Dental Sleep Practice - Winter 2014 Issue

Preventive Sleep Dentistry

— A Call to Action

by Barry D. Raphael, DMD

Pediatric

Sleep Disorders Winter 2014

by Ping-Ru Ko, MD, and Maida Lynn Chen, MD

“Doc, my kid snores.

Should I be worried?”

An interview with Rolf Maijer, DDS, D.Ortho, FRCD(C)

Communications 101 Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Amy Morgan

Pre-treatment airway volume

“

THIS USED TO BE

REALLY TOUGH

FOR ME TO DO...“ – Sebastian, Patient of Dr. Juan-Carlos Quintero

Post-treatment airway volume

©2014 i-CAT | ISI-Mktg-DM-0004 RevA

Sebastian had been suffering from snoring, mouth breathing and grinding his teeth at night, plus battling frequent sinus and ear infections. He was also struggling with any kind of vigorous athletic activity— all of which are just not normal for a boy his age.

“What I found analyzing a full field of view 3D scan changed my practice – and the life of this special young boy.”

SEE THE FULL REPORT AT STORIES.i-CAT.COM

– Dr. Juan-Carlos Quintero Quintero Orthodontics, Miami, FL

#their3Dstory

Available exclusively through Product indications for use at i-cat.com/ifu No doctor or patient was compensated for their participation

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INTRODUCTION

Every Generation Deserves Better Health

H

ave you thought about your growing dental sleep practice and how many people in your community remain to be treated?

How many patients in our practices and how many people on the street are unaware, not only of their disease, but of the choices of therapy? It’s a very large number – the adults you treat, the ones you ‘recognize’ in public and the people in various stages of PAP therapy.

How did all these grown-ups get to be poor sleep breathers in the first place?

Inadequate airways grow that way. Maybe there was a chance, unrealized while they were young, to influence that space. Consider a different path, one that would have them breathing easier as adults today. Imagine the impact and important role dentists have in this vital health initiative.

Readers of this magazine are interested in a whole-body approach to health – using therapy that affects physiology quite remote from the oral cavity. We must understand how to achieve maximum positive impact with what we can do. Research in pediatric populations is showing how helping the airway get bigger, through surgery or mechanics, can significantly influence the child for the better. Active treatment at ages where a ‘wait and see’ approach has been popular for years is looking to often be the optimum choice. Kids who don’t breathe well have wide-ranging problems – two physicians from Seattle Children’s Hospital have prepared an essay for us touching on some of those health areas.

Orthodontists, Otolaryngologists, and Pediatric Dentists are reading more and more studies about the importance of adding airway evaluation to their traditional preventive and esthetic services. I find it interesting that FDA clearance for oral appliances for treat-

ing SDB does not extend below age 18, yet a Herbst device can be used to treat “mandibular growth deficiencies” as soon as the dentist recognizes the problem. How they differ is a mystery to me, but I am happy dentists can employ known therapy to solve Steve Carstensen, DDS airway problems early, even if they Diplomate, American Board of can’t name it thus.

Dental Sleep Medicine It’s not just about the appliances, of course – first we must change our point of view. Drs. Raphael and Maijer are putting tremendous effort into getting this Research in message out worldwide. Leaders like these bring powerful teaching across the spectrum, pediatric populafrom families to whole professions, raising tions is showing awareness of possibilities and opening eyes to see. “Lips Together, Breathe Through Your how helping the Nose, Tongue In The Roof Of Your Mouth” airway get bigger, This mantra, taught to me by Barry Raphael, through surgery may improve worldwide health more than any other thirteen words ever strung together. or mechanics, How do you do this? Finding excellent can significantly teachers like Dr. Jonathan Parker, getting your team on board, using the right technolinfluence the child ogy resources, and being brave about starting for the better. the meaningful conversations necessary to help grow these young airways represent the future of dental sleep medicine. Welcome to this issue of Dental Sleep Practice!

Your thoughts, requests, questions, and insights are enthusiastically invited: SteveC@MedMarkAZ.com

DentalSleepPractice.com

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CONTENTS

6

Cover Story

3D imaging for better diagnosis and treatment of pediatric airway and TMD

by Robert Kaspers, DDS, MS Looking beyond 2D allows more predictable treatment planning.

18

10

Orthodontist’s Perspective

“Doc, my kid snores.

Should I be worried?”

An interview with Rolf Maijer, DDS, D.Ortho, FRCD(C) There are ways of identifying kids at risk for SDB; finding and treating them is hugely rewarding.

Physician’s Perspective

Pediatric Sleep Disorders

by Ping-Ru Ko, MD, and Maida Lynn Chen, MD Pediatric sleep physicians give insight into the complexity of treating sleep breathing in little ones.

Bigger Picture

Preventive Sleep Dentistry – A Call to Action

38 2 DSP | Winter 2014

by Barry D. Raphael, DMD A focus on growth and development is the way to identify which kids can be helped and why you should be involved in that treatment.

46

Practice Management

Communications 101: How to Communicate to Parents about Sleep Disordered Breathing!

by Amy Morgan What you see is important, but it’s what you can help your patients see that makes a difference.

Enter to Win a $25,000 Marketing Makeover for your dental practice!

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Share this great opportunity with your friends and colleagues!

www.somnomed.com/MAKEOVER

CONTENTS

24

Surgeon’s Perspective

Pediatric Sleep Apnea: Don’t miss out on making the diagnosis

by Bryce Williams, DDS, Oral and Maxillofacial Surgeon Screening patients is necessary. Surgeons can also use endoscopy to pinpoint where the problems lie.

29

Clinician Spotlight

Winter 2014 Publisher | Lisa Moler Email: lmoler@medmarkaz.com

Creating Exceptional Experiences

Editor in Chief | Steve Carstensen, DDS Email: steve@medmarkaz.com

The DSP Interview with Dr. Jonathan Parker Intentionally mastering connections with patients and applying innovative teaching skills creates influence across our profession.

Managing Editor | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com

34 Clinical Focus The Perfect Start System is Effective in Addressing Sleep-Disordered Breathing in Children

by Earl O. Bergersen, DDS, MSD You may be able to get children back on the proper growth track with removable appliances!

44 Practice Management Helping Children with Obstructed Sleep Breathing: 8 Essentials All Dental Team Members Should Know

by Glennine Varga, AAS, RDA, CTA Making a connection with parents and patients is the first step. Wait until you hear about Connor Deegan.

50 Sleep Q&A Ez Sleep Pillow™ Talk: iDentifySleep™ Training Series An interview with Gy Yatros, DMD, and Richard Drake, DDS, ABDSM,

by Payam Ataii, DMD, MBA Finding patients to treat is no harder than looking in your own practice.

Hear what sleep experts Drs. Yatros and Drake have to say about that.

52 Legal Ledger A House Divided

by Ken Berley, DDS, JD, DASBA Standard of Care is not defined by dentists, but wouldn’t it be better if there were more agreement about it?

56 Sleep Humor 4 DSP | Winter 2014

Editorial Advisors Brian Allman, DDS Steve Bender, DDS Ken Berley, DDS, JD David Gergen, CDT Ofer Jacobowitz, MD Christina LaJoie Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Glennine Varga, AAS, RDA, CTA

General Manager | Adrienne Good Email: agood@medmarkaz.com National Account Manager | Michelle Manning Email: michelle@medmarkaz.com National Account Manager | Kimberly Burke Email: kimberly@medmarkaz.com Creative Director/Production Manager Amanda Culver Email: amanda@medmarkaz.com Front Office Manager | Eileen Lewis Email: elewis@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) 3 years (12 issues)

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©MedMark, LLC 2014. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

COVERstory

Figure 1

6 DSP | Winter 2014

COVERstory

by Robert Kaspers, DDS, MS

P

roper breathing is essential to a child’s health, development, and educational success. Early detection and correction of airway problems by health professionals, including orthodontists, can be integral to optimizing this fundamental physiology; and airway evaluation is an important part of the process. Comprehensive airway screening and subsequent treatment with the help of cone beam 3D imaging during childhood can help avert temporomandibular disorders and sleep-disordered breathing related issues in adulthood.

In my practice, evaluation of patients as young as six years old includes airway screening. Each patient receives a “low dose” CBCT scan to help diagnose common structural problems which would go undetected with conventional screening procedures. At this stage of development, skeletal problems can still be corrected with appliances whereas waiting until adulthood may necessitate orthognathic surgery to obtain the same results.

Airway and TMD screening are inter-related. Research conducted in my practice has shown that almost 75 percent of patients have a deficient lower jaw. As part of the research, I take all CBCT scans with the patient biting in maximum intercuspation.

In this way, I acquire an image that allows me to evaluate how the patient’s occlusion affects their condylar position (See Figure #1). Our compiled data shows that three out of four patients are indeed biting forward to get to maximum intercuspation. If the patient

Figure 2

is holding their lower jaw forward during awake hours, the tongue may interfere with the airway during sleep. i-CAT™ Tx STUDIO™ software provides helpful features for gathering clinical information as well as patient education. One such feature is the ability to take a fast, lowdose scan that gives me essential data for my particular evaluations. Another, the Airway Tool, provides color coding of the volume of a patient’s airway. Since the airway is difficult for patients and parents to visualize, this color-coding aspect of the software can help to better educate them. It is easier to understand that when the scan shows the airway color-coded in red or black for various levels of constriction (See Figure #2), and white or blue for a more open airway (See Figure #3).

In the past, if the patient was biting forward, orthodontists would have retracted the upper teeth to match up with the deficient lower jaw, but that type of treatment does not treat skeletal issues or help open the airway.

Figure 3

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COVERstory

Figure 4

Figure 5

Now, I utilize a Herbst appliance to stimulate growth of the mandible which helps improve both airway and skeletal asymmetries, and once again, 3D imaging helps to create more precision. By analyzing cone beam scans over the past four years, I found that growing patients who utilize the Herbst appliance average about 3-4 mm of additional growth of the mandible over the course of 12 to 18 months. This additional growth of the mandible helps open up the patient’s airway.

With my CBCT scans and software, I am able to titrate the Herbst appliance properly by analyzing the condylar position. By achieving an accurate 3-4 mm stretch of the mandibular muscles, I can “repeatedly” obtain the necessary mandible growth. Before 3D imaging, I was like every other orthodontist receiving mixed results using the Herbst appliance. To the best of my ability, I would try to hand manipulate the patient’s lower jaw in an attempt to acquire the proper stretch of

Figure 6

the mandibular muscles to stimulate mandibular growth. By analyzing a CBCT scan taken in maximum intercuspation, I know exactly which muscles are being activated to achieve a particular condylar position.

Several patients per year come to my office with Herbst appliances from orthodontists who do not use 3D imaging. The patients are in spasm because the orthodontist is not aware that the patient is already biting forward, and the Herbst appliance positions the jaw even further forward, throwing the lateral pterygoid into spasm and lockdown.

Sarah E. is a typical eleven-year-old girl with a retruded lower jaw and a constricted airway (See Figure #4). Her initial CBCT scan showed her condylar position considerably forward on the eminence (See Figure #5), and yet her airway was still constricted as shown by utilizing the “airway tool” (See Figure #6). A second CBCT scan was taken one month later with Sarah biting in maxi-

Dr. Robert Kaspers received his DDS with honors from the University of Michigan Dental School. He then completed specialty training in orthodontics at the Northwestern University Dental School and earned a Master of Science degree in Radiology. While in Ann Arbor, Dr. Kaspers worked with Dr. Major Ash on research projects pertaining to temporomandibular dysfunction. Dr. Kaspers has lectured to hundreds of dentists and orthodontists on diagnosis and treatment for both orthodontic and TMD cases. Dr. Kaspers is the founder of the Five Condylar Positions which has helped make diagnosing and treatment planning easier for the practitioner. Dr. Kaspers is the founder of ProActive Orthodontics, and it is his desire to help the profession understand the advantages of the CBCT scan so that diagnosis of orthodontic cases can be made more easily and more accurately. Currently, Dr. Kaspers maintains a private orthodontic and TMD practice in Northbrook, Illinois.

8 DSP | Winter 2014

COVERstory

Figure 7

Figure 9

mum intercuspation, and you can see that the condylar position is less protruded (See Figure #7). By utilizing the Airway Tool and measuring the airway from the posterior nasal spine to the hyoid bone, you can see that Sarah’s airway decreased from 9.0 cubic centimeters to 7.2 cubic centimeters (See Figure #6 compared to Figure #8). A Herbst appliance was placed to improve Sarah’s skeletal asymmetry and her airway. A CBCT scan was taken ten months later to assess when the Herbst appliance should be removed. You can see the significant improvement in her

Figure 8

Figure 10

airway (17.0 cc) as well as her condylar position (See Figures #9 & #10).

Orthodontists may improve health, reduce the possibility of development of future sleep apnea, and in some cases, possibly even save lives by being proactive with early treatment. Moving from 2D to cone beam imaging has considerably changed the way that I treatment plan for airway and TMD. Having that extra information and capacity for viewing the TMJ area and airway in 3D has changed my dreams for better patient care into reality.

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PHYSICIAN’Sperspective

by Ping-Ru Ko, MD, and Maida Lynn Chen, MD

P

ediatric sleep disorders describe a wide range of dysfunctional sleep and, because of their often subtle and exclusive occurrence in sleep, are often under-recognized by the child, by parents and caretakers, and even by pediatricians. All pediatric healthcare providers should be generally familiar with the weighty implications on long term health and developmental potential of undiagnosed sleep disorders. Dental providers, by virtue of being able to carefully and thoroughly inspect a child’s oral cavity and external craniofacial features, have a unique and crucial opportunity to identify and notify children and their caretakers about potential sleep problems, and particularly sleep disordered breathing. This review is not meant to be an exhaustive overview of pediatric sleep disorders, but aims to portray the wide variety of disorders seen in a pediatric sleep medicine clinic. For the purposes of this review, however, a larger emphasis will be placed on sleep disordered breathing.

10 DSP | Winter 2014

PHYSICIAN’Sperspective Pediatric sleep disorders encompass several categories of diseases and derangements in sleep. These include the following:

1. Sleep-Disordered Breathing (SDB)

The majority of patients seen by sleep medicine physicians have sleep disordered breathing. The classic example is obstructive sleep apnea (OSA), in which the patient experiences intermittent partial or complete blockage of their airway during sleep, sometimes with caretakers or roommates observing prolonged breathing pauses, labored breathing, or snoring in sleep, which leads to impaired ventilation and gas exchange. Patients may experience transient or prolonged oxygen desaturations, rises of arterial PCO2, or both, leading to central nervous system arousals and a systemic stress response with marked elevations in heart rate and blood pressure, and repetitive sleep disruption. These lead to poor sleep quality, and daytime symptoms such as excessive sleepiness, behavioral problems such as hyperactivity, and long-term cognitive problems such as poor academic performance. Milder formers of SDB including upper airway resistance syndrome (UARS), in which there are subtle disturbances of respiration during sleep which may not be associated with gas exchange abnormalities but is associated with increased respiratory effort with or without snoring, and may lead to daytime symptoms such as sleepiness or behavioral problems. An even milder form is primary snoring, in which snoring by itself is observed during sleep; however, even in these children, there may be evidence of subtle pathology in sleep and wakefulness.

The prevalence of sleep disordered breathing in children is estimated to be 4-11%, and obstructive sleep apnea constitutes a large

portion of SDB with estimated prevalence of 1-4%. Habitual snoring is reported to occur in about 5-12% of children, though there are reports as high as ~30%. Boys, obesity, African-American ethnicity, and atopy are all associated with higher prevalence. SDB can occur at any age; in infants and young children, large tonsils and adenoids, large body habitus, and craniofacial abnormalities play a larger role in SDB. In older teenagers, large body habitus and oral airway crowding are more prominent risk factors, similar to their adult counterparts.

Adenotonsillar hypertrophy may be exacerbated by recurrent or chronic upper airway infections, and can continue to grow, sometimes up to 12 years of age or more. Genetic syndromes such as Pierre-Robin sequence, TreacherCollins syndrome, achondroplasia, and other craniofacial dysplasia syndromes which lead to midface hypoplasia, micrognathia, retrognathia, or dental malocclusion, are all risk factors for OSA. Children with Down’s syndrome have high prevalence of OSA due to maxillary hypoplasia, small nose, hypotonia, and relative macroglossia. Other genetic syndromes leading to visceromegaly or hypotonia, such as lysosomal storage diseases, Prader-Willi syndrome, and neuromuscular disorders, also impart a higher risk of OSA. Screening for symptoms of SDB can be helpful but cannot be used to definitively diagnose SDB. The classic triad for pediatric OSA is snoring, labored breathing in sleep, and witnessed apnea in sleep; together, these three symptoms are thought to have the highest sensitivity and specificity for OSA. In addition, restlessness in sleep, recurrent nocturnal awakenings, diaphoresis, mouth-breathing, drooling in sleep, and nocturnal enuresis may also suggest SDB. Given that most parents do not sleep

Dr. Ping-Ru Teresa Ko is a graduate from the School of Medicine at University of California, San Francisco, and finished her general pediatrics residency at Children’s Hospital of Oakland in California before moving up to Seattle to complete her pediatric neurology residency at the University of Washington and Seattle Children’s Hospital. Currently, she is in a sleep medicine fellowship at the University of Washington.

Courtesy Seattle Children’s

Maida Lynn Chen, MD, is director of the Pediatric Sleep Center and attending physician at Seattle Childrens Hospital and assistant professor in the Department of Pediatrics at the University of Washington School of Medicine. She earned her MD at Northwestern University and completed a pediatrics residency at RushPresbyterian-St. Lukes Medical Center. She completed her pediatric pulmonary fellowship at Childrens Hospital Los Angeles, with special focus on respiratory control and sleep medicine.

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PHYSICIAN’Sperspective in the same room as their children and therefore cannot provide a complete observational history of their children’s sleep characteristics, daytime symptoms may be more prominent or more disturbing. These symptoms may include vague behavioral problems such as hyperactivity, difficulty focusing at school or at home, poor academic performance, mood lability, aggressiveness, poor appetite, and daytime sleepiness. In young infants with severe OSA, growth failure may occur. Overall, however, subjective symptom reporting by the patient and their caretakers is not completely sensitive or specific for SDB, and additional data, including a careful physical examination and especially objective data in the form of polysomnography, are crucial for diagnosing this common pediatric disorder.

Having a high suspicion for SDB during evaluation of any child is important, as the clinical consequences of untreated Having a high OSA can be profound. Untreated SDB can suspicion for SDB lead to pulmonary hypertension due to chronic hypoventilation, leading to right during evaluation heart strain. In one study of 27 children, of any child is right ventricular dysfunction and impaired cardiac wall motion in children with OSA important, as the improved after adenotonsillectomy as evidenced by radionuclide ventriculography.1 clinical consequences Children with OSA and tonsillar hypertroof untreated OSA phy were shown to have increased 24-hour pressure loads, and significant reduccan be profound. blood tions in DBP were seen after adenotonsillectomy.2 Failure to thrive and growth failure, as previously mentioned, may occur in children with OSA due to a combination of decreased appetite, impaired growth hormone secretion, and high energy expenditure due to increased work of breathing. In young children, OSA was shown to be a risk factor for community acquired pneumonia.3 Elevated serum inflammatory markers such as C-reactive protein and various pro-coagulation proteins have been observed suggesting increased oxidative stress and systemic inflammation. Several studies have demonstrated lower IQ scores in children with SDB compared to controls, although these scores are typically still within normal range.4 In other studies, lower grades in mathematics, spelling, reading, and science; impaired memory recall; and lower performance on a phonological processing test were seen in children with SDB compared to controls.

As in adults, diagnosis of pediatric OSA is through polysomnography, which is largely still in the laboratory setting in most pediatric

12 DSP | Winter 2014

sleep centers. In general, an obstructive apneahypopnea index (AHI) of 1.0 or above is diagnostic of obstructive sleep apnea in children, although adolescents can use the adult criteria of AHI or respiratory disturbance index (RDI) of 5.0 or higher with clinical symptoms.

Treatment can be curative or near-curative for some children with adenotonsillectomy.

Polysomnography is often done several weeks after adenotonsillectomy to document resolution of respiratory events, especially given the subtlety of signs and symptoms of residual disease in children. If the child is not a candidate for adenotonsillectomy, or if the procedure does not prove to be non-curative, positive airway pressure can be trialed, although this therapy is difficult to tolerate especially in children with developmental delay or other behavioral problems. Additionally, long-term usage of PAP masks can lead to abnormal development of the mid-face in growing children. In children with significant craniofacial dysmorphisms for whom our various PAP mask interfaces are not suitable, significant air leak can render PAP therapy unfeasible. In these cases, skeletal advancement procedures may be more beneficial. Mandibular distraction osteogenesis may be used in children with micrognathia or retrognathia. In children with maxillofacial dysmorphisms or dental malocclusion, rapid maxillary expansion (RME) or maxilla-mandibular advancement (MMA) can be used. Alternatives to the above procedures include oral appliances that gradually change maxillomandibular alignment using a series of removable acrylic mouthpieces. If the obstruction occurs lower down in the airway, tongue reduction, genioglossal advancement, or hyoid myotomy and suspension can be used. Sleep endoscopy, in which flexible endoscopy of the pharynx and hypopharynx is done while the child is under propofol to simulate sleep, can be a useful procedure to determine the level of obstruction and to direct surgical therapy. Adjunctive therapies include optimization of the nasal airway to nasal saline or corticosteroid sprays, positional therapy. Treatment of exacerbating conditions such as obesity, gastroesophageal reflux, asthma, and other chronic cardiopulmonary conditions can also be helpful. When other therapies have failed or are not available, supplemental oxygen may ameliorate hypoxemia, but should be used in caution in children with chronic hypercapnia due to potential decrease in central respiratory drive. Oral appliances are not generally used in children due to concerns for

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PHYSICIAN’Sperspective misalignment of permanent dentition in this age group. A Cochrane Review in 2007 regarding the use of oral appliances in children 15 years old or younger concluded that there is not enough evidence about their efficacy in the treatment of OSA in this age group.5

2. Insomnia

These can include difficulties falling or staying asleep, or both. They may be behaviorally induced, such as when children grow used to having a parent stay with them, sometimes in the same bed with them, until they fall asleep; these children have difficulties achieving on their own and require excessive effort from the parents each night to get to sleep. These can occur secondary to other sleep disorders, such as restless legs syndrome or obstructive sleep apnea. They occur in high prevalence in certain neuropsychiatric conditions such as autism spectrum disorder.

3. Hypersomnia

These involve an increased sleep drive, sometimes manifesting as longer sleep times at nighttime, unusually fast onset of sleep, and excessive sleepiness during the daytime. Narcolepsy is the classic hypersomnia, where the central nervous system’s regulation of sleep, especially rapid-eye movement (REM) sleep, and wakefulness become dysregulated. Other types of hypersomnias exist, including those that follow traumatic brain injury, sedatives and other psychotropic medications, and idiopathic forms.

4. Circadian Rhythm Disorders

These involve differences in each individual’s circadian rhythm, which is dictated by natural biological rhythms in the body, as well as melatonin release from the pineal gland which is influenced by light exposure in the eyes. In advanced sleep phase syndrome, the individual has a natural tendency to fall asleep early in the evening and wake up early the next morning; in contrast, in delayed sleep phase syndrome, the child has a natural tendency to fall asleep later and wake up later. This is, essentially, a characterization of the so-called “morning lark” versus the “night owl.” Young children tend to have an earlier sleep phase compared to their parents (i.e, they go to bed earlier and wake up earlier). However, adolescents naturally develop a tendency toward a delayed sleep phase, which can become pathologic in the setting of early school start times. Another

14 DSP | Winter 2014

form is shift work disorder, common in individuals who have erratic work schedules that include graveyard or night shifts.

5. Parasomnias

Arousals from the various stages of sleep can cause different types of parasomnias, or partially-awake, partially-asleep behavior. In children and even some adults, arousals from deep sleep, or slow-wave (N3) sleep, can lead to spectrum of abnormal behavior, ranging from mild and brief confusion (called confusion arousals) upon awakening to episodes of screaming, crying, and fear in which the child cannot be fully awakened or calmed, even by the parents (called night terrors). Other, more widely known phenomenon include sleep walking and sleep talking, in which the individual will have seemingly purposeful or semi-purposeful verbalizations and movements, but will not remember them the next day. There is also a phenomenon called sleep eating. These types of parasomnias are more common in children and become less prevalent with age, and importantly are all characterized by lack of recall in the morning. This is in contrast to nightmares, which are “bad” dreams which children have vivid recall of that dream.

6. Sleep-Related Movement Disorders

Restless leg syndrome is a clinical syndrome that can occur at any age. It is characterized often by an ill-defined discomfort, more often in the legs although they can sometimes also involve the arms or the whole body, sometimes described as a sense of itching not relieved by scratching or a dull ache or pain, which induces an urge to move the legs. This discomfort classically improves with continuous movements of the legs, but returns as soon as movements cease. This phenomenon may worsen at night or occur exclusively at night, and can lead to difficulties with falling or staying asleep. Other phenomena include periodic limb movements in sleep, which may be associated with sleep disordered breathing but occasionally appear to be idiopathic. These movement disorders need to be distinguished from neuropathic pain, musculoskeletal pain from arthritis or traumatic injuries, and other cause of movements in sleep. Children who suffer from sleep deprivation or fragmentation from leg movements may present with seqeulae of daytime sleepiness, such as hyperactivity, poor academic performance, emotional difficulties, and overt sleepiness.

PHYSICIAN’Sperspective Dental providers are often on the front line in assessing children for potential sleep problems. Dental providers have a distinct advantage compared to pediatricians and many other healthcare providers in this regard as they are afforded a long and careful look in the oral cavity, and can assess for signs of bruxism, enlarged tonsils, and craniofacial features that may predispose to SDB including micrognathia, retrognathia, a high arched palate, macroglossia, and other signs of oral airway crowding. Dental providers can inspect the oral cavity when the child is laying supine, which mimics the normal sleeping position and may bring out features suggestive of sleep disordered breathing, whereas most pediatricians often must make do with inspecting the child’s nose and mouth in an upright position. Similarly, from their vantage point, dental providers may also be able to detect abnormalities of the nose such as nasal septal deviation, asymmetry of the nostrils, and wide columella with relatively narrow nostrils, or the presence of audible and obligate mouth-breathing, or labored breathing in the supine position. Helpful screening question to ask the child’s caretakers are: S: Does your child snore or have loud breathing when asleep?

N: Does your child have nasal congestion or breathe mostly through his or her mouth?

O: Have you ever observed your child pause in his or her breathing during sleep, even for just a few seconds?

R: Is your child restless in sleep? Does your child move around a lot, sweat a lot, wake up frequently at night, or seem to be uncomfortable in sleep?

E: Is your child excessively sleepy, hyperactive, aggressiveness, or inattentive during the daytime?

If any of the above questions are answered positively, directing the child to his or her pediatrician and getting a referral to a sleep medicine specialist is highly advised.

In conclusion, pediatric sleep disorders encompass sleep disordered breathing, parasomnias, and movement disorders, insomnias, hypersomnias, and circadian rhythm disorders. Similar to their adult counterparts, children with SDB may suffer from cardiovascular complications, systemic inflammation and stress response with untreated SDB; compared to adults however, children can have misleading daytime symptoms of inattentiveness, hyperactivity, aggressiveness, and other behavioral problems, and as well as poor

academic performance. These can negatively impact the quality of life of both the child and the family, and have long-term cognitive implications. Dental providers can help assess for pediatric sleep disorders by closely inspecting the oral cavity as well as the craniofacial structure of the child, and using a short set of questions inquiring about snoring, nasal symptoms, witnessed pauses in breathing, restless sleep, and daytime behavioral symptoms. A referral to pediatric sleep medicine specialist should be made promptly assess for the presence of sleep disorders; in the case of SDB, treatment can impact cardiovascular and cognitive complications.

References 1. Tal A, et al. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonol. 1988;4(3):139-43.

2. Ng DK, et al. Ambulatory blood pressure before and after adenotonsillectomy in children with obstructive sleep apnea. Sleep Med. 2010 Aug;11(7):721-5 3. Goldbart AD, et al. Sleep-disordered breathing is a risk factor for community-acquired alveolar pneumonia in early childhood. Chest. 2012 May;141(5):1210-5.

4. Sheldon SH, et al. Principles and Practice of Pediatric Sleep Medicine. London: Elsevier Saunders, 2014. Print.

5. Carvalho FR, et al. Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005520.

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ORTHODONTIST’S perspective

“Doc, my kid snores.

Should I be worried?”

An interview with Rolf Maijer, DDS, D.Ortho, FRCD(C)

W

ith the increased awareness about sleep apnea among the public at large, more and more parents are raising questions about their kids’ snoring.

DSP recently spoke with Dr. Rolf Maijer, an orthodontist who lectures across North America and Europe about sleep problems and sleep disordered breathing in kids and teenagers.

18 DSP | Winter 2014

ORTHODONTIST’S perspective DSP: “What prompted you to focus on the younger population regarding sleep apnea?”

RM: Over the years in my pedodontic and later in my orthodontic practice, parents have made comments like “You know, after you gave that appliance to Jonathan to widen his upper teeth, he stopped snoring” and “After Zoe started her expander treatment, she became a much better student in school.”

I finally connected the dots about nine years ago when a teacher that I was treating in my Nunavut practice [in the Canadian Arctic], made an observation about three of her students who were also in treatment.

She observed that these three children had always been very sleepy in class, but after they started orthodontic (expansion) treatment, they were much more attentive. Suddenly, the comments from the past made a lot more sense. My “ah-ha” moment came when I realized what a profound impact that we as dentists can have in children’s overall lives – in their health, quality of life and ability to learn – if we start looking at our patient’s craniofacial structure and the oral cavity in the context of the airway and sleep.

Today, my wife and I spend a lot of our time actively reaching out to health care professionals, educators and parents to create awareness about the importance of sleep hygiene and the risks associated with sleep fragmentation and sleep disordered breathing in children.

DSP: What concerns you most about kids and their sleep health?

RM: Among my top concerns are how much time children (as well as adults) spend in front of screens, especially just before bed!

It’s amazing how much time kids spend with personal electronics, such as phones and tablets in bed. The blue light emitted from laptops, tablets and cellphones is known to affect melatonin levels. This can have a negative impact on a child’s ability to fall asleep as well as sleep quality. Kids are not the only ones at risk for poor sleep due to blue light exposure before bed. Adults are as well!

When it comes to sleep disordered breathing, our medical colleagues hardly pay attention to “primary snoring” in the child population, despite a growing body of literature over the last 15 years. Simple snoring to-

gether with periodic airway obstructions can have a very damaging effect on growth and development. A child’s executive function and the speed with which he or she comprehends subject matter in the classroom can also be affected.1

DSP: Why do you focus on speaking to pediatric and orthodontic clinicians?

RM: Orthodontists and pedodontists are in a unique position to screen patients for SDB. They can readily see airway obstructions in their workups and radiographic material.

It is extremely important that these two specialties understand that their early diagnosis can have a tremendous impact on the growth and development of young patients, as well as on their quality of life.

DSP: Why do we need to intercept SDB in children early? And what happens if we don’t?

RM: The earlier that we identify and address SDB the better. Expansion of the upper arch and compensatory occlusal adjustments in the lower arch occur much more easily when the child is six or seven than when we have a teenager. Remember that by age six, 60% percent of the skull has formed. At age twelve, 90% of the cranium is complete. Furthermore, an abnormal breathing pattern intercepted early allows us to stop the process that can lead to problems shown in Figure 1.

DSP: What are some of the things that a general dentist can do to screen their patient population for sleep issues?

RM: General dentists also play an important role in screening kids for sleep problems and educating parents about the importance of sleep health. Keep in mind that about 12% to 16% of the pediatric population will have some form of SDB at some point between the ages of six and eighteen.2 A simple addition to your intake questionnaire about “regular”

% 0 6 90% By age six

of the skull has formed

At age twelve

of the cranium is complete

Figure 1: Pathways of abnormal breathing in children Stage 1 • • • • •

Nasopharyngeal obstruction Mouth breathing starts Mouth breathing irritates throat Tonsils enlarge Tonsils become infected

Stage 2 • • • • •

Chronic mouth breathing Orbicularis muscle loses tone Tongue posture altered Palate collapses Vertical growth pattern ensues

DentalSleepPractice.com

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ORTHODONTIST’S perspective snoring, excessive daytime sleepiness and morning headaches will uncover a host of surprises. (It’s important to differentiate “regular” snoring from “occasional” snoring due to a cold or congestion.)

In our Dutch practice, we put up a sign in the waiting room that read: “Does anyone in your family snore? If so, please see front desk for information.” We saw 30 patients with SDB that day! If you learn that a parent snores or suffers from obstructive sleep apnea, use the opportunity to start a conversation with the patient or the parent about the child’s sleep.

It is important to train the whole office so that everybody is on the same page and speaks the same language. When we bring on a mentee, we don’t just work with the dentist. We train the entire office. It’s just as important for the front desk staff to recognize signs and symptoms of sleep issues among pediatric patients as it is for those that work chairside.

DSP: What should the dentist look for in a child patient?

RM: There are a number of tell-tale signs that should ring a bell.

• Venous pooling under the eyes • Chronic mouth breathing while reading or playing an electronic game (e.g. in the waiting room) • Forward tongue posture (tongue hanging out while reading or performing a task) • Complaints of morning headaches • Falling asleep in the waiting room or dental chair • Acting out or boisterous behavior

Figure 2: BEARS Sleep Screening Protocol The BEARS instrument provides a comprehensive screen for the major sleep disorders affecting children in the 2- to 18-year old range. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview.

B = Bedtime problems E = Excessive daytime sleepiness A = Awakenings during the night R = Regularity and duration of sleep S = Snoring Mindell JA, Owens JA. A clinical guide to pediatric sleep: diagnosis and management of sleep problems.: Wolters Kluwer; 2009.

20 DSP | Winter 2014

DSP: How do you evaluate kids for sleep problems?

RM: The first step is to engage the parents. Ask questions about their child’s sleep hygiene. “What time does Henry go to bed?

Is Jenny watching TV before going to sleep?”

I use the BEARS Assessment which is a simple, 5-item pediatric sleep screening tool for use in primary care settings.3 This instrument helps you document information about five different domains of sleep health, including sleep hygiene and SDB. Since I like to have the results before I see the patient in the clinic, my assistant typically asks these questions of the parent or the child (depending on age.)

If the BEARS assessment indicates possible SDB issues, I typically issue an overnight SleepImage® test to gather additional objective data about the child’s sleep.* This device is a simple, one-lead ECG monitor that records the stability and quality of the child’s sleep. This screening tool can be used cost-effectively, especially in large practices. We use it in both our adult and pediatric practices and have started a new training program to help other dentists learn how to integrate it into their day-to-day practice.

The spectrogram produced by the SleepImage® helps me identify the presence of snoring, leg movements and effects of airway resistance (obstruction) on the child’s heart rate. It also shows to what degree the child’s sleep is fragmented and aids in explaining why their child experiences excessive daytime sleepiness. (See Fig. 4.)

As screening and communication tools, both the BEARS assessment and the SleepImage® spectrogram are invaluable. Depending on the findings, I will triage the case for further investigation or initiate treatment. Pediatricians and PCPs, alike, respond favorably when I attach a BEARS result and sleep-spectrogram to a letter requesting further assessment. When incorporated into routine practice, these tools facilitate EARLY recognition of sleep issues in patients!

DSP: We’ve heard that the “cure” for pediatric sleep disordered breathing is to send the patient to an ENT for * For further information, contact SleepImage®, Broomfield, CO, 720-708-4217. www.sleepimage.com.

ORTHODONTIST’S perspective Figure 3. Examples of developmentally appropriate trigger questions Toddler/preschool (2-5 years)

School-aged (6-12 years)

Adolescent (13-18 years)

1. Bedtime problems

Does your child have any problems going to bed? Falling asleep?

Does your child have any problems at bedtime? (P) Do you have any problems going to bed? (C)

Do you have any problems falling asleep at bedtime? (C)

2. Excessive daytime sleepiness

Does your child seem overtired or sleepy a lot during the day?

Does she still take naps?

Does your child have difficulty waking in the morning, seem sleepy during the day or take naps? (P) Do you feel tired a lot? (C)

Do you feel sleepy a lot during the day? In school? While driving? (C)

3. Awakenings during the night

Does your child wake up a lot at night?

Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? (P) Do you wake up a lot at night? Have trouble getting back to sleep? (C)

Do you wake up a lot at night?

Have trouble getting back to sleep? (C)

4. Regularity and duration of sleep

Does your child have a regular bedtime and wake time? What are they?

What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep? (P)

What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get? (C)

5. Snoring

Does your child snore a lot or have difficult breathing at night?

Does your child have loud or nightly snoring or any breathing difficulties at night? (P)

Does your teenager snore loudly or nightly? (P)

(P) Parent-directed question

(C) Child-directed question

Mindell JA, Owens JA. A clinical guide to pediatric sleep: diagnosis and management of sleep problems.: Wolters Kluwer; 2009.

Figure 4: Sleep spectrogram of 8 year old boy without snoring.

Figure 5: Sleep spectrogram of 6 year old boy with snoring.

Image courtesy of MyCardio, LLC.

Image courtesy of Population Sleep, LLC.

DentalSleepPractice.com

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ORTHODONTIST’S perspective Snoring and excessive daytime sleepiness are important warning signs of a potential problem that should not be ignored. It’s our role as dentists to connect the dots so parents understand the relationship between craniofacial anatomy and sleep disordered breathing. removal of the tonsils and adenoids.

What do you think?

RM: In the past, we all assumed that the tonsils and adenoids (T&A) were the culprit and that removal was the cure. Several recent articles on post-surgical outcomes have shown, however, that many patients develop SDB sequellae two years post-surgery.4,5 The “obstruction problem” appears to be a lot more complex than simply eradicating an interfering tonsil or adenoid.

T&A removal is often the right call for addressing a child’s SDB problem. However, due to the frequency that SDB reoccurs in children after T&A surgery, it is absolutely imperative that we as clinicians recognize that a tonsillectomy and/or adenoidectomy may not solve the issue by just removing the obstruction. As noted by Bhattacharjee, we can’t rely on T&A as a “cure” for pediatric sleep disordered breathing.6

DSP: What are the “take home” points that you give to parents when you talk to them about their child and the child’s sleep?

RM: We stress that habitual snoring will not “just go away.” Snoring and excessive daytime sleepiness are important warning

signs of a potential problem that should not be ignored. It’s our role as dentists to connect the dots so parents understand the relationship between craniofacial anatomy and sleep disordered breathing. If we find clinically that a child has a narrow arch (or crossbite) and a small mandibular arch, we explain that this “narrow bony box” may have a limiting effect on the airway.7 If the youngster is overweight, I bring out a picture that shows lateral pharyngeal fat pads restricting the airway.8 We want parents to realize that poor sleep and sleep fragmentation – no matter what the cause – is not healthy for their growing child.

For this reason, we talk about the importance of good sleep hygiene and limiting the use of electronics before bed.

In cases where I do a screening and workup, I make sure that parents know that I will send a letter with my findings to the child’s pediatrician and other specialists involved in their kid’s care. Parents are generally very appreciative of the time you spend explaining why sleep is so important and giving them actionable information about how to improve their child’s sleep health.

DSP: Any final thoughts?

RM: Snoring and sleep apnea are in the news right now. You can’t pick up a newspaper or magazine without running into an article on sleep-related issues. As dentists, we can use this general awareness to shift the attention to our youngsters. We have to create awareness among parents, teachers and other health care providers that dentists play an essential role in catching sleep problems early. Dental intervention for sleep disordered breathing, when appropriate, can make a profound difference in a child’s health and quality of life.

References 1.

Cortese S, Brown TE, Corkum P, et al. Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(8):784-796.

2.

Katz E. Personal Communication. Toronto, Ontario 2013.

3.

Mindell JA, Owens JA. A clinical guide to pediatric sleep : diagnosis and management of sleep problems. 2nd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.

4.

Dayyat E, Kheirandish-Gozal L, Gozal D. Childhood Obstructive Sleep Apnea: One or Two Distinct Disease Entities? Sleep medicine clinics. 2007;2(3):433-444.

5.

Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. The Journal of Pediatrics. 2006;149(6):803-808.

6.

Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. American journal of respiratory and critical care medicine. 2010;182(5):676-683.

7.

Pirila-Parkkinen K, Pirttiniemi P, Nieminen P, Tolonen U, Pelttari U, Lopponen H. Dental arch morphology in children with sleep-disordered breathing. Eur J Orthod. 2009;31(2):160-167.

8.

Schwab RJ, Pasirstein M, Kaplan L, et al. Family aggregation of upper airway soft tissue structures in normal subjects and patients with sleep apnea. American journal of respiratory and critical care medicine. 2006;173(4):453-463.

22 DSP | Winter 2014

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SURGEON’S perspective

24 DSP | Winter 2014

SURGEON’S perspective

Pediatric Sleep Apnea:

Don’t miss out on making the diagnosis

by Bryce Williams, DDS, Oral and Maxillofacial Surgeon Assistant Professor, University of Utah Heath Care

Y

our Thursday clinic is completely booked. As you move from patient to patient you tackle each problem presented to you in the most efficient way that you can. Thomas, your patient in exam room 4, is doing well at his 6 month recall appointment and requires occlusal sealants today. Lisa in exam room 2, a 36 year-old female with primary snoring, has had a good response to the mandibular advancement device that you ordered and fitted for her and her primary physician is pleased with the treatment as well. In exam room 1 is Mitchell, a six year-old male is presenting for his very first visit to the dentist with his mother and his 12 year-old sister. Mitchell appears excessively hyperactive for his age and has difficulty paying attention to what you or his mother is saying to him. During your examination, Mitchell sits in his mother’s arms and begins to doze off towards the end of the exam, but wakes up after you stand up to wash your hands.

Afterwards, Mitchell is interested to learn that he has 20 teeth and no cavities. The oral exam reveals that his tonsils are +1 in size, which is fairly small for his age. You prescribe a prophylactic cleaning today and a 6-month follow-up. Mitchell leaves the office, and his obstructive sleep apnea leaves with him.

Dr. Williams was raised in Northern California and completed his undergraduate training at Brigham Young University. He received his dental degree from the University of the Pacific in San Francisco, graduating magna cum laude. He then completed an Oral Maxillofacial Surgery residency at Highland Hospital at Alameda County Medical Center. His residency included training at Children’s Hospital in Oakland and extensive experience in orthognathic surgery at Kaiser Permanente, also in Oakland. His clinical interests include treating patients with obstructive sleep apnea for which he offers multiple surgical procedures including maxillomandibular advancement surgery.

DentalSleepPractice.com

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SURGEON’S perspective Sleep apnea in the pediatric population typically has different manifestations compared with sleep apnea in the adolescent and adult population. This can make the diagnosis of sleep disordered breathing in the child much more challenging. Knowing the difference might mean uncovering undetected sleep apnea in one child and ruling it out in another. Diagnosis and effective treatment can mean improved academic and social performance for the child as well as allowing them to reach full developmental potential. In short, it can make a big difference in a child’s life and subsequent maturation.

In adults and adolescents, the primary symptoms most frequently consist of daytime somnolence, however, in the pediatric population this symptom may not be so easily observed by the child’s parents or other adults that they interact with daily. Children with sleep disordered breathing may tend to show signs of hyperactivity and inability to focus, which seems counterintuitive and therefore makes detection of this disease in children more difficult.1 For this reason, using a standardized screening questionnaire, such as the Epworth Sleepiness Scale, is not as effective with children as it is with adults.2 In fact, a detailed history can be considered an inadequate tool for investigating sleep breathing aberrations in the pediatric population.2 There are several validated screening tools specific for the pediatric patient, that have a positive predictive power value as high as 85%.3,4 Knowing the risk factors, exposing the Table 1: Pediatric Signs and Symptoms of Sleep Apnea Hyperactive Inattentive Poor appetite Difficulty swallowing Mood swings Anger control issues Excessive sleepiness Behavior problems at school Poor development of language skills Memory impairment Diagnosis with ADHD Depression Failure to thrive

26 DSP | Winter 2014

Figure 1

symptoms and vigorously pursuing subtle clinical signs may be the best method to approach pediatric sleep apnea. As young children have immature communication skills, they usually cannot accurately articulate their symptoms. An interview with a concerned parent can elucidate subtle cues such as hyperactivity, poor appetite, aggression and difficulty at school [see Table 1]. While several of these signs are associated with other diagnoses, namely ADHD (Attention Deficit Hyperactivity Disorder), up to 30% of children with sleep apnea exhibit behavioral problems that closely mimic ADHD.5 Hearing such behaviors from the patient’s mother or father may prompt you into looking a little closer during the clinical examination to determine if this child may be at risk for obstruction of the airway at night.

The fictional story about Mitchell above also illustrates another important consideration: sometimes clinic signs do not assist in identifying a child at risk for obstructive sleep apnea. For instance, Mitchell had +1 tonsil size (equivalent to <25% obstruction of the posterior pharynx) found in his oral examination. If the same finding of a +1 tonsil was found in an adult, the observation might be considered insignificant. A tonsil size rating of +4 approximates 100% occlusion of the oropharynx by the tonsils [see Figure 1].

A recent systematic review revealed that the correlation between tonsil size and polysomnography-proven sleep apnea is poor.6 This is further elucidated in a meta-analysis putting

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SURGEON’S perspective

An effective screening by a curious clinician can translate to additional diagnostic testing, to diagnosis, to treatment, to improvement or cure.

the cure rate of adenotonsillectomy at 82% — which demonstrates that removal of the tonsils and adenoids is not necessarily the silver bullet in the child with obstructive sleep apnea that it was previously thought to be.7 In summary, occasionally the clinical exam of a pediatric obstructive sleep apnea patient can trick even the most seasoned clinician.

Because tonsillar hypertrophy may be absent in a small subset of children with obstructive sleep apnea, the head and neck assessment must look for additional anatomic evidence that could be causing nocturnal pharyngeal obstruction. For instance, the clinic exam must not only inspect the patient for enlarged tonsils and adenoids, but also report on growth disturbance, craniofacial abnormalities, relative neck size, absolute tongue size, lingual tonsil hypertrophy, turbinate hypertrophy, hypertensive blood pressure readings and evidence of gastroesophageal reflux.

Additional referral to an internal medicine physician, pulmonologist and/or otolaryngologist to determine just how significant these findings are, but discovering them may be the first step in establishing a diagnosis of sleep disordered breathing in a child. An effective screening by a curious clinician can translate to additional diagnostic testing, to diagnosis, to treatment, to improvement or cure.

While adenotonsillectomy, or removal of the adenoid tissue and palatine tonsils, is still the most favored and effective treatment, it may not be as effective as previously thought with failure rates from 20-40%.8 Obesity, multilevel airway obstruction, and associated craniofacial syndromes, along with a host of other factors, can compromise the cure rate of adenotonsillectomy. In order to better understand the location of obstruction within the airway, whether it is singular or multi-level, drug-induced sleep endoscopy (DISE) may be a helpful diagnostic adjunct to target surgical therapy specifically to the areas where obstruction is observed in real-time. DISE is performed by the treating surgeon in the op-

erating room under the care of an anesthesiologist. A topical nasal decongestant and a topical anesthetic agent are used in the patient’s nasal cavity in preparation for introduction of a flexible endoscope. Finally, an infusion of a hypnotic/sedative agent (typically Propofol or Midazolam) is used to simulate sleep. The sedative agent is carefully titrated until the patient is in sleep-like state but spontaneous breathing is still maintained. At that point, a flexible endoscope is introduced into the patient’s nose and each level of the airway is observed in real-time to determine any if any anatomic abnormalities of the pharynx is present and to record the location(s) of occlusion of the airway. After the endoscopic examination, the patient can be placed under full general anesthesia and the surgeon can prescribe and immediately perform the needed airway surgery based on the findings during DISE. Alternatively, the surgeon can end the procedure and perform the procedure later on, after discussing the findings during the DISE with the patient’s legal guardians.

DISE combined with surgical therapy in patients that have failed conservative measures (CPAP) has shown promising results.9 Despite Mitchell being a fictitious character, his situation represents an unknown number of undiagnosed pediatric sleep apnea patients that are suffering daily and are at risk of failing to thrive if they continue along that path. Because many of the symptoms of sleep-disordered breathing overlap with other conditions, misdiagnosis is a valid concern. As stated earlier, up to 30% of pediatric patients diagnosed with ADHD are actually suffering from a sleep-disordered breathing and may find improvement with CPAP or adenotonsillectomy.5 Refining our tools for detection and screening, enhancing our clinical examination skills, and obtaining the appropriate consultations with other medical and dental disciplines will, hopefully, limit the number of children that continue undiagnosed and untreated.

References 1.

Melendres MC. Lutz JM. Rubin ED. et al. Daytime sleepiness and hyperactivity in children with suspected sleep-disordered breathing. Pediatrics 114 (2004):768–75.

2.

Alexander NS. Schroeder JW. Pediatric Obstructive Sleep Apnea Syndrome Pediatric Clinics of North America 60.4 (2013):827-840.

3.

Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S. STOP questionnaire: a tool to screen patients for obstructive sleep apnea, Anesthesiology 108 (2008):812–821.

4.

Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ):validity and reliability of scales for sleep-disordered breathing, snoring, sleepinessand behavioral problems, Sleep Med. 1 (2002): 21–32.

5.

Sedky K, Bennett DS, Carvalho KS. Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: a meta-analysis. Sleep Med Rev. 18.4 (2014):349-56. doi: 10.1016/j.smrv.2013.12.003.

6.

Nolan J, Brietzke SE. Systematic review of pediatric tonsil size and polysomnogram-measured obstructive sleep apnea severity. Otolaryngol Head Neck Surg 144 (2011):844–50.

7.

Brietzke SE, Gallagher D.The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg. 134.6 (2006):979-84.

Epub 2013 Dec 24.

8.

Friedman M, Wilson M, Lin HC, et al. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 140.6 (2009):800–8.

9.

Wootten CT, Chinnadurai S, Goudy SL. Beyond adenotonsillectomy: outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 78.7 (2014):1158-62. doi: 10.1016/j.ijporl.2014.04.041. Epub 2014 May 2.

28 DSP | Winter 2014

CLINICIANspotlight

Creating

Exceptional Experiences The DSP Interview with Dr. Jonathan Parker

H

ow did you learn to provide sleep services in your practice? Did you find the instructor at the courses you took inspiring? Did you see her/him as someone you could emulate? Over a career, dentists take hundreds of hours of education from dozens of instructors. How many do you remember? Have you made a difference in your patientâ&#x20AC;&#x2122;s lives because of what you learned?

Chances are, if youâ&#x20AC;&#x2122;ve learned sleep medicine from Jon Parker, every answer will be positive, and you are having fun helping people get healthier in your community. Dental Sleep Practice sat down with Dr. Parker to explore what makes him one of the premier teachers of dental sleep medicine.

DSP: Dr. Parker, thank you for taking time to speak to me about your role in our profession. All good teaching is fueled by wisdom, which comes from experience. You see patients every day; what do you think is unique about your practice?

My practice intention is unique in the way that my team and I work together to create an exceptional patient experience. It is focused on guiding the patients through this experience of being cared for and of learning about their sleep, health, treatment options and about themselves. We are able to develop a relationship with them and educate them from the initial phone conversation through all phases of their treatment. We have also created a wonderful healing energy in our space/environment and patients are keenly

aware of it from the moment they walk into the office. I want to empower them to make the right choices for themselves and I want them to feel good about their experience every step of the way in their treatment process.

DSP: Your practice is not just about making appliances for referred patients.

Our practice is about helping patients improve their sleep and their health. I have been influenced by a number of gifted holistic physicians and dentists who have created practices around developing a relationship with their patients in a way that helps them understand their health issues and guides them through a process of reclaiming their health and vitality. I have been influenced by many people in my professional career. I am inspired by practitioners who have taken DentalSleepPractice.com

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CLINICIANspotlight a different path in their medical training and practice, understand the science and art of medicine at a deep level, and view the healing process in an integrative way. Deepak Chopra, MD and Bill Manahan, MD are both physicians who have inspired me to explore an integrative approach in medicine that helps the patient heal on a physical and consciousness level. I will have discussions with my patients about sleep, health and healing both physically and spiritually. In addition, guiding my patients who have chronic health conditions to practitioners who use this approach has been very helpful for them and very rewarding for me.

In dentistry, my colleagues (and friends) Drs. Alan Lowe and Rob Rogers, who are real pioneers in this area of dentistry, continue to kindle the fire in me to do this work and advance the art and science of dental sleep medicine.

My parents have also inspired me. My father was an internationally-known architect and my mother was a pre-school teacher. My father had a private practice and he taught at the University of Minnesota School of Architecture for 40 years. His unique teaching style and approach to architecture had a profound impact on architects around the world and he certainly influenced how I created my path in dentistry. They both instilled the important values that continue to guide me in my work and in my life.

DSP: Dentists you’ve taught, then, come away with more than ‘how to do’ appliance therapy.

Illustrations from Dr. Parker’s animated video “An Overview of Sleep Medicine“

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Dental sleep medicine is much more than just fitting an oral appliance. We need to understand all aspects of sleep and the anatomy and physiology of the system we are managing. Since I have been fortunate enough to practice in dental sleep medicine for so many years, I believe it is my responsibility to teach and mentor others so they also have the chance to change people’s lives through this work. My practice is so rewarding for me that I want to help others enjoy their ‘work’ as much as I do.

I am disappointed with some of the teaching methods typically used in dentistry and other educational settings. So, I have tried to find unique ways of presenting and express-

ing the information that I am teaching by using visual, verbal, and written techniques to engage the audience. It is with this idea in mind that I created the animated video “An Overview of Sleep Medicine”. The video uses a white board format and it has been well received by dentists, physicians, and patients.

People have said that they learned a lot and really enjoyed the entertaining way in which the information was presented. I believe we, as educators, need to find new and creative ways to deliver the information so the attendees at courses will learn and remember the material being taught and are able to apply it in their practices.

I have also tried my best to present the information in an unbiased way so it allows the attendees to make their own decisions about the various choices they have related to diagnosis and treatment of sleep-related breathing disorders.

I just hope my joy of teaching and my love of dental sleep medicine will shine through during my presentations so the audience feels that same spark within themselves. I want them to see how fun it is to work in this area of dentistry. There are so many people suffering from sleep apnea and we need more dentists out there helping them.

DSP: Sounds like you’ve put as much ‘intention’ into your teaching as you do your practice. How did you come to this?

The story of how I was introduced to sleep medicine is relatively simple. I grew up in Minnesota and received my undergraduate and dental degrees at the University of Minnesota. I took an elective course in “Management of TMDs” during my senior year in dental school and the dentist/professor who taught the course hired me in a part-time position in his TMD private practice in 1983. At the same time I was a part-time associate in a general dental practice. In 1990, my mentor in the TMD practice accepted a position at the University of Oklahoma and I bought the TMD practice from him and left the general dentistry practice to manage TMD patients on a full-time basis in my new practice. In 1992 I had a TMD patient, who was a technologist at the local sleep disorders center, tell me about a patient of theirs who had a sleep study while using a dental device and had great success with it. They had never seen an oral appliance so she invited me to come to their Wednes-

CLINICIANspotlight day staff meetings at the sleep center and this invitation started my journey into sleep medicine. I attended the staff meeting at the hospital sleep center every Wednesday (and still do—now the meetings are once per month) and met with the sleep medicine physicians who helped educate me and began referring patients to see me for oral appliance therapy.

After this initial exposure to sleep medicine, I went to the library and looked for articles on oral appliance therapy. However, it became clear that there was not a lot of research on this treatment approach. In 1992, I attended my first course on sleep medicine and dentistry that was presented by Alan Lowe, DDS and Melvin Lopata, MD in Chicago. It was so exciting for me to see that there was some science in sleep medicine that correlated the effects of sleep and breathing problems and the concept of oral appliance therapy had some support in the literature (although limited). I knew that although this discipline was in its infancy in dentistry it would give me an opportunity to help patients shift

their health. After that course in Chicago, I couldn’t wait to get back to my office to start screening patients with questionnaires and eventually to begin treating them.

I incorporated dental sleep medicine into my TMD practice in 1992 and provided care for both conditions for about 8 years. The dental sleep medicine part of my practice grew steadily and in 2000, I made the choice to sell my part of the TMD practice to my partner and I created a full-time dental sleep medicine practice.

DSP: How did you get involved in teaching sleep medicine? I remember my first AADSM meeting you were teaching the Introduction to Dental Sleep Medicine course.

My teaching career began in 1986 when I was asked to present on various TMD topics for local study clubs and at the Minnesota Dental Association “Star of the North” meeting. I continued to lecture solely on TMD issues until 1993 when I was invited by a den-

Dr. Parker teaching

What do industry leaders say about Dr. Jonathan Parker’s teaching?

“Jon Parker is arguably the premier educator in dental sleep medicine today. He has effectively treated patients for sleep-disordered breathing for the past 20 years and his educational courses are widely known to be imaginative, meaningful and effective.”

Robert R. Rogers, DMD, DABDSM Founding President, American Academy of Dental Sleep Medicine

Courses designed to help you successfully and profitably integrate dental sleep medicine into your practice Comprehensive Course in Dental Sleep Medicine A course for dentists that provides:  A foundation-building course in dental sleep medicine  An energizing, small-group learning environment  Hands-on work with patients

Masters Course in Dental Sleep Medicine (Advanced) A course for dentists and team members that features:  Proven techniques for successful patient care  Effective marketing to grow your practice  Successful insurance reimbursement procedures

Call or visit us online for additional course information Phone: 952-345-0290 www.dentalsleepology.com

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CLINICIANspotlight

Every day I will have 3 or 4 patients tell me that the care they have received in my office has changed their lives and they are so grateful for the work we have done together to improve their sleep, their health, and their energy level.

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tal laboratory company to lecture about dental sleep medicine to dentists in their community.

A few months later I was invited to present on this topic at the Minnesota Dental Association meeting. From that time forward my lecture schedule started to grow as I received invitations from local study clubs, dental laboratories, and state and national dental associations.

I started lecturing at the Sleep Disorders Dental Society (now the AADSM) Annual Meeting in June 1994. The program committee asked me to chair the Introductory course “A Review of Dental Sleep Medicine” in June 2000 at the meeting in Las Vegas and I chaired that program for many years after that. We had a nice lineup of speakers and it was exciting for me to see that Review Course grow. The attendees seemed to be inspired by the presentations that were given. I believe that course was important for dentists who were just starting to explore dental sleep medicine and it was fun for me to be a part of it.

For the past 13 years, I have been teaching courses, 3 times per year, in my office to small groups of dentists and their staff.

Also, I feel blessed to continue to give presentations to larger groups at study clubs, local, state and national dental association meetings in the US and internationally.

DSP: Teaching is hard work, and takes you away from your ‘normal life.’ What keeps you going?

What keeps me going and inspires me to teach and care for patients with snoring and sleep apnea is that it gives me a chance to be helpful to other people. I am grateful for the opportunity to assist patients directly by helping them sleep and breathe better and to improve their health through the work we do together. In addition, I am blessed to have the chance to teach other dentists to integrate dental sleep medicine into their practices and in this way I indirectly help many more people improve their health through the work of other dentists. It is a “ripple effect” and I never know who or how many others will be impacted by the teaching and interactions I have with dentists in a course.

Dental sleep medicine has a bright future. It is estimated that only 5% of patients receiving treatment for OSA in the US are being treated with oral appliances. I believe that within 5 years about 30% of patients will be prescribed oral appliances for OSA. This means there will

be incredible growth of this therapy in the future. The amount of research that is being published on oral appliance therapy is increasing dramatically and will continue to support this growth. In order for dental sleep medicine to remain viable we will need to maintain an ethical, patient-centered approach to managing the patients. Developing protocols for patient care in collaboration with our medical colleagues will be a key element in the development of this approach.

Although I really enjoy my work, what I love most is spending time with my wife, three children and three grandchildren. It is a joy for me to see how they are pursuing their lives and I really enjoy the time I have to spend with them. I have made the choices to spend time away from my family doing research, serving in the AADSM and ABDSM, and teaching largely because of what others have done for me over the years. I am grateful to those leaders who have moved this field forward and encouraged me along the way.

DSP: What are your top tips for adding DSM to a successful practice?

1. Continue to expand your knowledge by finding good dental sleep medicine educational opportunities.

2. Educate your staff in the areas of direct patient care, practice management and insurance reimbursement so they can support you in growing this part of your practice.

3. Collaborate with sleep medicine physicians and primary care physicians in managing your patients (build a good relationship with them).

4. Gain expertise with multiple oral appliances so you can choose the appliance that best fits each patient’s situation.

5. Join the AADSM and get involved in the organization. It will expand your knowledge and understanding of DSM and will build the relationships and support you need to grow this part of your practice.

6. When you are ready, complete the ABDSM certification exam and become a Diplomate. This will build your credibility in the sleep community and help your practice grow.

DSP: How do today’s practice challenges compare to your experience?

When I started in dental sleep medicine 23

CLINICIANspotlight years ago, I was viewed as a bit of a maverick for expanding into an area of dentistry that was not well known. In addition there was not very much research evidence available on oral appliance therapy at that time. I was challenged by my medical (and many of my dental) colleagues who questioned the effectiveness of oral appliance therapy. It has been difficult at times to convince my colleagues of the effectiveness of this approach to managing OSA patients. I have continued to update them on the research data as it has continued to grow and it has been very helpful in encouraging the physicians and dentists to refer patients for treatment.

Today’s dentists have a growing body of research evidence to support them as they approach their colleagues about being part of the solution for patients. However the landscape in health care is changing and there are challenges that exist now that were not as much of a concern when I started in this area of dentistry. The dentists involved in dental sleep medicine will need to create new systems for collaboration with physicians to grow their practices. In addition, they will need to edu-

cate themselves on the medical insurance protocols. Since the costs of care continue to rise, it will be important to develop affordable ways to manage the millions of patients who are in need of our services.

DSP: The rewards don’t only come from being paid, though, do they?

I really enjoyed my TMD practice, but I found the work with the patients who had sleep disorders to be even more rewarding.

This has been the most satisfying part of my career in dentistry. Every day I will have 3 or 4 patients tell me that the care they have received in my office has changed their lives and they are so grateful for the work we have done together to improve their sleep, their health, and their energy level. I do not believe there is another area in dentistry that has this type of impact on people’s lives. So, I love going into the office each day. It is very fulfilling to do this work.

Visit www.dentalsleepology.com to learn about Dr. Parker and his educational courses.

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CLINICALfocus

The Perfect Start System is Effective in Addressing Sleep-Disordered Breathing in Children by Earl O. Bergersen, DDS, MSD

S

leep-Disordered Breathing in Children can manifest itself in various symptoms that can easily be overlooked, misdiagnosed, and be left untreated. Common labels placed on these children are ADD/ ADHD. It is extremely important for the dental community to understand sleep-disordered breathing, the cause, the cure, and how to treat.

Sleep-disordered breathing occurs when there is interference of the free passage of air to and from the lungs through the nose and pharynx often called sleep disordered breathing; hypopnea (low breathing) and apnea (complete stoppage) which interrupts a childâ&#x20AC;&#x2122;s sleep cycle and prevents them from completing a full nightâ&#x20AC;&#x2122;s sleep and often has serious medical implications. Both of these symptoms can be present from birth to any age. Nighttime mouth breathing also occurs frequently in children. Any child that snores fairly frequently and sleeps with their mouth open often suffers from lack of sleep and as a result also frequently has oxygen desaturation of the blood. The various symptoms listed below occur in about 1 out of 5 children who often snore.

Early intervention is effective in the deciduous through transitional dentition (4 to 10 years of age) to successfully treat children with sleep problems. There are several serious symptoms that can occur in children with improper sleep habits: 1. Snoring from 2 to 7 nights per week 2. Hyperactivity 3. Excessive daytime sleepiness 4. Daytime and/or nighttime mouth breathing 5. Attention deficit 6. Tooth grinding

34 DSP | Winter 2014

CLINICALfocus 7. Restless sleep 8. Throat infections 9. Difficult breathing while sleeping 10. Bed wetting 11. Poor ability to study 12. Headaches in the morning 13. Sleep talking 14. Falling asleep watching TV 15. Allergic symptoms 16. Awakening at night These common symptoms are over 2 times more prevalent in habitual snorers (5 to 7 nights per week) than in non-snorers (16.8% vs. 40.2%). In fact, in those children that snore periodically (2 to 4 nights per week) have 1.6 times the incidence of these 16 symptoms over those children that do not snore (16.8% vs 26.1%).1,2

How to Identify, Treat, And Cure

A dentist is often the first in line to diagnose abnormal breathing symptoms, and is the logical person to initiate treatment of any associated orthodontic problems. As a result, the dentist can also be the one to initiate such interceptive treatment that can greatly benefit the young patient.

The Perfect Start Treatment is designed to address interrupted breathing habits. Sleep deprivation in children, particularly between 3 and 10 years of age, most often affects their behavior and these characteristics are often strong indications of problems A Dentist should get more information from the parent by having them fill out a questionnaire.

Several important questions should be asked of the parent of a young child of 3 to 10 years of age. The following questions are the important ones to ask a parent: 1. Does your child snore?

2. Does the snoring occur 2 to 4 nights a week (moderate snoring)?

3. Or does it occur 5 to 7 nights a week (habitual snoring)?

4. Is it interrupted snoring where the child stops breathing?

5. Does this interrupted snoring last 4 seconds or more at least twice per hour?

6. Is your child hyperactive?

7. Does your child lack attention (attention deficit)?

8. Does the child have headaches in the morning?

9. Sweat profusely while sleeping?

10. Is your child fidgety?

11. Do you have trouble understanding the childâ&#x20AC;&#x2122;s speech?

12. Have trouble pronouncing consonants like P, B, V, T, etc.

13. Is the child a restless sleeper?

14. Look sleepy during the day?

15. Does poorly in school, particularly in mathematics or spelling?

16. Does your child breathe through the mouth?

17. Does your child often wet the bed at night?

18. Does your child grind his or her teeth?

19. Does your child often have nightmares?

(Sahim et al, 2009; Urschitz et al, 2004) Reviewing data (from Sahin, Eitner, and Guenther, 2004) indicate that ADD, ADHD, daytime sleepiness, restless sleep, daytime mouth breathing, bed wetting, tooth grinding, poor school performance and morning headaches are 290% more prevalent in the habitual snorers than in non-snorers. Swollen tonsils and adenoids should be routinely checked on all children.

Testing for poor sleep breathing for children is done with polysomnography â&#x20AC;&#x201D; the overnight sleep study; if apneic events and lowered blood oxygen are found, physicians most often prescribe surgery or PAP therapy.

Typical dental appliances that advance the mandible in adults are not appropriate for treating airway issues in children, since they may cause excessive lower jaw growth. It takes a growth-oriented approach for dentists to impact airway health.

A dentist is often the first in line to diagnose abnormal breathing symptoms, and is the logical person to initiate treatment of any associated orthodontic problems.

Treatment

The Perfect Start System is a series of specially designed appliances that are provided to help promote proper breathing habits. The system addresses mouth breathing, an openbite, narrow palate, sucking and swallowing problems, and speech difficulties. The system prevents the mandible from slipping posteriorly while sleeping which stops the snoring,

Earl O. Bergersen, DDS, MSD, is former assistant professor, Northwestern University Orthodontic Department and was in former private practice in Winnetka, Illinois.

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CLINICALfocus maintains an open airway, and can prevent many of the symptoms of sleep-disordered breathing.

The advancement of the mandible can stimulate 54% more mandibular growth when compared to a similar control sample from 5 to 8 years of age.3,4 The Perfect Start™ treatment moves the lower jaw in an anterior direction in the proper amount while also advancing the tongue. The Perfect Start System has the effect of increasing the pharyngeal space between the base of the tongue and the posterior wall of the pharyngeal airway.

The Perfect Start™ System treats additional orthodontic problems such as crowding, overbite, overjet, gummy smiles and lack of coordination between the arches. These

Figure 1A: The initial view of a severe overjet and retrusive mandible.

Typically Asked Questions Q. Can you give an example of a typical child that had these problems and the result obtained?

A. A 6 ½ year old boy in 2nd grade snored regularly, was a night mouth-breather, was hyperactive, had attention deficit, poor school performance, restless sleep, aggression toward peers, sleep walking and talking, poor ability to study, and bed wetting. He was given a Perfect Start “C” series and wore it only at night for 2 years. He immediately stopped snoring and only breathed through the nose while sleeping. His mathematics achievement had a 950% improvement (from the 6th to 57th percentile) and had a 3.84 grade point average (out of 4.0) at the end of 4th grade. Most of his behavioral problems were non-existent at the end of the 2 year period.

Q. What school subjects are most improved with this procedure?

A. Mathematics, science and spelling show significant improvement while reading and writing are usually not affected.

Q. If children have a sleep disorder, what is the likelihood of developing ADD / ADHD. A. Children with moderate (19.8% of children) and severe (13.8%) sleep problems are 12.1 times more likely to have ADD / ADHD. Q. Do these behavioral problems self-correct with increase in age?

A. No they do not; they tend not to improve or get worse with increasing age.

Q. Does an untreated child develop into an adult with severe breathing problems?

A. There is no research at present that can confirm this, but genetics does play a role.

Q. Are there other health problems that can occur when these sleep problems are left untreated?

A. The most severe health risks have to do with cardiovascular problems, high blood pressure, hypertrophy of the right side of the heart, low blood flow to the lungs, depression, poor physical growth, and speech problems.

36 DSP | Winter 2014

Figure 1B: The final result as a result of only nighttime wear of the Perfect Start Kids appliance.

conditions can be corrected with the Perfect Start™ System will little or no future relapse of the correction.

A typical example of the mandibular advancement possible with the Perfect Start Kids™ appliance is seen in Figures 1A-1B. One should always be aware that children with recessive mandibles are also strong candidates for restricted pharyngeal airways and sleep-disordered breathing.

For further information on The Perfect Start™ System, please visit www.perfectstart. com, e-mail info@perfectstart.com, or call 1-844-413-2166.

References Sahin U, Ozturk O, Ozturk M, Songur N, Bircan A, Akkaya A. 1.

Habitual Snoring in Primary School Children: Prevalence and Association with Sleep-Related Disorders and School Performance. Med Princ Pract. 2009; 18:458-465.

2.

Urschitz MS, Eitner S, Guenther A, et al. Habitual Snoring, Intermittent Hypoxia, and Impaired Behavior in Primary School Children. Pediatrics. 2004; 114:1041-1048.

3. Keski-Nisula, K., Keski-Nisula, L., Salo, H., Volpio, K., and Varrela, J., Dentofacial changes after orthodontic intervention with Eruption Guidance Appliance in the early mixed dentition. Angle Orthod., 78: 324-331, 2008.

4. Katri Keski-Nisula, DDS, Raija Lehto, DDS, Vuokko Lusa, DDS, Leo Keski-Nisula, MD, PhD, and Juha Varrella, DDS, PhD, Occurance of malocclusion and need of orthodontic treatment in early mixed dentition. AJO-DO, vol. 124, no. 6, 2003.

BIGGERpicture

Preventive Sleep Dentistry

– A Call to Action

by Barry D. Raphael, D.M.D.

T

wo cardiac surgeons are sitting at lunch discussing the comparative benefits of bypass surgery versus stents for maintaining coronary artery patency when a PCP sitting at the next table rudely interrupts, “Wouldn’t it be better to prevent the obstruction in the first place?”

Two sleep docs are sitting at another table discussing the comparative benefits of CPAP versus mandibular advancement devices when the same nosy-body again interrupts, “Wouldn’t it be better to prevent the obstruction in the first place?”

The analogy is apt and significant. No one would deny that many of the factors that lead up to a coronary can be addressed, by both therapeutic or behavioral interventions, and that, certainly, prevention is a far better choice. But there has been an absence of such discussion regarding occlusion of the airway. The purpose of this article is to stimulate such a discussion and to paint, with fairly broad strokes, a picture of what a preventive approach to sleep disordered breathing would look like.

The etiology and predisposition to breathing disorders during sleep

It was once thought that obstructive sleep apnea was a disease of old, fat men. We have since learned that thin, athletic women can also fall victim to this problem. We have learned that while weight and age add to the susceptibility to obstructive sleep disorders, they are not the root causes. Difficulty breathing at night comes from resistance to airflow and there are many circumstances that can make breathing difficult. Efforts at pinpointing the source of resistance are important to determining proper remediation.

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We have learned from flow physics and airway physiology that there are three main determinants of airway resistance:1 1. Size of the airway 2. Collapsibility of the airway 3. Velocity and turbulence of the airflow Delving in to the physics of each is not the point of the article. Instead, the way that each of these factors can be addressed – well before the first apnea ever occurs, with either therapeutic or behavioral interventions – will be the goal of this series. By defining opportunities to mitigate predisposing risk factors to airway resistance we can begin to build a new paradigm in airway and sleep management.

As such, the focus will be on prevention so that, just as we might prevent the heart attack, the end-stage disease of obstructive sleep apnea might never occur. From this discussion will emerge a new field of Airway Dentistry and Orthodontics that can define a possible future for sleep and breathing health.

The size of the airway

Yes, losing weight and reducing fat deposits in the neck is important, but we also know that craniofacial morphology is a primary risk factor for breathing problems as well.2,3,4,5 Orthodontics has long been concerned with the growth and development of the face with regard to facial profile and the correction of skeletal and dental malocclusion, but has only recently considered its relevance to the

BIGGERpicture formation of the naso-oro-pharyngeal airway.6 Anatomically, the maxilla (and the soft palate which hangs off the back of it), and the mandible (with the tongue attached to it) create the anterior boundaries of the airway. Studies have shown how retroposition of the bones relative to the face narrow the airway and create the risk for obstruction.7,8 This is true in both adults and children. Orthopedic treatments in children are now being explored to help enlarge – or at least prevent restriction of – the airway in a more natural and permanent way.9 Most of the focus in orthopedic research has been on palatal expansion, with the purpose of widening the nasal aperture and palate, with equivocal results.10, 11 Studies show that bringing either or both jaws forward with advancement appliances or orthognathic surgery can be effective in opening the airway in the adult.12 We also know helping either jaw grow forward in the child may also be helpful.13 More recent work shows that changing maxillary growth in all three planes of space, including advancement, provide even more promising results.14 Playing off findings in the anthropology literature, the shape of the maxilla has changed dramatically in the modern human, associated with a rapid change in dietary (high sugar and refined carbohydrate content), metabolic (autonomic and digestive stressors), cultural (early feeding and weaning habits), breathing (open mouth and low tongue postures), postural (forward head and slumped shoulders), sleep (artificial light and altered sleep cycles), and inflammatory (a changing gut biome) environmental challenges that have all become rampant in today’s world.15 Given the rapidity of the environmental change, purely genetic variations must be ruled out.

Epigenetic variations of the bone’s shape, however, indicate that it is changing in width, yes, but also slumping downward and failing to fill out sagitally as well, a condition being called Craniofacial Dystrophy.16 This near universal mid-face deficiency (no matter the Angle classification of the teeth) has formed a bone with a collapsing palate with insufficient room for the teeth, which often restricts the forward growth of the mandible, and hampers proper positioning of the tongue, all of which limit the eventual size of the airway.

Helping the jaws grow forward, not just wider, is the ultimate goal. Reversal of midface collapse presents numerous challenges to

current orthodontic paradigms that often look to retract teeth and jaws distally, but it also empowers us as well. There has been a thread of thought throughout the historical orthodontic literature supporting the idea that a palate is not just congenitally narrow, but becomes narrow due to habits and practices that occur after conception.17 Altering these habits can begin to heal the dystrophy.

If the modern lifestyle can create these changes to the modern face so rapidly (in the past 300-400 years), then human ingenuity can reverse them as well. Originally separately stated by leaders of thought like George Crozat18, Edward Angle, and Alfred Rogers19 in the early part of the last century, modern philosophies of treatment including Crozat, Advanced Lightwire Functionals, Postural Orthodontics, Biobloc Orthotropics, Cranial Osteopathy, and Myofunctional Orthodontics all seek to reverse the conditions that lead to mid-face collapse. All these schools of thought have a common goal of reestablishing postural support of the growing maxilla by maintaining the resting tongue on the palate as a scaffold for the growing (and non-growing) bone.

The protocols that encourage forward growth of the jaws have all found some measure of success in reducing sleep disordered breathing.20,21,22 Furthermore, treatments that restrict forward growth or reduce the size of space for the tongue have been shown to reduce airway size, and for purposes of breathing, should be avoided.23 More research in this area is needed but common sense says that any technique that widens the airway space will be helpful in combating breathing problems.

Resilience of the airway

Even a fairly substantial airway can be closed off if the walls cannot withstand the turbulence created by the airflow within it. There are a number of points along the way from the

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Dr. Barry Raphael is a practicing orthodontist in Clifton, New Jersey for over thirty years. His transition to airway-thinking came 25 years into practice so as he says, “I know what it takes to make the transition.” He teaches these concepts at the Mt. Sinai School of Medicine in New York City. He is the owner of the Raphael Center for Integrative Orthodontics and the founder of the Raphael Center for Integrative Education.

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Tonsils and adenoids are currently thought of as the predominant risk factor for sleep disordered breathing in children.

i nt atie p h Dr. Raphael wit

40 DSP | Winter 2014

n

nose to the lungs where soft tissue is apt to give way to the negative pressure. And there are a number of conditions which can decrease the resilience and increase the collapsibility of these tissues, all of which are reversible to some extent.

1. Swelling of lymphoid tissue is perhaps the most commonly recognized problem.24 Tonsils and adenoids are currently thought of as the predominant risk factor for sleep disordered breathing in children. The American Academy of Pediatrics has recently stated that surgical removal of lymphoid tissue can be considered a first-line of treatment in obstructive sleep apnea.25 But one question that is rarely asked is: why do lymphoid tissues get so swollen as to block the airway? While they are known to be more active in a young growing child, their enlargement, like the collapsed palate, is not a congenital given. Efforts to reduce the swelling can sometimes dramatically open the airway and may reduce the need for surgery.

Some of the methods used to reduce lymphoid swelling include: 1. A transition from mouth breathing – which allows unfiltered air to irritate the tonsils – to nasal breathing – which filters and conditions the air before it gets to the lymph tissue – can reduce swelling within weeks; 2. Improvements in body posture and muscular movement, as with regular exercise, can also help lymph tissue drain adequately; 3. A transition from accessory muscle use to proper use of the diaphragm for breathing also helps lymphatic circulation, 4. Nasal lavage to keep sinus pores and airway walls clean can help, 5. Massage and bodywork can help lymphatic circulation, 6. Acupuncture and homeopathic remedies that encourage drainage of lymph tissue throughout the body, 7. The use of ozone and ozonated water injected into the swollen tissue has been shown to reduce lymph swelling, and, of course, 8. Short term use of nasal steroids and decongestions for a good head-start are helpful.

Certainly it’s better to try to shrink swollen lymph tissues as a preliminary approach. The

frequent recurrences seen after surgical removal are probably linked to a failure to incorporate some of the above conservative measures post-surgically, especially continued oral breathing. This makes a conservative approach all the more important as a first line of defense as it has to be done even when the tissues are removed.

2. Poor muscle tone is also associated with blockage of the airway. Certainly the tongue falling back into the oral cavity at night is well recognized as a risk factor for sleep disordered breathing. But well-toned extrinsic and intrinsic glossal muscles resist backward displacement. The use of myofunctional therapy, with specific exercises for creating better muscular balance of the pharyngeal musculature, has been shown to be helpful in reducing airway collapse at night and deserves more attention in this field.26 Even learning to play the Australian didgeridoo has been shown to be helpful in reducing pharyngeal collapse at night.27 3. Chronic inflammation of pharyngeal tissues makes them less able to resist negative pressure due to loss of elasticity. The constant trauma to the tissues of the flapping of snoring only serves to irritate, elongate, and soften pharyngeal tissues and the soft palate. Chronic assault by stomach acid from gastric or laryngeal reflux is another source of inflammation that needs to be addressed. The cause of reflux itself can be addressed by changes in breathing mode (e.g. nasal breathing) and posture, too, thereby reducing reliance on protein pump inhibitors that have their own side effects. Finally, honing in on foods – some natural, some not – that instigate inflammation or disturb the natural flora in the gut and supplanting them with healthier choices can change the condition of the airway as well as the rest of the body.

Velocity and turbulence of the airflow

Though the way air flows through the breathing space has been tested and studied, and recognition of air pressure changes within the pharynx and within the thoracic cavity has been given due consideration, little attention has been paid to the behaviors that actually create these negative pressure conditions. In fact, some theorize that it is not the night time breathing that creates the biggest problem, but the daytime habits of breathing that set up the circumstances for airway collapse at night.28 These conditions include habitual overbreathing in response to the many chronic stress-

BIGGERpicture ors that we encounter each day. Our autonomic nervous system is constantly activated without a chance for recuperation, setting in motion a cascade of events that results in, among many other things, rapid shallow breathing with tidal volumes nearly three times what is necessary for efficient oxygenation. In other words: chronic hyperventilation.

It is said that over breathing is just as dangerous to health as overeating. Chronic hyperventilation, especially with large portal of an open mouth, shifts the balance between oxygen and carbon dioxide in the lungs and in the blood. Chronic hypocapnia is a common condition in mouth breathers and can result in reduced oxygenation of tissues (the Bohr Effect) and increased smooth muscle spasm (think vessels and organs). The symptoms from these two phenomena alone are quite diverse, affecting the vasculature (hypertension, venous pooling), organs (enuresis, digestive issues), tubes (asthma, reflux, xerostomia), and tissue perfusion (neurocognitive deficits like attention, memory and learning, anxiety, and muscle fatigue and spasm). And, oh yes, apnea.

Heavy breathing at night pulls air through the pharynx rapidly, creating increased turbulence and negative pressure. This can compromise an otherwise healthy system (e.g. snoring only when you get intoxicated). Combine that with small airway size and increased collapsibility and you have the perfect internal storm….a hurricane in a box, if you will.

Some think that central sleep apnea is nothing more than the body’s respiratory mechanism taking a pause to restore proper carbon dioxide levels and maintain homeostasis. While this thinking seems to be in direct opposition to the commonly held view that sleep disordered breathing is a problem of hypoventilation and hypercapnia, a change in daytime breathing mode – again, from oral to light nasal breathing –can alter nighttime distress almost immediately in some patients.29 In fact, the relationship between daytime breathing habits and nighttime distress is so strong the syndrome should be called Breathing Disordered Sleep instead of Sleep Disordered Breathing.

Adopting new changes in daytime breathing behaviors should be the first line of defense in the treatment of breathing disordered sleep.

Simple breathing training includes: 1. Nasal breathing primarily, even during activity if possible;

2. Reduction of tidal volume by reducing breathing rate and depth; 3. Use of the diaphragm for powering inspiration.

Biofeedback techniques are especially helpful in retraining daytime breathing.

Once the body can accommodate to this new breathing mode, there is often no longer such a struggle at night. And a very least, modalities like CPAP and MADs can become more tolerable.

eiv ent rec ing train Pati er

Airway-related Craniofacial Dysfunctions: a change in paradigm

Besides sleep apnea, there are a host of refractory conditions that dentistry has been struggling with that are now being looked upon as Airway-related Cranio-facial Dysfunctions (ACD’s).

They include: 1. Chronic Naso-pharyngeal Obstruction (physical or functional)30 2. Tethered Oral Tissues (Lip-tie and tongue-tie)31 3. Open Mouth Rest Posture (with the tongue off the palate)32 4. Myofunctional disorders (Swallowing, chewing,etc.)33 5. Chronic Hyperventilation and Hypocapnia34 6. Breathing Disordered Sleep (OSA, UARS, snoring)35 7. Bruxism, parafunction and dental deterioration36 8. TMD and facial pain components37 9. Cranial and postural issues38 10. Craniofacial Dystrophy with Malocclusion39 Each topic deserves its own discussion, but putting them under the umbrella of Airway Dysfunctions seems to have answered a lot of challenging questions for practitioners in all disciplines. In fact, once you see the relationship, it’s hard to see how we ever thought otherwise.

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Airway dentistry and orthodontics: a change in protocol

Putting these concepts into practice will be the next great challenge of the 21st Century for dentistry. Developing the protocols that will engender an understanding of the need for behavior change in our patients, and creating the settings in which to support these changes, is what we need to begin to do now. There DentalSleepPractice.com

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Ac ti

ow nd wi pat Dr. Raphael assessing

42 DSP | Winter 2014

t ien

are five domains in which airway dentistry and orthodontics must create innovative and even disruptive (in the business sense), solutions: 1. Assessment: Looking at how once unclear symptoms are related to the need to breathe and achieve homeostasis will allow us to catch a system that is headed off course much earlier than any sleep screening currently does.

2. Prevention: When should treatment begin? As soon has the habits that create poor facial growth are discovered. This may begin before birth, at birth, in infancy, or whenever any airway related problem begins.

Many ancient cultures were well aware to never let their young leave their lips apart at rest. Breastfeeding is best feeding since it creates mechanical stimulation of growing bones. Tongues must not be tethered. Children need to chew real food. And that is just the starting point.

3. Mitigation: By the time a person gets to OSA, it may be too late to do much but treat symptoms. But whenever damage from bad habits has been discovered, all attempts to reverse this damage should be made, and certainly nothing should be done that would worsen or even perpetuate the damage (e.g., reducing or maintaining inadequate tongue space).40 4. Habit Training: It’s not easy. I will never say it’s easy. Or quick. Or certain. But if nothing changes in a person’s actions, nothing will change in a person’s health. There are no pills, no shots, no surgeries and no short cuts.

Breathe right. Eat right. Sleep right. Be right.

5. Interdisciplinary Collaboration: This can be seen as another obstacle for what was once a cottage industry. No one practitioner can handle all the etiologies one patient may bring with them. As the Chinese say: “One disease, a thousand treatments…one treatment, a thousand diseases.” Such is the lot when looking at the whole person. A specialist may be able to reduce a person into small segments with isolated diseases and treat just those. But to create wellness, a variety of approaches may be necessary requiring input from a variety of practitioners. The health and wellness center of today may be the best mode of practice for the future. While corporations are gobbling up practices and practitioners, this may also be the way to maintain some autonomy in your profession.

The sleep practice of the future will include, in either one place or many: 1. Sleep dentist, 2. General dentist, orthodontist or pediatric dentist doing orthodontics, 3. Health educator (who knows myofunctional therapy, breathing and postural training, nutrition, lactation for the very young, and maybe some body work), 4. Sleep/ENT/pulmonologist/allergist MD, 5. Cranial osteopath or practitioner who manages the craniofacial skeleton, 6. Other auxiliaries in child development and well care.

In this practice, there will be ample time set aside for talking with the patient/parent, for collaborative treatment planning and for follow-up care. The environment will be conducive to learning as well as therapy. And finally, it will be a place where patients can get preventive, holistic, and allopathic care.

The goals of airway dentistry and orthodontics

Here it is, for young and old, in a nutshell: 1. Breathe gently through the nose 2. Keep the lips together when not talking or eating 3. Keep the tongue on the palate at rest 4. Swallow without using the facial or cervical muscles 5. Balance yourself well against gravity (Sit and stand straight!)

6. Eat to nourish (with foods your body appreciates) 7. Sleep to rest

The future of sleep dentistry

The current gold standard treatment – if gold is the appropriate color – for obstructive sleep apnea is to artificially pry open the airway at night with air, plastic, or scalpel. Perhaps someday we’ll have Swarovski-studded tracheostomy plugs for a more perfect (read: fashionable and quick) solution.

But if you look at the progression leading up to obstruction, there are many, many opportunities to intervene, to change the trajectory of the disease, and to increase the quality of life. By helping the airway to grow larger (size), keeping it physically fit (resilience), and optimizing its use (flow), the problem can be, at worst, delayed and at best, avoided.

While opportunities to mitigate the progression of airway dysfunction from birth to

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to pay attention to the child attached to the teeth as much as the teeth attached to the child.

3. Results will necessarily be subject to a bell curve, like it is with any educational system. Though most dentists are trained to strive for “perfect”, we will have to learn to settle for, as does medicine, and live with, “better” as a standard of care. One might even argue that the health of the airway takes precedence over the occlusal schema, or, heaven forbid esthetics, should a choice have to be made.

This is a real shift in priorities.

In recent years, the orthodontic profession has been arguing about the relative benefits of early orthodontic treatment asking, “Is the benefit worth the burden?”42 One could ask the same question about the effort needed to prevent heart disease.

Yet, today, fitness centers and whole foods establishments are becoming mainstream in our society answering that question by popular demand. Perhaps in days soon to come there will be similar outcry looking for better sleep and breathing as well.

Chandra, RK. Diagnosis of Nasal Airway Obstruction. Otolaryngol Clin N Am,2009, 42, 207–225.

Aihara K, et. al ,Analysis of anatomical and functional determinants of obstructive sleep apnea.

Sleep Breath. 2012 Jun;16(2):473-81.

Dempsey, Jerome, et.al. Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects, CHEST September 2002 vol. 122no.

3 840-851 Lowe, Alan, et.al., Facial morphology and obstructive sleep apnea. AM J ORTHOO DENTOFAC ORTHOP 90: 484-491, 1988.

Ikävalko, et.al.,Craniofacial morphology but not excess body fat is associated with risk of having sleep-disordered breathing—The PANIC Study (a questionnaire-based inquiry in 6–8-yearolds), Eur J Pediatr (2012) 171:1747–1752 Carlysle, Terry, et.al Orthodontic Strategies for Sleep Apnea, Orthodontic Products, April/May 2014, Pages 92-101.

Dempsey, ibid.

Vandana Katyal,et.al. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis AJODO, 2013 Jan;143(1):20-30 Singh, G. Dave, et.al, Evaluation of the Posterior Airway Space Following Biobloc Therapy: Geometric Morphometrics, Cranio April 2007 (25:2), 84-89.

Rose and Schessell, Orthodontic Procedures in the treatment of OSA in Children, J.OrofacialOrthopedics, 2006,67:58-67 Ruoff and Guilleminault, Orthodontics and sleep-disordered breathing, Sleep Breath, June 2012, Volume 16, Issue 2, pp 271-273 Holty JE, Guilleminault C (2010) Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev 14:287–297 Emine Kaygısız et.al., Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway, Angle Orthodontist, Volume 79, Issue 4 (July 2009) Singh, G. Dave, ibid.

Boyd, Kevin, Darwinian Dentistry, An evolutionary perspective on the etiology of maloclussion, JAOS, Nov/Dec 2011, 34-40.

Mew, Mike. Craniofacial Dystrophy: A possible syndrome?, British Dental Journal, 216 :10 MAY 23 2014 , 555-558 Rogers, Alfred, Stimulating Arch Development by the Exercise of the Masseter-temporal Group of Muscles., IJOOSR, 1922, 8:2, 61-64.

Crozat, George, The Crozat Philosophy of Treatment, Monograph, New Orleans, 1-8 Rogers, ibid Oktay, H, Ulukaya,E., Maxillary Protraction Appliance Effect on the Size of the Upper Airway Passage, Angle Orthodontist, Vol 78, No 2, 2008, 209-218.

Singh, ibid.

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sleep apnea are plentiful, there are three large challenges to overcome, all of which are common to medicine and dentistry: 1. Preventive medicine lacks the urgency most people need to create the behavior changes that create optimal health.

Symptomatic treatment engenders changes but only so long as the symptoms last. Education and understanding are the only way to get people to change. Look how much we changed once we understood how the tobacco industry was victimizing us. Perhaps the same will happen for sugar soon. And then for sleep.

2. While reducing treatment to its most simplistic outcome (i.e.: prying the airway open, or Class I occlusion) makes good business sense, this reductionist practice – as well as reductionist research that supports it – distracts us from dealing with the bigger picture.41 We must pay equal attention to “holistic” aspects of the human, with all its variables and vagaries. While it may require a change in thinking, in our education, and in our practice, we have

tion

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c Braces off

e

Villa, M., et.al. Randomized Controlled Study of an Oral Jaw-Positioning Appliance for the Treatment of Obstructive Sleep Apnea in Children with Malocclusion, American Journal of Respiratory and Critical Care Medicine, Vol. 165, No. 1(2002), pp. 123-127.

Qingzhu Wang, et.al., Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion, Angle Orthodontist, 2012, 82:1,115-121.

Li, A.M., et.al, Use of tonsil size in the evaluation of obstructive sleep apnea, Arch Dis Child, 2002, 87:2, 156-159 Marcus, Carole, et.al., Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome, Pediatrics, (doi: 10.1542/peds.2012-1671.

Pitta ,Danielle Barreto e Silva, et.al. Oral Myofunctional Therapy Applied on Two Cases of Severe Obstructive Sleep Apnea Syndrome. Intl. Arch. Otorhinolaryngol 2007, 11:3,350-354.

Milo A Puhan, et. al. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomized controlled trial. BMJ 2006;332:266 Litchfield, P. Respiratory Fitness and Acid-Base Regulation. Psychophysiology Today. 2010, 7:1, 6-12.

Birch, M. Sleep Apnoea: A survey of breathing retraining. Australian Nursing J., 2012, 20:4, 40-41 Chandra, RK. Diagnosis of Nasal Airway Obstruction. Otolaryngol Clin N Am,2009, 42, 207–225.

Kotlow,L. Infant Reflux and Aerophagia Associated with the Maxillary Lip-tie and Ankyloglossia (Tongue-tie). Clinical Lactation, 2011, 2:4, 25-29.

Mew, M. ibid Ka´tia C. Guimara˜es, et al. Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome.AM J OF RESP AND CRITIC CARE MED 2009, 179, 962-966.

Ritz, Thomas. Changes in pCO2, Symptoms, and Lung Function of Asthma Patients During Capnometry-assisted Breathing Training, Appl Psychophysiol Biofeedback. 2009,34:1–6.

Litchfield, P. ibid.

Hosoya, H, et.al. Relationship between sleep respiratory and sleep bruxism events in patients with OSAS. Sleep Breathe, 2014, 18:837-844.

Gelb, Michael. Airway Centric TMJ Philosophy, CaliDentAsso JOURNAL, 2014, 42:8, 551562.

James, G. An Introduction to Cranial Movement and Orthodontics. IJO, 2005, 16:1, 23-26.

Mew, M. ibid.

Huang Y-S and Guilleminault C, Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front. Neur. 2013,3:184, 1-7.

Howard Jacobson and T. Colin Campbell. Whole: Rethinking the Science of Nutrition, Ben Bella Books, 2013 McNamara, James. Early Orthodontic Treatment: Is the Benefit Worth the Burden? U. Michigan Press, 2007

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8 PRACTICEmanagement

Helping Children with Obstructed Sleep Breathing:

Essentials All Dental Team Members

Should Know

by Glennine Varga, AAS, RDA, CTA

44 DSP | Winter 2014

P

ediatric airway is a fairly new topic being discussed in our profession. As dental sleep medicine becomes a more common topic in dental offices, so should awareness of sleep breathing in children.

Here are 8 essentials dental team members can use to initiate helping children with obstructed sleep breathing inside and outside the practice: 1) Educate yourself. Find out if your dentist offers any early intervention therapies to support the airway such as palatal expansion, functional orthodontics, myo-functional therapy or lingual frenectomy procedures.

Research continuing education courses that offer topics regarding airway. The American Academy of Physiological Medicine & Dentistry (AAPMD) and courses like Orthotropics Mini-Residency by Dr. Bill Hang, Early Orthodontics by Dr. Brock Rondeau and Airway Centric courses by Dr. Howard Hindin and Dr. Michael Gelb. Dr. Barry Raphael, who writes for this magazine, offers “Airway Ortho Lecture Series.” There are many others – you get the idea that it’s about helping the kids out early in life.

2) Identify. Dental team members are exceptional at connecting with patients and can spend the most time with them. The obstacle is introducing the topic. Valerie Deegan recently spoke on behalf of the Foundation for Airway Health, sharing the story of her son Connor. His behavior was at times irritable, inattentive, hyperactive, impulsive, aggressive, and withdrawn. Signs included lips apart with mouth closed, dark circles under his eyes, forward head posture, mouth open, recessed jaw and long face. She also described him as a noisy eater, snoring, gasping during the day and night, and troubled with asthma. She described his sleep as restless; he would fall asleep very fast, fighting to stay awake yet hard to wake in the morning and embarrassed by nighttime enuresis. After a diagnosis of airway restriction and treat-

PRACTICEmanagement ment, she says she suddenly had a new son.

Be ready to cry, and check out Valerie’s video on YouTube: https://www.youtube.com/ watch?v=Sk5qsmRyVcE “Finding Connor Deegan”. Sharing stories like this could be a great way to introduce the topic.

3) Educate others. This topic is the single most important step. Find ways to educate parents, teachers, family, friends, patients and the community. Sleep airway education to the general public is woefully inadequate.

The dental profession has the drive to change that and it should start with you!

4) Communicate. Amy Morgan of Pride Institute offers a compelling article (p. 46, following) regarding communication with parents for children with sleep related breathing disorders. It is imperative that these conversations occur. A short conversation can have a LIFE-CHANGING impact on a growing child (and the family!).

5) Have a game plan. If your office does not offer any early intervention to positively impact a child’s airway, talk with your dentist and find out to whom you can make a referral. Research your community for an orthodontist or dentist promoting airway growth or check out airway practitioner networks such as the AAPMD (www.aapmd.org.) If referring is not an option, consider a talk with your dentist about investing in continuing education to learn procedures that support the airway.

6) Understand the cost of waiting. Consider a child born tongue-tied and unable to position the tongue on the roof of the mouth during swallow. The palate develops vertically rather than laterally and impacts the floor of the nose making it difficult to breathe.

Since form follows function the teeth become crowded and the tongue seems too big for mouth possibly developing a full collapse of the airway during sleep. The health care cost for a child unable to breathe could be astronomical. A simple lingual frenectomy and functional exercises could impact the growth and development of a child immensely. Investing in breathing early may prevent major cost later.

7) Insurance. Well, this is always a hot topic. Pediatric procedures involving the airway are typically reserved for Ear, Nose and Throat doctors with procedures like adenoidectomies and tonsillectomies. Dentists are able to provide frenectomy, functional ortho-

dontics and some oral devices. Will the insurance cover it? That depends. Oral devices for OSA are considered medically necessary with medical insurance, but none are FDAcleared for growing children. If a procedure is being performed as a medical necessity it could be billed to medical insurance. Always check the patient’s dental insurance policy as well; some appliances to promote growth are covered by orthodontic benefits.

8) Document your cases. Whether you are treating adults or children, hav- Sleep airway education ing the proper documentation is critical. to the general public Develop a series of records to track your patient’s successes such as subjective is woefully inadequate. questionnaires and photos. Images make The dental profession the biggest impact when educating, and videos can be used on websites and has the drive to change other practice social media. Talk to your that and it should patients and parents of patients about sharing treatment success with a release start with you! form. Most all of us are emotionally driven and the ability to share success stories is a great way to spread the word about the silent airway issues impacting our children’s growth and development.

Use these Essentials to become a credible resource for your immediate circle of family, friends, community and patients!

This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. Let us know your specific issues by email to: Editor@ DentalSleepPractice.com, while we can’t respond to every individual. Your feedback will help us create the most useful Sleep Team Column we can!

Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain.

She has been employed in dental education for over 18 years. Glennine is certified in radiology, electrodiagnostics, expanded duties dental assistant in the treatment of temporomandibular disorders. She has been a TMD/ Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and has trained the use of electrodiagnostic equipment for five years. Glennine is currently employed, full time, by IDEA Communications including OSA University. Glennine has trained and assisted hundreds of dental offices on practice management, TMD/Sleep Apnea concepts, medical billing and team training.

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PRACTICEmanagement

By Amy Morgan

46 DSP | Winter 2014

I

f you are a family practice, orthodontic practice or pediatric practice, one of the major communication hurdles that has to be crossed is influencing parents to support ideal treatment choices for their children. When you have a vision or brand promise that includes dental solutions that promote overall health and well-being, then that conversation can and should include education regarding sleep disorders in both young and old!

PRACTICEmanagement Sleep Disordered Breathing absolutely has an impact on the growth and development of the children you serve as patients in your practice! Parents will want to know and appreciate the fact that you and your team are unique, as you take the time to educate them on all aspects of their children’s oral and overall health. From a marketing standpoint (the art of being well known and well thought of), just asking the questions about a child’s sleep patterns will separate your practice from the standard perception of the “average” dental experience. In this competitive environment, what you offer and how you communicate those offerings is the makeor-break point for continued success. So the question is not whether you should be communicating about sleep solutions to parents, it’s how and when.

1. It starts with your online presence!

Whether we are talking about your website, social media, or e-newsletters, your online presence allows you to educate and motivate new and existing patients 24/7, 365 days a year! Having a space devoted to sleep solutions for children and adults on your website is essential. Training your entire team to value and use that information daily is where the “rubber hits the road”. To post effective website descriptions, FAQs or blogs, it is important that the team understands the warning signs that would indicate “SDB” and be able to communicate the potential solutions in non-clinical, benefit-oriented terms to the parent! Studies are showing that sleep disorders, related to sleep apnea in children, can contribute to everything from bed-wetting and sleep-walking, to retarded growth as well as an overall failure to thrive. Parents want

to know these important facts and, more importantly, do something to protect their child from exhibiting any of these results!

2. The wonderful world of open ended questions and active listening! At Pride Institute, we teach that from the initial telephone screening, to the preclinical interview and through the treatment conference, it is essential to capitalize on every opportunity to educate and influence parents to make the right decisions for their chil- “Just asking the dren. This requires excellent verbal skills questions about a used at every point of contact. Where to begin? Influencing always starts with child’s sleep patterns asking the right kind of questions and lis- will separate your tening carefully with curiosity. The right kinds of questions are open-ended, which practice from the means they invite more than a one word standard perception response from the person being asked.

Starting your question with, “what can of the “average” you tell me...”or “how does this affect dental experience.” your son...” or “why is this a problem” is the perfect way to court an open-ended response! To me, the most elegant, simple question to ask right from the get-go is, “How does your son/daughter sleep?”

3. Ask the right screening questions!

Whether a child has any apparent symptoms related to sleep apnea, screening for sleep disorders shows the parent that the practice’s philosophy of clinical care goes well beyond dentistry! This creates additional value, loyalty and commitment to long-term care for the entire family! If you are already screening for OSA in adults by using the Epworth Sleepiness Scale, you can start by implementing the BEARS Sleep Screening Algorithm*. The “BEARS” instrument was developed as a comprehensive, age-appropriate screening

Amy Morgan is CEO of Pride Institute, a nationally acclaimed results-oriented Practice Management consulting company. Amy and her team of highly qualified consultants have revitalized thousands of dental practices using Pride’s time-proven Management Systems, resulting in dentists becoming more secure, efficient and profitable.

Pride Institute, founded in 1976, is dedicated to substantially improving doctor’s professional, financial and personal lives. Specifically, Pride has taught over 20,000 dental offices how to excel in effective Leadership, Staff Management, Treatment Presentation, Scheduling, Patient Financing, Cash Flow/Goal Setting, Social and Traditional Marketing and Transition Strategies. For more information, please contact the Pride Institute at 800-925-2600 or info@prideinstitute.com.

DentalSleepPractice.com

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PRACTICEmanagement vehicle for toddlers (2-5 years old), school aged children (6-12 years old) and adolescents (13-18 years old). “BEARS” is an acronym with targeted questions directed to both the parent and child, regarding bedtime problems, sleepiness and snoring. This can be asked during a pre-clinical interview when the child and parent are present. Additional questions can be used to highlight any causes for further exploration by the doctor and team such as:

• How much does your child weigh?

• Does your child show any other signs of disturbed sleep?

As a parent myself, I always valued the experts who took the extra time to provide my children with the best advice and counsel.

If you are interested in creating raving fans who become ambassadors to your unique philosophy and results, applying these skills will make a difference! Inspire your team, upgrade your systems and enjoy the ride!

The “BEARS” instrument is divided into five major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children in the 2- to 18-year old range. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview.

B = bedtime problems E = excessive daytime sleepiness A = awakenings during the night R = regularity and duration of sleep S = snoring

BEARS SLEEP SCREENING ALGORITHM Toddler/preschool (2-5 years)

School-aged (6-12 years)

Adolescent (13-18 years)

1. Bedtime problems

Does your child have any problems going to bed? Falling asleep?

Does your child have any problems at bedtime? (P) Do you have any problems going to bed? (C)

Do you have any problems falling asleep at bedtime? (C)

2. Excessive daytime sleepiness

Does your child seem overtired or sleepy a lot during the day? Does she still take naps?

Does your child have difficulty waking in the morning, seem sleepy during the day or take naps? (P) Do you feel tired a lot? (C)

Do you feel sleepy a lot during the day? In school?

While driving? (C)

3. Awakenings during the night

Does your child wake up a lot at night?

Does your child seem to wake up a lot at night? Any sleepwalking or nightmares? (P) Do you wake up a lot at night? Have trouble getting back to sleep? (C)

Do you wake up a lot at night? Have trouble getting back to sleep? (C)

4. Regularity and duration of sleep

Does your child have a regular bedtime and wake time? What are they?

What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep? (P)

What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get? (C)

5. Snoring

Does your child snore a lot or have difficult breathing at night?

Does your child have loud or nightly snoring or any breathing difficulties at night? (P)

Does your teenager snore loudly or nightly? (P)

(P) Parent-directed question

(C) Child-directed question

Source: “A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems” by Jodi A. Mindell and Judith A. Owens; Lippincott Williams & Wilkins

48 DSP | Winter 2014

Like sleep apnea, practice management issues shouldn’t give you a restless night’s sleep. Rest assured, Pride Institute can ease your troubles and get you back to sleeping like a baby again.

Put an end to your sleep issues and take advantage of Pride Institute’s complimentary dental practice assessment.

As an added value,

you’ll receive our self-guided training module, “Motivating Patients to Want the Treatment They Need,” a $149 value, yours for free.

800/925-2600 or info@prideinstitute.com Offer expires 1/31/15

PRIDE INSTITUTE is the premier dental practice management firm serving the dental profession since 1974. Through our training, consulting and products, we enable dental practices to increase productivity, profitability and quality of care by identifying and implementing immediate and long-term practice management solutions.

SLEEPq&a

Ez Sleep Pillow™ Talk iDentifySleep™ Training Series An interview with Gy Yatros, DMD, and Richard Drake, DDS, ABDSM, by Payam Ataii, DMD, MBA

Dr. Ataii: Between the two of you, you have over 25 years of experience treating patients that suffer from snoring, upper airway Dr. Ataii resistance or sleep apnea conditions. What’s been your greatest take away from that journey so far?

Dr. Yatros: In the years of dedicating our time to these treatment modalities, our greatest take away is the positive impact on our patients’ lives in a way that no other aspect of denDr. Yatros tistry can provide. Sure, a full mouth rehab or a new smile with eight veneers is a wonderful feeling. However, when treating sleep patients, it’s much more. We help restore marriages, save lives, give grandparents back to their grandchildren. It’s an amazing feeling and an awesome responsibility.

Dr. Drake: I would add that we have an obligation to our patients. As dentists, we are obligated to ensure the patient’s wellbeing. Since we have a front row seat to the airway — Dr. Drake at the very least — all dentists should ensure their patients are screened and, when appropriate, tested for sleep disordered breathing (SDB). It’s unfortunate these simple but important tasks are not being performed more frequently.

Dr. Ataii: Both are excellent points.

Talking to dentists during my lectures, I know that most general dentists are overlooking the importance of identifying and treating patients that suffer from sleep disorders.

Dr. Drake: We lecture dozens of times each year around the country and encounter the same thing. It’s alarming. When considering the published prevalence statistics, we see that approximately 20% of the adult population suffers from some degree of sleep disorders; whether it’s obstructive sleep apnea, RERAs, or periodic limb movement disorders.

What other health care provider is in a better position to help identify these patients? I feel it should be our obligation as dentists, at the very least, to help identify these potential patients.

Dr. Yatros: Think about that. If you screened 100 of your adult patients today, at least 20 of them would be at risk of suffering

50 DSP | Winter 2014

SLEEPq&a from sleep disorders and warrant a diagnostic test.1 Of those 20, according to the prevalence stats, approximately 14 of them would likely suffer from an obstructive airway and would benefit from a dental device. Dentists are regularly foregoing an opportunity to dramatically improve their patients’ quality of life while also missing an opportunity to add revenue to their practice. It’s really a win-win situation.

Dr. Drake: We think that this is a no-brainer. Gy and I talk about this frequently. We simply can’t understand why every dentist is not considering getting involved.

Dr. Ataii: When I speak with colleagues they express concerns about ‘not having the patients’ or they cite the hurdles inherent to sending patients to the sleep lab.

Dr. Drake: Here’s the issue I have with that. The process is actually not as diffcult as it may appear to be and when utilizing a proven system, practices will learn to incorporate this seamlessly into their practice.

For instance, integrating a simple screening form into the practice’s standard intake paperwork will address the issue of ‘not having the patients.’ They are already there in the practice. It’s likely that no other health care provider is talking to them about the quality of their sleep and we have that opportunity.

These screening forms help identify existing patients of record so we can begin a dialogue about the quality of their sleep and their degree of sleepiness.

Dr. Yatros: Agreed. The process is not that complex. It requires almost no time for the staff and even less time for the dentist.

These days, when patients present with a risk of some sleeping disorder, ruling out sleep apnea or upper airway resistance is simple.

Concerns regarding patients going to sleep labs and disappearing into the ‘CPAP black hole’ become a non-issue. When appropriate, a home sleep test is an excellent means to diagnose patients. There are different ways to do this but we opt to work with EZ Sleep because they are a dedicated home sleep testing company. They understand the needs of the dental practice, they are responsive, and the process is simple.

Dr. Drake: It should be noted that the regulatory and payer environments have 1.

changed so dramatically over the past 5 years regarding home sleep testing. Many payers now mandate that home tests are used over a sleep lab, except in certain circumstances. On that note, the use of oral devices to treat patients that suffer from sleep apnea or snoring has increased since the medical community has begun to understand the benefits that the dental practitioner offers in this arena. Even the CPAP manufacturing companies are recognizing this benefit – so much so, that the largest manufacturer of CPAP machines, ResMed, bought a dental lab and markets an oral appliance to treat sleep apnea.

Dr. Ataii: You bring up a good point Dr. Drake, this industry is evolving. More and more, patients and physicians alike are beginning to understand the benefits of oral devices when addressing sleep apnea. There seems to be more discussion in traditional media and trade journals about sleep disorders and the benefits of oral appliances. However, as a dental and medical community, we are not doing enough to identify patients that suffer from these conditions. Numbers are as high as 90% of the population that has a sleeping disorder remains undiagnosed.

By screening every adult in your practice, you remove stereotypical assumptions about who may or may not have a condition.

Dr. Yatros: Exactly, that is why we educate practices to screen their entire adult population. Of those 100 patients, as we mentioned before, 20 – at minimum – will statistically have some sort of insuffcient sleep.

Dr. Drake: By screening every adult in your practice, you remove stereotypical assumptions about who may or may not have a condition. The truth is that you will not know until the patient is tested. That is the only definitive way to rule out a possible condition. But there are plenty of clues: snoring, high vaulted arches, scalloped tongues…

Dr. Yatros: Visually impaired airways, bruxism, and a whole sleuth of cranial-facial deficiencies. The point is not to assume that just because you see an obese patient in his 40s, that those are the only people your practice should screen.

Dr. Ataii: No. Everyone gets tested. And trust me, you will be surprised.

Register to receive your free customized patient awareness kit.

Use promo code: PILLOWTALK www.ezsleeptest.com/pillowtalk

According to the Centers for Disease Control, at least 20% of the adult population in the United States suffer from insufficient sleep. 20082009 BRFSS, Centers for Disease Control and Prevention.

DentalSleepPractice.com

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LEGALledger

A HOUSE

DIVIDED

by Ken Berley, DDS, JD, DASBA

“And if a house be divided against itself, that house cannot stand.”

Mark 3:25

D

ental Sleep Medicine is truly a house divided. In my 34 years of practicing dentistry and 20 years of practicing law I have never been associated with a more splintered, and apparently confused, group. Unfortunately, each faction seems staunchly determined to stand their ground and battle to the death.

DSM is divided down the middle between the “haves and the have-nots.” Or, if you prefer, between, those dentists who receive adequate numbers of referrals from Sleep Physicians to survive and those who don’t. Personally, I am in a unique position. For those of you who have heard me lecture, you know that I have no agenda. In this argument, I find myself in the unique position of understanding and agreeing with both sides.

DSM is separated into two factions. The first group of dentists want desperately to practice Dental Sleep Medicine but they have no diagnosed patients. They are fearful that a referral to a Sleep Physician will result in the patient being forced into CPAP without OAT

52 DSP | Winter 2014

being offered. These dentists are being encouraged by corporate entities to employ HST and avoid Sleep Physician referral. The second faction in Dental Sleep Medicine are those dentists who became involved very early in the practice of DSM. These dentists worked hard to develop a referral pool of Sleep Physicians and enjoy their confidence now. Many of these practitioners have been able to limit their practices to Sleep Disordered Breathing and are able to fill their schedules with patients referred by Sleep Physicians. Therefore, DSM has two separate and distinct practice models and both groups adamantly defend their practice philosophy. However, legally we cannot have two standards of care.

LEGALledger Contrary to the belief of some, I am not trying to disenfranchise Sleep Physicians or damage the AADSM. I am simply trying to help DSM avoid a legal feeding frenzy that will surely come if we remain divided.

OSA is a very small part of my practice and likely will remain that way. I truly have no “skin” in this game. However, in my practice, I chose to refer ALL of my patients to a Sleep Physician for a face-to-face consultation. I do so because we have no established standard of care and I am risk-averse. As a result of my referrals, I now receive semi-regular referrals from 3 Board Certified Sleep Physicians in Northwest Arkansas. These referrals average around 10 patients per month, which obviously will not sustain a full time OSA practice. I appreciate and respect these physicians for entrusting me with the care of their patients. However, it took 2 years of referring patients from my practice (82 to be exact) before I received a single referral. With persistence and an abundance of referrals, I have won over 3 of the 4 Sleep Physicians in my area. While the referrals I personally receive are few in number, I understand the mentality of those who have been successful in garnering the trust of Sleep Physicians in their market. However, I empathize with those who are trying to play by the Position Papers of the AADSM/AASM and have NO patients to treat. I know the frustration and alienation of referring only to watch my patients with an AHI of 6-10 forced into CPAP. To better understand the two sides of the argument I attended numerous courses in Dental Sleep Medicine. I have been present as MD’s have informed me that criminal charges could be filed against me if I owned a Home Sleep Testing unit. That to own HST equipment was out of my scope of practice.

To quote, “I hope you look good in an orange jumpsuit.” Out of curiosity, I attended several commercially motivated continuing education courses. The common goal of these courses is to get dentists involved in the practice of DSM with the hope that the new dentists will purchase the presenter’s wares.

Each of these commercial courses seem to recommend Home Sleep Testing ordered by the new dentist and diagnosed by a Sleep Physician working for the HST Company.

However, many of these courses rarely or never mentioned the need for a referral to a Sleep Physician. Never is there a reference

to the “Position Paper of the AADSM/AASM 2013.” Nor did I hear a comment that the dentist might be practicing outside the “Standard of Care.”

It cannot be intelligently argued that DSM has an established standard of care. When referring to the Standard of Care, most dentists think this is a dental/medical term that signifies what a practitioner “should do” in a particular circumstance. So what do you do if well-meaning professionals disagree on what you “should do?” For anyone who has spent Standard of Care is actually a significant time in court, you know in any malpraca legal, not a medical term. tice litigation, more than one The legal determination of standard of care is presented.

Generally the plaintiff and dethe “standard of care” for fendant have experts swearing any procedure or treatment an oath and testifying to completely different standards of is a result of numerous care. In DSM we have two diflegal proceedings where ferent factions each presenting their approach to the practice the same or similar results of Dental Sleep Medicine as were found. the standard of care.

Standard of Care is actually a legal, not a medical term.

The legal determination of the “standard of care” for any procedure or treatment is a result of numerous legal proceedings where the same or similar results were found. For example, we are all aware that it is the standard of care to place a rubber dam before root canal therapy. This is a legal precedent resulting from many cases on the matter. Contrary to popular belief, DSM has NO established standard of care, because no body of case law is available on the subject. There has been no legal determination of what “should be” done in any area of Dental Sleep Medicine. Therefore, to those who repeatedly write articles regarding the standard of care in DSM, please be aware that the LAW, not dentists, determines the standard of care. As stated earlier, I am presented with more than one standard of care in every malpractice case. The legal definition of Standard of Care? “Whatever the 12 people in the Jury say it is.”

The problem:

It is my professional legal opinion that the “AADSM/AASM Practice Parameters 2006” will be introduced into evidence as DentalSleepPractice.com

53

LEGALledger a learned treatise exception to the hearsay rule in a malpractice action. It could easily be used by the jury to determine a standard of care for DSM. This document does not require a face-to-face visit with a Sleep Physician; it does not state who must write the prescription for OAT; it does not require that a dentist provide treatment (qualified dental personnel); however, it does require the patient return to the referring physician for monitoring.

It is my professional legal opinion that the “AADSM/AASM Policy Statement of 2013” will NOT be introduced into court as your standard of care. This document contains a number of legally inaccurate statements, therefore, it is my opinion that no trial judge would allow this document into court. However, you should realize that my opinion has not be adjudicated and therefore, I could be wrong. The 2013 Policy Statement: requires a face-to-face consultation with a Sleep Physician before a dentist can provide OAT; requires that a Sleep Physician write the prescription for OAT; requires that a qualified dentist provide treatment; and it requires that the patient be monitored by a Board Certified Sleep Physician.

Therefore we have two published “standards of care” by the same organization.

What a legal mess. I believe that this disparity is responsible for the divergent approaches outlined by different practitioners. We need strong leadership in Dental Sleep Medicine to bring these two groups together. Our house is divided and will not last in this state of disarray.

Dr. Ken Berley is a practicing general dentist with over 30 years of private practice experience focusing on complex reconstruction and 20 years of experience as an attorney licensed to practice law in Arkansas and Texas. He has extensive experience as a litigator and was a full partner in Travis, Borland and Berley, Attorneys’ at Law before moving to Northwest Arkansas. Dr. Berley is a Diplomate of the American Sleep and Breathing Academy and a Diplomate (candidate) for the ABDSM. He lectures in the area of sleep medicine risk management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years.

54 DSP | Winter 2014

From the Mail Bag Ken I have a few dentists an hour north of me asking about treating sleep apnea without an official diagnosis. They know a lot about sleep apnea (trained by moi) but they live in an anti-government “off the grid” type area.

Many of their patients just want to pay cash for an HST and appliance and not have their insurance or Medicare find out. At least they know better than to treat without an HST but they also don’t want their patients going to the dentist down the street that will make them a “snore guard” sometimes ignorance is bliss right? xxxx, DDS Dear xxx, DDS: This is my most frequently asked question. And the answer is “sure they can treat them” but they won’t be following the alleged standard of care. That is like extracting a tooth without an x-ray. You can do it!! The question is not can you, but should you. If I were in that situation and were tempted, I would do HST and have it diagnosed by the Sleep Physician working for the HST Company. Then I would send the patient to his PCP for a physical if he had not had one within the last year to ensure no co-morbid diseases that are undiagnosed. Then the dentist is not taking full responsibility for the medical condition of the patient. Have the PCP sign the Rx. Make sure the dentists document any changes in subjective and objective symptoms after placement by repeating the HST. Then recall each year. Have the patient sign my informed consent and release of liability and I think they would be defensible in court if something happened.

K For those who will not like this article, please don’t feel led to call and attack me. I received an adequate number of those over the last article explaining my Scope of Practice. Please call the leaders of the AADSM who created this monster. That is where the problem lies. I’m only the messenger.

However, as Socrates said, “To avoid all criticism: Say Nothing, Do Nothing and Be Nothing.”

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