodâ&#x20AC;?  during  which  data  tool  in  the  assessment  of  insomnia  often  take  weeks  or  months  to  achieve.   collected,  is  typically  only  one  or  two  according  to  American  Academy  of  7KLV LV QRW D UHĂ&#x20AC;HFWLRQ RI D ODFN RI nights.   It  is  widely  appreciated  that  there  Sleep  Medicine  guidelines4  A  comparable  HIÂżFDF\ RI 05'V LQ WKH PDQDJHPHQW RI LV VLJQLÂżFDQW QLJKW WR QLJKW YDULDELOLW\ maladaptive  response  by  both  children  and  mild  to  moderate  OSAS  but  an  honest  of  sleep  often  observed  from  sleeping  adolescents  has  also  been  observed.5 representation  of  the  time  that  is  often  in  a  sleep  laboratory  vis-­à -­vis  at  home.   When  a  patient  who  has  been  diagnosed  required  for  the  patient  to  comfortably  This  phenomenon  often  leads  to  an  with  obstructive  sleep  apnea  syndrome  adapt  the  necessary  3-­dimensional  changes  LQDFFXUDWH UHSUHVHQWDWLRQ RI WKH SDWLHQWÂśV (OSAS)  is  deemed  to  be  CPAP-­intolerant,  sleep.    This  â&#x20AC;&#x153;inaccuracyâ&#x20AC;?  can  be  manifest  KH RU VKH PD\ EH UHIHUUHG WR D TXDOLÂżHG either  a  classic  First  Night  Effect  (FNE)  dentist  for  management  of  the  OSAS  with  WWW.SLEEPGS.COM

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nocturnal  mandibular  repositioning.  The  Sleep  Dentist  will  often  utilize  Unattended  Portable  Monitors  (PM)  during  the  MRD  titration  progress  to  ascertain  when  maximum  medical  improvement  (MMI)  has  been  achieved.    Because  of  the  RFNE,  this  clinician  has  often  observed  a  relative  worsening  of  the  disease  level  when  the  PM  results  are  downloaded.   Naively,  the  novice  dental  clinician  who  may  be  unaware  of  a  confounding  RFNE  might  misinterpret  the  seemingly  worsening  status  of  his  or  her  patient  as  a  manifestation  RI DQ LQVXIÂżFLHQWO\ titrated  MRD  or  that  the  MRD  was  making  the  patient  worse.   If  one  is  unaware  of  this  phenomenon  it  is  altogether  possible  that  the  PM  will  be  looked  upon  as  faulty  or  lacking  VXIÂżFLHQW VHQVLWLYLW\ never  even  considering  that  the  problem  might  lie  with  the  sensitivity  of  the  correctness  of  the  PSG.     Retrospective  cohort  studies  have  shown  that  the  prevalence  of  RFNE  may  YDU\ FRQVLGHUDEO\ UDQJLQJ IURP ³ to  43%.â&#x20AC;?   The  same  study  went  on  to  FRQFOXGH WKDW ³KLJK QLJKW WR QLJKW variability  of  AHIs  and  microarousal  LQGH[HV´ UHVXOWDQW IURP D )1( DQG that  â&#x20AC;&#x153;an  important  number  of  subjects  presented  false-­negative  resultsâ&#x20AC;?  and  that  a  FNE  was  found  â&#x20AC;&#x153;to  be  more  frequent  among  severe  casesâ&#x20AC;?.  7   The  purpose  of  this  article  is  to  raise  the  level  of  suspicion  that  the  PSG  may  ODFN VXIÂżFLHQW VHQVLWLYLW\ DQG WKDW LQ VRPH

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cases,  there  may  be  a  much  higher  level  of  OSAS  than  was  reported  from  data  JOHDQHG IURP WKH ³¿UVW QLJKW´ LQ WKH VOHHS lab.   It  is  crucial  that  the  Sleep  Dentist  be  aware  of  this  because  it  can  have  a  profound  effect  upon  treatment  to  the  extent  that  the  treating  clinician  may  even  decide  from  the  onset  of  treatment  that  a  MRD  alone  might  not  be  VXIÂżFLHQW DQG the  patient  will  be  made  aware  that  a  â&#x20AC;&#x153;Hybridâ&#x20AC;?  approach  (MRD  plus  CPAP)  will  likely  be  necessary.  When  it  is  clear  that  a  RFNE  is  in  effect,  it  is  the  exception  that  the  PSG  will  be  repeated  due  to  this  inaccuracy  and  again,  probably  because  of  the  cost.   It  is  also  less  common  to  read  in  the  summary  of  a  PSG  report  that  a  First  Night  Effect  (or  RFNE)  was  observed  and  that  it  (the  PSG)  will  be  or  should  be  repeated,  instead,  one  will  read  that  there  was  a  VLJQLÂżFDQW LQFUHDVH RI ODWHQF\ WR 5(0 increased  wakefulness  or  decreased  VOHHS HIÂżFLHQF\ DQG PDUNHG UHGXFWLRQ in  %  REM  of  Total  Sleep  time  (TST).   These  intimations  by  the  report  sleep  specialist  of  a  problem  with  sensitivity  of  the  diagnostic  PSG  are  not  meant  to  deceive,  rather,  such  an  event  for  the  patient  whose  OSAS  will,  in  most  cases,  be  controlled  with  CPAP  therapy,  only  means  an  additional  centimeter  or  two  of  + 2 SUHVVXUH QRW D SUREOHP LI WKH SDWLHQW can  tolerate  the  treatment  but  if  such  error  means  an  additional  millimeter  or  two  of Â

mandibular  advancement,  this  could  be  D VLJQLÂżFDQW URDGEORFN WR VXFFHVVIXOO\ treating  with  OSAS  with  a  MRD  alone.  The  PSG  to  this  date,  is  performed  with  the  knowledge  that  if  a  problem  is  IRXQG WKDW &3$3 ZLOO Âż[ LW GHVSLWH WKH dreary  compliance  rates  reported  by  many.   Consequently,  a  little  problem  of  underestimation  of  disease  level  because  of  a  RFNE  such  that  the  diagnosis  is  perhaps,  Upper  Airway  Resistance  Syndrome  or  mild  OSAS  when  there  is  in  fact,  a  severe  level  of  OSAS  exists  is  VWLOO QRW D SUREOHP &3$3 ZLOO Âż[ LW ZLWK D Ă&#x20AC;LFN RI WKH ZULVW 7KH HQOLJKWHQHG VOHHS specialist  who  considers  MRD  therapy  as  an  essential  part  of  the  strategies  for  managing  OSAS  will  understand  that  it  is  important  to  get  it  right  because  of  the  limitations  of  MRD  therapy  but  such  individuals  are  the  exception,  albeit,  that  is  changing  but  until  that  day  arrives,  it  will  incumbent  upon  the  dentist,  to  whom  this  CPAP-­intolerant  patient  is  being  referred,  that  he  or  she  be  able  to  anticipate  when  a  RFNE  is  in  effect.   It  might  even  be  prudent  to  offer  a  PM  to  the  patient  BEFORE  making  any  promises  or  commencing  treatment.  I  hope  through  â&#x20AC;&#x153;Case  Presentationâ&#x20AC;?  to  illustrate  this  problem  and  how  to  best  anticipate  when  the  PSG  data  might  be  confounded  by  a  RFNE.   Because  treatment  strategies  for  MRD  therapy  may  vary  considerably  with  the  level  of  OSAS,  it  may  perhaps  be  necessary  to  reassess  OSAS  levels  by  performing  an  unattended  PM  sleep  study  BEFORE  proceeding  with  MRD  therapy  in  order  to  communicate  any  changes  in  the  potential  outcome  of  MRD  therapy  to  the  patient.   It  is  critical  WKDW WKH SDWLHQW EH VXIÂżFLHQWO\ LQIRUPHG of  their  probability  of  success  given  the  adverse  medical  consequence  resultant  from  failure  to  effectively  manage  such  a  disease.

CASE  STUDY  This  is  a  study  of  a  42  y.o.  female,  JM,  ZKR SUHVHQWHG WR RXU GHQWDO RIÂżFH ZLWK complaints  of  â&#x20AC;&#x153;sensitive/chipping  teethâ&#x20AC;?  ,  â&#x20AC;&#x153;TMJ  painâ&#x20AC;?  and  â&#x20AC;&#x153;fatigueâ&#x20AC;?.    Clinical  examination  of  the  teeth  alone  was  remarkable  because  of  the  severity  of  the   generalized  attrition  of  the  teeth  on  all  surfaces  with  severe  cervical  erosions  present  both  lingually  and  facially  on Â

many   of  the  teeth.   Naturally,  further  questioning  ensued  only  to  reveal  that  she  had  GERD,  nocturia,  profound  fatigue,  recently  discovered  elevation  of  her  blood  SUHVVXUH *LYHQ WKHVH FOLQLFDO ÂżQGLQJV DQG KHU VLJQLÂżFDQW PHGLFDO KLVWRU\ LW ZDV suggested  that  she  might  have  a  sleep  and  breathing  problem  contributing  to  her  apparently  severe  bruxism  problem.    A  PM  was  offered  to  shed  light  on  the  problem.   The  results  of  the  PM  study  can  be  seen  below.  The  results  of  the  PM  strongly  support  a  diagnosis  of  OSAS  and  given  that  we  had  5(0 VOHHS ZH FDQ EH FRQÂżGHQW that  a  RFNE  was  not  confounding  our  results.   Closer  inspection  shows  Oxygen  Saturation  statistics  which  are  both  interesting  and  disconcerting.   The  %  of  Sleep  Time  <90%  is  0.9%  of  TST  with  a  Minimum  Saturation  of  69%.   Clearly,  this  person  is  in  need  of  a  referral  to  a  sleep  specialist  for  a  PSG  evaluation.   A  copy  of  our  PM  results  were   included  in  the  referral  to  the  sleep  specialist.   We  assured  her  that  many  of  her  â&#x20AC;&#x153;complaintsâ&#x20AC;?  would  be  addressed  by  confronting  this  apparent  sleep  and  breathing  problem.

Indeed,  arrangements  for  a  referral  to  a  sleep  specialist  were  made  and  a  diagnostic  PSG  was  performed  a  few  weeks  later.   A  summary  of  the  report  can  be  seen  below.

&RPSDULQJ 5HVSLUDWRU\ ,QGLFHV RI WKH 36* YV WKH 30 6OHHS 6WXG\ A  closer  look  at  the  Diagnostic  PSG  shows  that  Stage  REM  was  only  4%  of  TST  in  contrast  to  our  PM  where  Stage  REM  was  20.5%.   The  normal  range  for  Stage  REM  LV RI 767 DQG UHĂ&#x20AC;HFWLQJ RQ WKH triad  of  RFNE,  i.e.:   VLJQLÂżFDQW LQFUHDVH RI ODWHQF\ WR 5(0 GHFUHDVHG VOHHS HIÂżFLHQF\ DQG 3.  striking  reduction  in  %  REM  of  Total  Sleep  time  (TST)  It  was  clear  that  in  contrast  to  our  PM  results,  that  the  Diagnostic  PSG  had  been  confounded  by  RFNE  but  sadly,  the  patient  was  told  that  she  did  not  have  OSAS  and  was  offered  Provigil  for  management  of  her  â&#x20AC;&#x153;annoying  fatigueâ&#x20AC;?  despite  the  results  of  the  PM  which  were  quite  to  the  contrary.   If  one  were  not  aware  of  the  existence  of  this  phenomenon  of  the  REVERSE  FIRST  NIGHT  EFFECT,  naively,  the  inexperienced  dental  sleep  clinician  may  think  that  the  decision  to  move  forward  with  MRD  therapy  had  been  a  mistake  or  that  he/she  was  in  fact  causing  harm  with  the  chosen  MRD.   Indeed,  many  of  these  patients  whose  sleep  data  was  compromised  by  the  RFNE  should  have  been  offered  CPAP  but  because  the  diagnostic  PSG  is  seldom  repeated  despite  this  confounding,  for  reasons  previously  discussed,  this  is  our  reality.   It  is  therefore  incumbent  upon  the  dentist,  who  is  throwing  his  hat  into  the  ring,  to  be  aware  of  this  phenomenon  so  that  he  may  be  able  to  adequately  educate  his  patient  if/ when  such  complications  occur.   This  will  provide Â

the  proper  perspective  for  the  patient,  i.e.  WKDW D 05' DORQH PLJKW EH LQVXIÂżFLHQW and  will  open  the  conversation  for  consideration  of  Hybrid  Therapy  (MRD  +  CPAP),  which  is  often  very  effective.   Additionally,  it  will  also  explain  why  the  MRD  titration  process  might  take  a  while  to  complete  because  in  fact,  the  level  of  disease  that  we  are  hoping  to  â&#x20AC;&#x153;neutralizeâ&#x20AC;?  with  this  intraoral  strategyâ&#x20AC;?  is  might  more  profound!  Certainly,  there  may  be  other  interpretations  and  this  writer  does  not  purport  to  be  a  sleep  specialist.   But  having  scratched  my  head  more  than  a  few  times  in  the  past  and  wondering  why  things  were  getting  worse,  compelled  me  to  present  this  information.   Hopefully,  this  information  will  raise  the  level  of  suspicion  of  the  dentist  who  is  attempting  to  help  the  patient  with  sleep  disordered  breathing  that  the  â&#x20AC;&#x153;Devil  is  in  the  Detailsâ&#x20AC;?  of  the  PSG  and  that  devil  is  the  Reverse  First  Night  Effect.

BIBLIOGRAPHY 1. Aschengrau A. Essentials of Epidemiology in Public Health. Jones & Bartlett Publishers; 2003.

2. Ahrens W, Pigeot I. Handbook of Epidemiology. Springer Verlag; 2005.

3. Toussaint M, Luthringer R, Schaltenbrand N, et al. First-night effect in normal subjects and psychiatric inpatients. Sleep. 1995;18:463-9.

4. DePaso W. Principles and Practice of Sleep Medicine, (Kryer MH, Roth T, Dement WC). Vol 51. DAEDALUS ENTERPRISES INC; 2006:1475.

5. Scholle S, Scholle HC, Kemper A, et al.

First night effect in children and adolescents undergoing polysomnography for sleepdisordered breathing. Clinical Neurophysiology.

2003;114:2138-45. Available from: http:// linkinghub.elsevier.com/retrieve/pii/ S1388245703002098.

6. Kushida C, Morgenthaler T, Littner M, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: An update for 2005. Sleep.

2006;29:240-3. Available from: http://www. aasmnet.org/Resources/PracticeParameters/ PP_Update_OralApplicance.pdf.

7. Le Bon O, Hoffmann G, Tecco J, et al. Mild to moderate sleep respiratory events* one negative night may not be enough. Chest.

2000;118:353-9.

8. Kamal I. Lung volume dependence of pharyngeal cross-sectional area by acoustic pharyngometry. Otolaryngology-Head and Neck Surgery. 2002;126:164-71.

9. Monahan KJ, Larkin EK, Rosen CL, Graham G, Redline S. Utility of noninvasive pharyngometry in epidemiologic studies of childhood sleep-disordered breathing. Am J Respir Crit Care Med. 2002;165:1499-503.

10. Gozal D, Burnside MM. Increased upper airway collapsibility in children with obstructive sleep apnea during wakefulness. Am J Respir Crit Care Med. 2004;169:163-7.

WWW.SLEEPGS.COM

55

OSA and Eye Vision CUT ALONG LINE AND FAX

Awareness of the possible associations in order to diagnose them earlier.

By  Troy  Bedinghaus  OD

CUT ALONG LINE AND FAX

Sleep  apnea  is  a  common  disorder  in  which  a  person  has  one  or  more  pauses  in  breathing  or  shallow  breaths  while  sleeping.  Sleep  apnea  affects  more  than  12  million  people  in  the  United  States.  The  most  common  type  of  sleep  apnea  is  obstructive  sleep  apnea  (OSA).  In  OSA,  the  throat  muscles  relax  and  block  the  airway.  It  is  associated  with  a  number  of  diseases,  including  the  following  eye  conditions:  Â&#x2021; )ORSS\ (\HOLG 6\QGURPH  In  this  syndrome,  the  eyelids  can  turn  inside-­ out  during  sleep.  The  eyes  may  become  VLJQLÂżFDQWO\ GU\ FDXVLQJ DQQR\LQJ V\PSWRPV such  as  irritation,  tearing,  mucus  discharge  and  blurry  vision. Â&#x2021; *ODXFRPD  Having  sleep  apnea  seems  to  increase  the  risk  of  developing  glaucoma.  Glaucoma  is  the  most  common  cause  of  irreversible  blindness.  OSA  has  been  associated  with  two  forms  of  glaucoma,  primary  open-­ angle  glaucoma  (OAG)  and  normal-­tension  glaucoma  (NTG).  Â&#x2021; 1RQDUWHULWLF $QWHULRU ,VFKHPLF 2SWLF 1HXURSDWK\ 1$,21  NAION  is  a  sudden,  painless  loss  of  vision  in  one  eye  often  noticed  upon  awakening.  Certain  studies  suggest  an  increased  incidence  of  OSA  in  patients  diagnosed  with  NAION.   Â&#x2021; 3DSLOOHGHPD  Papilledema  is  characterized  as  a  swelling  of  the  optic  nerve  in  both  eyes  usually  due  to  increased  pressure  in  the  skull.  This  condition  may  damage  the  brain  and  may  cause  vision  loss.  Patients  with  OSA  often  have  a  higher  incidence  of  papilledema.  Although  it  is  not  understood  exactly  why  OSA  may  contribute  to  certain  eye  conditions,  it  is  important  for  health  care  professionals  to  be  aware  of  the  possible  associations  in  order  to  diagnose  them  earlier.  Patients  with  obstructive  sleep  apnea  should  be  asked  about  possible  eye  problems  and  possibly  have  their  eyes  examined.  Conversely,  patients  who  already  have  these  eye  conditions  should  be  evaluated  for  sleep  apnea. ÂĽ "Y 4ROY "EDINGHAUS /$ HTTP VISION ABOUT com/od/sportsvision/a/Sleep_Apnea.htm). Used with permission of About, Inc. which can be found online at www.about.com. All rights reserved.

56

DENTAL Â SLEEP Â MEDICINE

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