The Sleep Magazine- 4th Issue by The Sleep Magazine

The Fastest Growing Dental Specialty

Change the way you practice dentistry

for the health of your patients!

Using Anatomical Assessment to Guide Oral Appliance Therapy .................................................... 3 Good Night! ................................................................................................................................. 6 Polycystic Ovarian Syndrome Patient ............................................................................................ 8 Athletes and Sleep Apnea .......................................................................................................... 12 OSA Is Here to Stay ................................................................................................................... 14 Getting Personal With Your Sleep Patterns .................................................................................. 16

Using Anatomical Assessment to Guide

The “D” Words .......................................................................................................................... 17

Oral Appliance Therapy

The Virginia Academy of Dental Sleep Medicine ......................................................................... 19

Dr. Atul Malhotra

The Future of Sleep Apnea - Diagnosis and Treatment ................................................................ 24

tableofcontents

SLEEP DISORDERS

Implementation of Monitoring to Prevent Respiratory Complications ........................................... 20 Decisions, Decisions ................................................................................................................. 21

t’s All About The Air ................................................................................................................... 27 Sleep Seminars 2011 Schedule .......................................................................................... 28-29 No More Guessing Position ........................................................................................................ 30 Welcome Aboard! Dr. Moscovitch............................................................................................... 31 Academic Currents ................................................................................................................... 33

Athletes of Sleep Apnea Holly Jordano

Oral Sleep Appliance - Get Your Air In ......................................................................................... 34 Putting Your Sleep Practice on The Map ..................................................................................... 36 Dental Medical Model ............................................................................................................... 39 Dental Sleep Medicine Seminars Q&A ....................................................................................... 43 Do It For You and Them .............................................................................................................. 44 Million Dollar Question .............................................................................................................. 46 The NEW Art of Dentistry ........................................................................................................... 47 Interpreting Home Sleep Studies ............................................................................................... 48 Sleep Group Solutions Company Profile .................................................................................... 56

No More Guessing Position The The Future Future of of

Acoustic Airway Imaging

Adam Moscovitch, M.D.

Dental Sleep Clinics Directory .................................................................................................... 60

Finding new sleep apnea patients made easy

1-800-SLEEPTEST 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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3. Hudgel DW, et al. Pharmacologic treatment of sleep-disordered breathing. Am J Respir Crit Care Med 1998;158:691-9. 4. Ayas N, Malhotra, A, and Epstein, L. Alternative Therapies for Sleep Apnea. Drugs of Today 1999;35:81121. 5. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea [see comments]. Chest 1996;109:1269-75. 6. Zeng B, Ng AT, Darendeliler MA, Petocz P, Cistulli PA. Use of flow-volume curves to predict oral appliance treatment outcome in obstructive sleep apnea. Am J Respir Crit Care Med 2007;175:726-30.

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7. Kezirian EJ, Malhotra A, Goldberg AN, White DP. Changes in obstructive sleep apnea severity, biomarkers, and quality of life after multilevel surgery. Laryngoscope 2010;120:1481-8. 8. Eckert DJ, Malhotra A, Jordan AS. Mechanisms of apnea. Prog Cardiovasc Dis 2009;51:313-23. 9. Saboisky JP, Chamberlin NL, Malhotra A. Potential therapeutic targets in obstructive sleep apnoea. Expert Opin Ther Targets 2009;13:795-809. 10. Mostafiz W, Dalci O, Sutherland K, et al. Influence of Oral and Craniofacial Dimensions on Mandibular Advancement Splint Treatment Outcome in Obstructive Sleep Apnea. Chest 2011. 11. Fredberg JW, MEB. Glass, GM. Dorkin, HL. Airway area by acoustic reflections measured at the mouth. J Appl Physiol 1980;48:749-58. 12. Hoffstein V, Fredberg JJ. The acoustic reflection technique for non-invasive assessment of upper airway area. Eur Respir J 1991;4:602-11. 13. Itzhaki S, Dorchin H, Clark G, Lavie L, Lavie P, Pillar G. The effects of 1-year treatment with a herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest 2007;131:740-9. 14. Wellman A, Malhotra A, Jordan AS, Stevenson KE, Gautam S, White DP. Effect of oxygen in obstructive sleep apnea: role of loop gain. Respir Physiol Neurobiol 2008;162:144-51.

appliancereview

Good Night!

An Alternative to CPAP for Treating Sleep Apnea Finding the most comfortable, compliant and effective therapy. %\ 0LFKDHO 3 +QDW '0'

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The American Academy of Sleep Medicine recommends

oral sleep appliances as first line treatment options for those

with mild and moderate levels of sleep apnea as well as for

individuals who are CPAP intolerant.

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Implementation of Monitoring to Prevent Respiratory Complications with Sedation

Difficulty with intubations, and increased sleep deprivation contribute to elevated risk in the perioperative patient. %\ .DWKU\Q +DQVHQ %6 5((*7 &3&

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Decisions, Decisions! PSG or Home Sleep Test: Which is Better? Testing for Obstructive Sleep Apnea (OSA).

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ōVJG TGOCKPU VJG IQNF UVCPFCTF 6JWU YG KPUVCDKNKV[ GVE 6JWU VJG VTGCVKPI OCUMŎ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isclosure: Dr. Malhotra receives funding from the NIH and AHA. He has received research and/or consulting salary from SGS, SHC, Philips, Ethicon, Medtronic, Pfizer, Merck, Cephalon, Sepracor, Itamar, Apnex 1. Malhotra A, White D. Seminar: Obstructive Sleep Apnea. The Lancet 2002;360:237-45. 2. Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS medicine 2009;6(8):e1000132. 3. Gottlieb JD, Schwartz AR, Marshall J, et al. Hypoxia, not the frequency of sleep apnea, induces acute hemodynamic stress in patients with chronic heart failure. Journal of the American College of Cardiology 2009;54(18):1706-12. 4. Djonlagic I, Malhotra A. Risk of stroke from sleep apnea in men and women. Expert review of neurotherapeutics 2010;10(8):1267-71. 5. Saboisky JP, Chamberlin NL, Malhotra A. Potential therapeutic targets in obstructive sleep apnoea. Expert opinion on therapeutic targets 2009;13(7):795-809. 6. Badr MS. Pathophysiology of obstructive sleep apnea. Oral and maxillofacial surgery clinics of North America 2002;14(3):285-92. 7. Younes M. Role of arousals in the pathogenesis of obstructive sleep apnea. Am J Respir Crit Care Med 2004;169:623-33. 8. Patil SP, Schneider H, Schwartz AR, Smith PL. Adult obstructive sleep apnea: pathophysiology and diagnosis. Chest 2007;132(1):325-37. 9. Gottlieb DJ, et al. Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study. Am J Respir Crit Care Med 1999;159(2):502-7. 10. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered Breathing and Cardiovascular Disease. Cross-sectional Results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19-25. 11. Ayas NT, Patel SR, Malhotra A, et al. Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis. Sleep 2004;27(2):249-53. 12. Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Annals of internal medicine 2007;146 (3):157-66. 13. Eastwood PR, Malhotra A, Palmer LJ, et al. Obstructive Sleep Apnea: From pathogenesis to treatment: Current controversies and future directions. Respirology (Carlton, Vic 2010;15(4):58795. 14. Eckert DJ, Malhotra A, Jordan AS. Mechanisms of apnea. Progress in cardiovascular diseases 2009;51(4):313-23. 15. Campana LM, Owens RL, Clifford GD, Pittman SD, Malhotra A. Phase Rectified Signal Averaging as a Sensitive Index of Autonomic Changes with Aging. J Appl Physiol in press. 16. Somers VK. Debating sympathetic overactivity as a hallmark of human obesity: an opposing position. Journal of hypertension 1999;17(8):1061-4. 17. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proceedings of the American Thoracic Society 2008;5(2):136-43.

::: 6/((36(0,1$56 &20

18. Owens R, Wellman A, Malhotra A. The chicken-or-egg debate in OSA pathogenesis. Sleep 2009;32(10):1255-6. 19. Horner RL. Motor control of the pharyngeal musculature and implications for the pathogenesis of obstructive sleep apnea. Sleep 1996;19(10):827-53. 20. Patel S, White DP, Malhotra A, Stanchina M, Ayas NT. The Effect of CPAP Therapy on Subjective and Objective Sleepiness in Obstructive Sleep Apnea: A Meta-analysis of Randomized Controlled Trials. Arch Int Med 2002:in press. 21. Li HY, Engleman H, Hsu CY, et al. Acoustic reflection for nasal airway measurement in patients with obstructive sleep apneahypopnea syndrome. Sleep 2005;28(12):1554-9. 22. Kingshott RN, Vennelle M, Hoy CJ, Engleman HM, Deary IJ, Douglas NJ. Predictors of improvements in daytime function outcomes with CPAP therapy. Am J Respir Crit Care Med 2000;161(3 Pt 1):866-71. 23. Hoy CJ, Venelle M, Douglas NJ. Can CPAP use be improved? Am J Respir Crit Care Med 1997;155:304A. 24. Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea

syndrome? Am J Respir Crit Care Med 1999;159(4 Pt 1):1096100. 25. Ferguson K. Oral appliance therapy for obstructive sleep apnea: finally evidence you can sink your teeth into. Am J Respir Crit Care Med 2001;163(6):1294-5. 26. Kezirian EJ, Malhotra A, Goldberg AN, White DP. Changes in obstructive sleep apnea severity, biomarkers, and quality of life after multilevel surgery. Laryngoscope;120(7):1481-8. 27. Zeng B, Ng AT, Darendeliler MA, Petocz P, Cistulli PA. Use of flow-volume curves to predict oral appliance treatment outcome in obstructive sleep apnea. Am J Respir Crit Care Med 2007;175(7): 726-30. 28. Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep 2008;31(4):543-7. 29. Kezirian EJ, White DP, Malhotra A, Ma W, McCulloch CE, Goldberg AN. Interrater reliability of drug-induced sleep endoscopy. Archives of otolaryngology--head & neck surgery;136(4):393-7. 30. Weaver EM, Maynard C, Yueh B. Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 2004;130(6):659-65.

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Oral Sleep Appliances: Get Your Air In!

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*Read Dr. Brock Rondeauâ&#x20AC;&#x2122;s article on OSA, and get a free CE. Fax the 10 questions on page 55 or Log on to www.dentalsleepseminars.com to fill out the quiz. Dr. Brok Rondeauâ&#x20AC;&#x2122;s credentials FELLOWSHIPS/MASTERSHIPS/DIPLOMATES 1988 Fellowship International Association for Orthodontics 1988 Diplomate of the International Board of Orthodontics 2005 Fellowship American Academy of Craniofacial Pain 2005 Diplomate American Board of Craniofacial Pain CONTRIBUTIONS TO THE FIELD OF DENTISTRY Contributing Editor, Journal Clinical Pediatric Dentistry Contributing Editor, Journal of General Orthodontics Contributing Editor, Functional Orthodontist PROFESSIONAL ACHIEVEMENTS 1982 Certified Instructor, International Association for Orthodontics 1983 IAO Pinsker Award Winner 1986 IAO Past President 1993 AAFO Clinician of the Year Contributing Editor, Journal of General Orthodontics 2006 Voted one of Dentistry Todayâ&#x20AC;&#x2122;s 9th Annual Top Clinicians in CE 2007 Voted one of Dentistry Todayâ&#x20AC;&#x2122;s 10th Annual Top Clinicians in CE CURRICULUM VITAE TMJ Care Centre Northland Dental Centre 1275 Highbury Avenue â&#x20AC;¢ Suite 16A â&#x20AC;¢ London, Ontario N5Y 1A8

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Give the gift of better sleep. It will likely improve your health and your quality of life; both night and day for both of you.

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Dr. JC Goodwin has practiced general dentistry in Prescott since 1987. His practice includes same-day crown technology, surgical and non-surgical laser therapy, DNA testing for periodontal disease and apnea management for patients who are not able to use CPAP therapy. He created the Sleep Effect Center for Apnea Management in 2009. Dr. Goodwin is a member of the American Academy of Dental Sleep Medicine, and the Academy of Clinical Sleep Disorders Disciplines and holds Diplomate status in the ACSDD. He can be reached at 928-708-9444 or 928-778-4555.

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Seminars ,Q D FLW\ QHDU \RX To register, visit us online at: www.dentalsleepseminars.com Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros January 14-15, 2011 Tampa, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros June 3-4, 2011 New York City

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA January 21-22, 2011 San Diego, CA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros June 17-18, 2011 Phoenix, AZ

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA February 4-5, 2011 Phoenix, AZ

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Tache June 24-25, 2011 Chicago, IL

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA February 18-19, 2011 Atlanta, GA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros July 15-16, 2011 San Diego, CA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Lipsey March 11-12, 2011 San Francisco, CA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Slabach August 19-20 Boston, MA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Lipsey March 18-19, 2011 Chicago, IL

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA September 16-17, 2011 Washington, DC

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros April 8-9, 2011 Boston, MA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Tache September 23-24, 2011 Dallas, TX

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros April 22-23, 2011 Las Vegas, NV

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA Sept. 30 -Oct. 1, 2011 Las Vegas, NV

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros April 29-30, 2011 Atlanta, GA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros October 21-22, 2011 Tampa, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Slabach May 6-7, 2011 Dallas, TX

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA November 4-5, 2011 Phoenix, AZ

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros May 20-21, 2011 Miami, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA November 11-12,2011 Boston, MA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Rondeau May 27-28, 2011 Calgary, AB

Sleep Group Solutions Dental Sleep Medicine Instructor: TBA December 8-9, 2011 Orlando, FL

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Figure 1: Meet SMF. SMF was referred to me initially in 2004. She had been referred by her general DDS who had provided a mouthguard which was not helping to reduce her complaints of pain. Her chief complaints at that time were as follows: 1. 2. 3. 4. 5.

“Jaw discomfort, feels like a toothache” “Jaw joint clicking and grinding noises when eating” “Earache” “Not sleeping well; awaken with sore jaws” “Tired all of the time”

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Part II: Managing The CPAPIntolerant PCOS Patient: A Case Study Demonstrating The Unique Challenge Of The PCOS Patient

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