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Future Therapy for Obstructive Sleep Apnea OSA patients will likely undergo careful assessments prior to the implementation of therapy. By Atul Malhotra, MD, Brigham & Women’s Hospital, Harvard Medical School

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bstructive sleep apnea is a common condition with major consequences.1 Despite its well recognized neurocognitive and cardiovascular sequelae, treatment of this condition remains inadequate.2 Nasal CPAP is the treatment of choice based on the available randomized trials.3,4 however, adherence to therapy is quite variable.5 Many patients avoid the diagnosis of OSA because they are reluctant to undergo therapy using a nasal mask. Such patients are never recognized as treatment failures since they are never diagnosed with OSA. In addition, such patients would generally not be enrolled in randomized trials since the participants in clinical trials frequently reflect the most motivated individuals. Other therapies for OSA are available including oral appliances and upper airway surgery.6,7 www.thesleepmagazine.com

Oral appliances are a reasonable alternative to CPAP, especially in mild to moderate OSA, particularly because patient preferences may drive improved adherence with the oral appliance approach.8,9 Data regarding outcome benefit from oral appliances are rapidly evolving10,11, but studies remain small and lacking in hard outcomes. Ongoing studies are also examining various techniques to predict who may or may not respond to mandibular advancement.12 Upper airway surgery also has a role in OSA therapy, but elimination of apnea is uncommon using this approach.13 However, because surgery leads to a permanent anatomical change, adherence is no longer an issue. As such, a partial response from

upper airway surgery may be preferable to a non-adherent CPAPtreated patient.14 Thus, considerable room for improvement exists in OSA therapy, which is likely to emerge from ongoing mechanistic research in this area.2 Current views on OSA pathogenesis

suggest that there are multiple pathways which yield apnea.15 That is, there are a variety of mechanisms that can lead to apnea and treatment of underlying cause is likely to be beneficial. Patients with OSA have anatomical compromise based on either obesity or abnormalities in craniofacial structure.16 However, anatomical measurements show considerable overlap between OSA patients and controls.17 Thus, anatomy is likely one of many variables that underlie OSA pathogenesis. Patients who have a marked improvement following uvulopalatopharyngoplasty likely have a problem primarily with velopharyngeal anatomy. Upper airway dilator muscles are also important in OSA pathogenesis, since a marked fall in activity in these muscles at sleep onset can yield apnea in those anatomically pre-disposed. However, upper airway dilator muscle responsiveness to various stimuli is also highly variable. Thus, if a therapy were available to activate these muscles e.g. pharmacologically, this approach is likely to benefit some but not all patients.18 Similarly, instability in ventilatory control (high loop gain) is also likely important in OSA pathogenesis.19 Variable output from the central pattern generator in the brainstem can lead to apnea when output to the respiratory muscles (diaphragm and


upper airway) is at its nadir. Strategies to stabilize ventilatory control are likely beneficial in carefully selected patients.20 However, randomized trials will be required to determine the impact of such interventions on clinical outcome. Other pathogenic mechanisms such as end-expiratory lung volume and upper airway surface tension are also likely to be important in subgroups of apnea patients.21-23 Thus, treatment of the underlying cause of sleep apnea is likely to be beneficial. In the future, OSA patients will likely undergo careful assessments prior to the implementation of therapy. Overnight sleep studies will hopefully yield more information than just apnea severity, but will also provide data on mechanism(s) underlying apnea and/or perhaps provide prognostic information, which can help guide therapy. While nasal CPAP will likely remain an important treatment option in the future, other treatment options targeting underlying cause are likely to evolve over time. By knowing the mechanism (or mechanisms) underlying apnea, an appropriate treatment strategy (or combination of treatments) could then be implemented. Acknowledgement: Dr. Malhotra is PI on multiple NIH grants and an American Heart Association Established Investigator Award. He has received consulting and/or research income from Respironics/Philips, Ethicon/J&J, Restore/Medtronic, Cephalon, Sepracor, Itamar, Apnex, NMT, Pfizer, SLEEP GROUP SOLUTIONS. 1. Malhotra A, White DP 2002 Obstructive sleep apnoea. Lancet 360:237-245 2. Saboisky JP, Chamberlin NL, Malhotra A 2009 Potential therapeutic targets in obstructive sleep apnoea. Expert opinion on therapeutic targets 13:795-809 3. Pepperell JC, Ramdassingh-Dow S, Crosthwaite N, Mullins R, Jenkinson C, Stradling JR, Davies RJ 2002 Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised parallel trial. Lancet 359:204-210 4. Jenkinson C, Davies, RJ, Mullins, R, Stradling, JR 1999 Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial. Lancet 353:2100-2105. 5. Redline S, Adams N, Strauss ME, Roebuck T, Winters M, Rosenberg C 1998 Improvement of mild sleep-disordered breathing with CPAP compared with conservative therapy. Am J Respir Crit Care Med 157:858-865

6. Lowe A, Fleetham J, Ryan F, Mathews B 1990 Effects of a mandibular repositioning appliance used in the treatment of obstructive sleep apnea on tongue muscle activity. Prog Clin Biol Res 345:395-404; discussion 405 7. Fleetham JA, Ferguson KA, Lowe AA, Ryan CF 1996 Oral appliance therapy for the treatment of obstructive sleep apnea. [Review] [5 refs]. Sleep 19:S288-290 8. Ferguson K 2001 Oral appliance therapy for obstructive sleep apnea: finally evidence you can sink your teeth into. Am J Respir Crit Care Med 163:1294-1295 9. Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA 1997 A short-term controlled trial of an adjustable oral appliance for the. Thorax 52:362-368 10. Deane SA, Cistulli PA, Ng AT, Zeng B, Petocz P, Darendeliler MA 2009 Comparison of mandibular advancement splint and tongue stabilizing device in obstructive sleep apnea: a randomized controlled trial. Sleep 32:648-653 11. Itzhaki S, Dorchin H, Clark G, Lavie L, Lavie P, Pillar G 2007 The effects of 1-year treatment with a herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest 131:740-749 12. Zeng B, Ng AT, Darendeliler MA, Petocz P, Cistulli PA 2007 Use of flow-volume curves to predict oral appliance treatment outcome in obstructive sleep apnea. Am J Respir Crit Care Med 175:726-730 13. Woodson BT, Conley SF 1997 Prediction of uvulopalatopharyngoplasty response using cephalometric radiographs. American Journal of Otolaryngology 18:179184 14. Weaver EM, Maynard C, Yueh B 2004 Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 130:659-665 15. Eckert DJ, Malhotra A 2008 Pathophysiology of adult obstructive sleep apnea. Proceedings of the American Thoracic Society 5:144-153 16. Schwab R, Pasirstein M, Pierson R, Mackley A, Hachadoorian R, Arens R, Maislin G, Pack A 2003 Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med 168:522530. 17. Sforza E, et al. 1999 Pharyngeal critical pressure in patients with obstructive sleep apnea syndrome. Clinical implications. Am J Respir Crit Care Med 159:149-157. 18. Kubin L, et al. 1996 Interaction of serotonergic excitatory drive to hypoglossal motoneurons with carbachol-induced, REM sleep-like atonia. Sleep 19:187195. 19. Younes M, Ostrowski M, Thompson W, Leslie C, Shewchuk W 2001 Chemical control stability in patients with obstructive sleep apnea. Am J Respir Crit Care Med 163:1181-1190 20. Wellman A, Malhotra A, Jordan AS, Stevenson KE, Gautam S, White DP 2008 Effect of oxygen in obstructive sleep apnea: role of loop gain. Respiratory physiology & neurobiology 162:144-151 21. Heinzer R, White DP, Malhotra A, Lo YL, Dover L, Stevenson KE, Jordan AS 2008 Effect of expiratory positive airway pressure on sleep disordered breathing. Sleep 31:429-432 22. Heinzer RC, Stanchina ML, Malhotra A, Fogel RB, Patel SR, Jordan AS, Schory K, White DP 2005 Lung volume and continuous positive airway pressure requirements in obstructive sleep apnea. Am J Respir Crit Care Med 172:114-117 23. Malhotra A, Jordan A 2005 Surface tension and sleep apnea: a sticky business. Sleep 28:392-393

Rani Ben-David President/Editor ranibd@sleepgs.com Donald Burke Creative Director design@sleepgs.com Dr. Dan Tache Co-Editor Contributed Articles Dr. Brock Rondeau Dr. Atul Malhorta Dr. Terrence Davidson Dr. Jorge Landa Dr. Leonard J. Feld Dr. Mark Levy Dr. Robert L. Horchover Dr. Steven J. Scheer Dr. Gy Yatros Dr. Michael Friedman Dr. Bryan Keropian Dr. JC Goodwin Dr. Marty R. Lipsey Dr. Michael Gelb Dr. Dennis Bailey Professor Jeffery Fredberg Shandra Cipriano William R. Beauchamp Randall L. Haupt, RPSGT David Baker - Embla Systems Tamir Cohen Pauline Bell Michael Wiegenstein

Sleep Group Solutions (SGS) 16830 Northeast 19th Avenue North Miami Beach, FL 33162 Toll-Free 1.866.353.3936 Email: info@sleepgs.com WWW.SLEEPGS.COM

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hanks for reading the Sleep Magazine, I would like to welcome you to the first 2010 issue of the new Sleep Magazine! The year 2009 was record setting for our company as the sleep market saw tremendous growth despite the poor economy. Looking ahead, Sleep Group Solutions (SGS) has some exciting new ventures that will continue to help grow our position as a leader in the dental and medical sleep medicine market. Recently SGS welcomed a new Medical Advisor – Dr. Atul Malhotra. Dr. Malhotra is the medical director for the Boston-based Brigham and Women’s Hospital (BWH) Sleep Disorders Research Program. Professor Jeffrey Fredberg, the Harvard professor who invented SGS’ Rhinometer and Pharyngometer, recommended that Dr. Malhotra join our team and we are pleased to have him on board. I recently had an opportunity to spend some time with Dr. Malhotra. I left that meeting more confidant than ever that we are not only taking advice from a world class sleep specialist, but a great person as well. Education is the backbone behind the SGS business. Educating dentists and physicians leads them to integrate sleep medicine in their practice. Educating patients increases awareness, diagnosis and treatment of a life threatening disorder. With this in mind, we have planned a more comprehensive series of educational seminars for 2010 than ever before. We brought in some new experts like Dr. Gy Yatros, Dr. Dawne Slabach, Dr. Jerry Gildner, Dr. JC Goodwin and Dr. Mark Levy to join SGS veterans Dr. Brock Rondeau and Dr. Dan Tache. Each of these instructors comes from a vastly different background and their practices span North America. What binds them together is that each of them has been successful in treating sleep disordered breathing in their community and each of them uses SGS Pharyngometer/Rhinometer and Embletta X100 diagnostic equipment. Additionally, none of our instructors are marketing their own oral appliance which means you get true unbiased information and reviews on the various devices in the market, and more information on how to properly integrate sleep medicine into your practice. Our education program is built around the single goal that every doctor who attends will be able to go back to his or her practice on Monday and be knowledgeable and confidant enough to begin immediately treating patients with sleep disordered breathing. Continuing with the theme of education, SGS has recently started a joint venture with the world-renowned dental marketing company 1-800Dentist. Our joint venture, 1-800Snoring will help propel our clients’ offices to leading positions in their community. This marketing effort will raise patient awareness like never before and bring more patients in for treatment. 1-800Snoring pairs the marketing power and state of the art call center from 1-800-Dentist with SGS’ education, instrumentation, training and protocols. Our magazine started as “Dental Sleep Magazine.” As we had more requests from medical doctors, we changed it to “The Sleep Magazine.” We always welcome feedback and comments. I encourage every one to email me directly at Ranibd@sleepgs.com with any concerns or issues. Our goal is to continue growing with our customers and provide optimum service. Our home sleep testing program has built a bridge between primary care doctors, ENTs, cardiologists, pulmonologists, dentists, sleep specialists, sleep labs and others. I look forward to working with new and existing clients in the coming year. SGS clients are saving thousands of lives every single day. We look forward to expanding our network and increasing this success! I would like to thank all our clients, vendors and friends once again. Rani Ben-David President Sleep Group Solutions

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SLEEP DISORDERS The Fastest Growing Dental Specialty

Dr. Atul Malhotra

Inside Cover

Utilizing Acoustic Pharyngometry .......................................................................................... 8-13 Using HST in a Sedated Apnea Management Program ................................................................ 16

Diagnosis and Treatment of Obstructive Sleep Apnea From The Dental Perspective. Dr. Terrence Davidson

pg. 5-7

Dental Management of Sleep Disorders ..................................................................................... 19 The Emergence of a Health Centered Practice .................................................................... 22-24 A.W.A.K.E. Support Group for Patients with Sleep Apnea ............................................................. 26 Who’s Looking At Our Kids? ................................................................................................ 28-29 World’s Largest Sleep Diagnostics Company Created ......................................................... 38-39 Sleep Group Solutions Seminar Schedule 2010 .................................................................. 42-43 TMD, Fibromyalgia, BiPolar Depression and Undiagnosed OSA ............................................ 40-48

Pharyngometry

Get Ready! ......................................................................................................................... 50-51

Questions & Answers

Oral Appliances for the Treatment of OSA ............................................................................ 52-55

Professor Jeffrey Fredberg

Efficacy of Tonsillectomony and Adenoidectomy ................................................................. 58-59

pg. 14

The Full Breath Solution ..................................................................................................... 60-61

Confirming Nasal Airway Patency Dr. Jorge Landa

pg. 30-36

tableofcontents

The Future Therapy of OSA

It’s Not All About You ........................................................................................................... 62-64 12 Pearls to Create That Practice You Really Want ............................................................... 66-68 New Development From Golani Holdings ................................................................................... 68 With Changes Comes Opportunity ............................................................................................. 69 Support for Sleep Disorders ............................................................................................... 70-71

Practicing Dentistry vs. Treating OSA and Snoring Dr. Gy Yatros

pg. 56-57 The Impact We Have on People’s Lives is Profound Dr. Michael Gelb

pg. 79

Embla Enterprise - Sleep Lab Management Software ................................................................. 72 So Who Are You? What Do You Do Anyway? ................................................................................ 46 Screening All Patients . . . A Winning Strategy ............................................................................. 74 Less Known But Common Symptoms Found in The Sleep Apnea Population ........................ 75-76 Dental Sleep Medicine A Full Team Approach ............................................................................. 77 The Gelb Center - Boutique VIP Course ....................................................................................... 78

Finding new sleep apnea patients made easy

1-800-SNORING pg. 20

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

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

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commentary SM

Dental Sleep Medicine… Sleep Disorders Dentistry

The dental treatment of snoring and sleep apnea.

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By John Nadeau, VP - Sleep Group Solutions

his rapidly growing field seems to in cities across the country. What does go by many different names these this mean for you? It means we’ve done days. There is certainly a lot of our homework, we have the protocols buzz surrounding it and for the first time spelled out, we have the education, we ever dentists are being approached by have the technology and we have the the physicians to help in treating this life contacts with the physicians. We just need threatening disorder. In fact, the American dentists interested in saving lives while Academy of Sleep Medicine issued new adding to their bottom line. practice parameters to their physicians Unlike nearly all other seminars out recommending that oral appliances be there on dental sleep medicine we will used as a first-line treatment option for not try to push just one appliance on you. mild to moderate Most importantly, “At your courses, will you teach you’ll learn how obstructive sleep apnea. Sleep Group me which appliance to use?” the position of the Solutions (SGS) mandible is the has affiliations critical factor for with hundreds of sleep success, not the name of labs nationwide and the appliance that puts we work hard to create it there. We will teach mutually beneficial referral you how to find proper relationships between these position, adjust appliances facilities and our dental and work with the sleep clients. labs and sleep physicians This is a call to action to increase success. for the dental community! Leading our seminars SGS With proper education, has brought together an instrumentation and training elite team of instructors. a dentist can successfully Most are diplomats of the treat this life threatening disorder. But Academy of Dental Sleep Medicine and wait you say – I’ve made “snore guards” they all share years of experience and before and they worked okay, what’s the diverse dental backgrounds while having difference? Let me be perfectly clear the same goal of putting attendees in a – making a “snore guard” without first position to begin treating sleep apnea ruling out life threatening apnea borders immediately. You won’t find instructors on malpractice. These days are over. There interested in building their ego’s, flaunting is a protocol for screening, diagnosing and their credentials or selling you their own treating snoring and sleep apnea. appliance. Just good solid information, So now what? You suspect many of hands-on experience and practical takeyour patients are suffering from this home knowledge that will enable you condition, where do you go to learn what to immediately implement what you’ve to do? SGS is here to help. We are the learned. largest dental sleep medicine company We look forward to meeting you at an and our sole focus is on increasing the rate upcoming course and applaud you for of diagnosis and treatment of sleep apnea taking these steps to change the lives of by training physicians and dentists and hundreds of your patients. facilitating cooperative treatment networks

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Sleep Group Solutions Seminars In a city near you!

To register go to page 85 or visit us online at: www.sleepseminars.com The Dentist’s Role in Snoring & Sleep Apnea Instructor: Dr. Brook Rondeau January 9-10, 2010 Toronto, ON

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. June 11-12, 2010 Hartford, CT

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache January 15-16, 2010 Chicago, IL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. June 25-26, 2010 Philadelphia, PA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros February 5-6, 2010 Orlando, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache July 17-18, 2010 Miami, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dawn Slabach February 12-13, 2010 Nashville, TN

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros July 23-24, 2010 Denver, CO

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dawn Slabach February 19-20, 2010 San Francisco, CA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. JC Goodwin August 13-14, 2010 San Diego, CA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Mark Levy March 5-6, 2010 Columbus, OH

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache August 21-22, 2010 Chicago, IL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros March 12-13, 2010 Las Vegas, NV

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros September 24-25, 2010 Denver, CO

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache March 20-21, 2010 Orlando, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache October 2-3, 2010 Minneapolis, WS

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Brook Rondeau April 9-10, 2010 Calgary, AB

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros October 15-16, 2010 Las Vegas, NV

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros April 16-17, 2010 Phoenix, AZ

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. JC Goodwin October 22-23, 2010 Phoenix, AZ

The Dentist’s Role in Snoring & Sleep Apnea Instructor: Dr. Brook Rondeau April 24-25, 2010 Chicago, IL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache November 6-7, 2010 Dallas, TX

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros May 14-15, 2010 Boston, MA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. November 12-13, 2010 St. Louis, MO

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Dan Tache May 21-22, 2010 Dallas, TX

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros December 10-11, 2010 Orlando, FL


Diagnosis and Treatment of Obstructive Sleep Apnea From The Dental Perspective. A True Paradigm Shift. By Terrence Davidson, MD, FACS, and Gregory Barkdull, MD, University of San Diego

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ason B is a 32 year old male who recently moved to town and wishes to establish care. You notice from the hallway that he repeatedly falls asleep and begins to snore while the hygienist performs the cleaning. Dental examination reveals excellent dentition, but you learn from further discussion that he snores on a nightly basis, and has snored ever since high school. Denies apneic episodes, but did comment that when he wakes up for work, he is not refreshed. Drinks several cups of coffee in the morning before he feels awake. He also notes that he is often sleepy in the afternoons and invariably when he goes to the movies he falls asleep midway through. Denies falling asleep while driving or car accidents. Mr. B’s medical history reveals hypertension (currently

under treatment with an ace inhibitor) and gastroesophageal reflux disease. Physical examination of the oropharynx reveals a Mallampati score of 4 with the tongue in repose. The uvula is enlarged and even at the afternoon examination is edematous. The palatine tonsils are present, but not protruding beyond the tonsil pillars. The diagnosis of obstructive sleep apnea was discussed with the patient, and he reveals that his older brother has already been diagnosed with sleep apnea. Mr. B. is then provided an Embletta (a multichannel home sleep test machine) and returns the following day. The apnea hyponea index (AHI) is 16. The patient is given the choice of consulting with a sleep physician to obtain a Positive Airway Pressure Machine (PAP machine) or to be fitted for a mandibular advancement device (MAD). A MAD with 6 mm of advancement is constructed using an acoustic oral pharyngometer to select the minimum mandibular advancement to open the posterior airspace. The patient returns in one week and reports his snoring has ceased and that he is feeling more refreshed upon awakening and throughout the day. He and his

wife had actually attended a movie “a chick flick” in which he was not particularly interested, but he had not fallen asleep. A repeat Embletta test was performed while wearing the mandibular advancement device. The apnea hyponea index was reduced to 5. Epidemiology OSA is a morbid, mortal illness and been linked to hypertension, obesity,

diabetes, heart failure, arrhythmias, nocturia, heart attack, stroke, gastroesophageal reflux disease and early death. A recent study of 6441 men and women in the sleep heart health WWW.SLEEPGS.COM

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study showed that men age 40-70 with sleep apnea had an increased risk of all cause mortality – twice that of those

without sleep apnea [Punjabi 2009]. The prevalence of obstructive sleep apnea is exceedingly high in all first world countries, in part due to the current obesity epidemic. An estimated 25% of males 9% of women will develop sleep apnea during their lifetime [Young 1997]. Pathophysiology The anatomy of the upper respiratory tract as it relates to obstructive sleep apnea was previously discussed in the September 2005, Dentistry Today article [Davidson 2005]. Our group has conducted additional research that further defines the role of the tongue and implicates the retrolingual airspace in cases of severe sleep apnea. A series of 80 patients with a diagnosis of obstructive sleep apnea underwent upper respiratory tract CT imaging. The retrolingual airway cross-sectional area was found to correlate with the severity of sleep apnea. While retropalatal airway crosssectional area was reduced, it did not correlate with severity of sleep apnea [Barkdull 2008]. In a separate study, our group further characterized the anatomy of the tongue by evaluating 121 specimens from the medical examiner’s office. Tongue weight and fat content were examined, and compared to

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subject’s anthropometric data. A direct relationship was noted between the tongue size and markers of obesity. Furthermore, serial sectioning of the tongue revealed a significantly higher overall percentage fat (35%) than skeletal muscle controls (3%) [Davidson 2007]. These two studies have added to our understanding of the anatomy of OSA. First, the retrolingual airway must pass through the rigid confines of the cervicomandibular ring. Second, the airway shares the space with a variable amount of soft tissue within the bony ring. Individuals with small mandibular size start off with less room to accommodate the soft tissues of the tongue, pharyngeal tonsils, lingual tonsils, and parapharyngeal fat. Then if they gain weight, their tongues also increase in size with increased fat content. This further reduces the size of the retrolingual airspace. This model helps understand the higher incidence of sleep apnea seen with obesity. The model also predicts that patients with a small mandible and therefore decreased cervicomandibular ring would be more likely to obstruct at the retrolingual airspace. The anatomy of sleep apnea has another layer of complexity, in that the continuous reflexive control over the

tongue musculature disappears during sleep. The loss of muscle tone, including the genoihyoid and genioglossus muscles explains why a patient with a large tongue and a marginal airway will obstruct during sleep. Anesthesia, sedation, and narcotic pain medication can also result in decreased muscle tone and cause the tongue to fall back into the oropharynx and obstruct the airway. Diagnosis Symptoms of adult sleep apnea include snoring with observed apnea events and daytime fatigue. Phenotypic abnormalities that correlate with sleep apnea include the presence of a small mandible, large neck circumference (17 inches or greater in men, 15 inches or greater in women), large waist (42 inches or greater), elevated BMI (greater than 30), prominent tonsils and uvular edema [Patel 2008]. A medical history may reveal the presence of hypertension, diabetes, gastroesophageal reflux, heart disease or other known OSA comorbidity. While the diagnosis of sleep apnea can be suspected clinically, it is best confirmed with a sleep study. Home sleep tests have been shown to provide excellent and reliable evaluations for obstructive sleep apnea. (CMS) Many dentists who see patients with sleep apnea have started offering home sleep testing. Cephalometric analysis can be a useful adjunct to sleep testing.(Sedgh) Studies have demonstrated a positive correlation between sleep apnea and the MPH measurement [Barkdull 2008]. MPH is the perpendicular distance from the inferior border of the mandible, down to the hyoid bone (See Figure 3). The hyoid bone is the inferior site of attachment of the extrinsic tongue muscles, and is suspended by a system of muscles and ligaments. A lower position of the hyoid likely reflects an increase in the tongue volume, which therefore explains the correlation with obstructive events. Most normal patients have an MPH value between 1.4-1.6 cm. The index of suspicion for OSA should increase when the MPH is 1.8 cm or greater. Other variables that


correlate with sleep apnea include a decreased sella-nasion-B point (SNB) and posterior airspace (PAS). Management Once the diagnosis has been made, treatment begins with patient education. Most patients are not aware of the significant adverse health effects of untreated sleep apnea. Furthermore, they may not realize that they are at a 7x increased risk for car accidents. (SASSANI) They should avoid narcotics, sedatives, sleeping pills and alcohol. Their obstructive events should be expected to increase, if they are taking narcotic pain medication after dental procedures. They should also be counseled about the increased risk of death following general anesthesia, and therefore expect to be observed overnight after elective surgeries in which general anesthesia is used. Patients with obesity should be counseled to pursue weight loss treatment. Successful weight loss, has been shown to improve sleep apnea. Patients who have undergone gastric bypass surgery for morbid obesity have benefited from a reduction in the number of obstructive events per night [Hianes 2007]. Weight loss likely reduces fat stores within the posterior tongue and relieves the additional truncal weight that promotes hypoventilation. Positive airway pressure (PAP) treatment is considered the gold standard therapy, and has been shown to reduce the risk of mortality and medical comorbidities [Martinez-Garcia 2009]. A major advantage, is the ability for PAP to simultaneously treat multilevel obstruction. It is important to work with the patient to find a comfortable mask to optimize compliance. Humidification can be added to the positive airway pressure machine to reduce dryness. Mandibular advancement devices which move the mandible forward and therefore move the tongue forward provide benefit in some patients. Transnasal endoscopy demonstrates the benefit of mandibular protrusion (See Figure 4). It is reasonable to try a MAD as first-line treatment in patients with mild sleep apnea (AHI 5-15).

A repeat home sleep test should be obtained to evaluate efficacy, and those with persistent elevation of AHI should proceed to PAP treatment. Some patients, who do not tolerate PAP can be offered surgical treatment. There are numerous surgical procedures currently under evaluation, however few produce reliable results. Maxillomandibular advancement has been successful in achieving long-term improvement [Li 2000]. Tonsillectomy can also be effective in patients with isolated tonsillar hypertrophy. Soft palate procedures can reduce snoring, but are rarely curative. Conclusion: The United States Healthcare System needs to better recognize OSA and initiate treatment in a timely fashion thereby reducing the associated morbidity and mortality. Many adults do not make regular visits to their primary care physician, but they do see their dentist twice a year. Proper recognition and treatment of patients with suspected OSA can have a tremendous positive impact on their health and longevity. References: • Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, et al. 2009 Sleep Disordered Breathing and Mortality: A Prospective Cohort Study. PLoS Med 6(8): e1000132. doi:10.1371/ journal.pmed.1000132. • Young T, Evans I, Finn I, Palta M. Estimation of the clinically diagnosed proportion of sleep apnoea syndrome in middle-aged men and women. Sleep 1997; 20: 705-6. • Davidson TM.: The Role of the dental profession in the diagnosis and treatment of sleep disordered breathing. Dentistry Today 24(9):118-120 2005. • Barkdull G, Kohl C, Davidson T. Computed tomography imaging of patients with obstructive sleep apnea. Laryngoscope. 118(8):1486-1492, 2008.

• Davidson T and Patel M. Waist, circumference and sleep disordered breathing. Laryngoscope 118:339-347, 2008. • Burton S, Davidson TM, Westbrook P, Kuhlmann DC. Invited commentary from members on the draft proposal released by the Centers for Medicare & Medicaid Services for modification of national coverage determination 240.4. J Clin Sleep Med. 15;4(1):78-80, 2008. • Davidson TM, Sedgh J, Tran D and Stepnowsky CJ: The anatomic basis for the acquisition of speech and obstructive sleep apnea: evidence from cephalometric analysis supports the great leap forward hypothesis. Sleep Medicine 6:497-505, 2005. • Sassani A, Findley LJ, Kryger M, Goldlust E, George C, and Davidson TM: Reducing motorvehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep 27(3):453-458, 2004. • Haines KL, Nelson LG, Gonzalez R, Torella T, Martin T, Kandil A, Dragotti R, Anderson WM, Gallagher SF, Murr MM. Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery. 2007 Mar; 141(3):354-8 • Martinez-Garcia MA, Soler-Cataluna JJ, EjarqueMartinez L. et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5 year follow-up study. Am J Respir Crit Care Med. 2009 Jul 180(1):36-41 • Li KK, Riley RW, Powell NB, Guilleminault C. maxillomandibular advancement for persistent obstructive sleep apnea after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope. 2000 Oct 110: 1684-8

Dr. Davidson is a Professor of Surgery in the Division of Otolaryngology Head and Neck Surgery and Associate Dean for Continuing Medical Education at the University of California, San Diego School of Medicine and Section Chief of Head and Neck Surgery at the VA San Diego Healthcare System. Professor of Surgery, Head and Neck Surgery Director, UCSD Nasal Dysfunction Clinic Director, UCSD Head and Neck Surgery Sleep Medicine Center

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patientcase

Utilizing Acoustic Pharyngometry to Improve . . . . . . Efficacy of Hybrid Therapy in the Management of an Unresponsive Severe CPAP-Intolerant Patient

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avigating one’s way through the medical literature can be a daunting task because of the sheer volume of information availble in both written and electronic format. It is the prudent reader who will recall the work done by Ernst1, 2 who organized what is referred to as The Hierarchy of Evidence when you consider that 10-15% of published articles are subsequently proven to be of lasting scientific value. As Greenhalgh states in her book, “How To Read A Paper”, usually, the level of evidence corresponds to the study design however, there can be redeeming value in the individual Case Study in that it may raise awareness of a clnical problem or possible solution to a clinical dilemma or simply may stimulate further investigation whereas had the time not been taken to report interesting findings, science would not have been advanced. It is logical that perhaps many or most RCTs are prompted as a result of questions raised from observations made from a single Case Study.3 The Case Study can often provide the impetus for future clinical and epidemiological studies by proposing a hypothesis which begs to be explored.4

By Dan Taché, DMD However, there is a confounding independent variable best described as patient tolerance which cannot be controlled or easily predicted, so at the end of the day, when attempting to help our Sleep Disordered Breathing (SDB) patients with their OSA problems, it is doing whatever we can do to help them with what their SDB problem. It is patient tolerance (or in-tolerance)

perhaps, which potentially subverts most all Evidence-Based treatment algorithims so an element of common sense must prevail. This is particularly true with the severe OSA patient who is offered CPAP therapy. Studies have shown that unless this patient has significant disease severity and subjective sleepiness, that compliance with CPAP therapy is often insufficient.5 A CASE STUDY of HYBRID THERAPY: THE SEVERE APENIC This is BG. BG is a pleasant 72 year old Causacian male. His past medial history revealed the following:

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• Excessive daytime sleepiness • Snoring • Hypertension • Dyslipidemia • Peripheral artery disease • Hypothyroidism, and • Palpitations He has a family history which is positive for stroke, type I and II diabetes, coronary artery disease, hypertension, dementia, and myocardial infarction. 04/20/09: Polysomnogram performed with standard EEG montage. He was diagnosed with severe obstructive sleep apnea. AHI=71; Mean Oxygen Saturation=92%; Lowest Oxygen Saturation=70%. Patient had significant sleep fragmentation therefore stringent criteria for application of CPAP were not met so AutoPAP will be provided for home titration and downloads used to adjust. Auto- and Bi-PAP DOWNLOADS 04/30/09-06/01/09: A REM Star AutoPAP (Philips Respironics) was initially prescribed and pressure set at 5-20cm of water pressure. Download data during this period showed 100% utilization; median pressure was 16 with a peak of 20 cm of water pressure; his masks leaks were high at 7.2 L/ min with a peak of 40.8 L/min which is considered high. AHI was still high at 46.9 despite average usage of 8 hours/ day. Download Information from 05/30/09-06/15/09: data during this period showed 100% utilization; Pressures range between 15-50 cm of


water pressure. AHI was still high at 44.2 despite average usage of 8 hours/ day. The decision to change to a REM Star BiPAP Auto S/V unit was made with pressure changes to 12-20 cm of water pressure. 07/27/09: Current setting of his BiPAP are as follows: IPAP of 25, pressure support of 4, minim EPAP at 10. Median pressure is 17.6 with a maximum of 21 cm of water pressure. His apnea index is elevated at 50.3. Median usage is 8 hours and leaks remain high. BG has been alternating between a nasal triangle (mask) and a full face mask due to the relatively high pressures. A request went out to the lab manager requesting that the data downloads be checked for accuracy. The decision to confer with BGs dentist for a MAD was also decided upon. 08/17/09: BG was referred to my office by BG’s dentist because he was not comfortable with managing what seemed to be a relatively advanced SDB case. 09/23/09 Dental Sleep Exam: 1. BMI: 30, Vital Signs: BP=130/88, Pulse=72, Neck Circumference=17.5 inches 2. Intraoral exam: • Soft tissue: WNL; Tongue Level: III; Mallampati Score: IV, Dental Occlusion: Angle Class II, div. 1, patient has >10 healthy teeth/arch; no active dental disease; regular biannual dental visits 2. Mandibular Range of Motion: • MO=58mm • Right Lateral=12mm • Left Lateral=12mm • Protrusive=8mm 3. Radiographs: • TMJ Tomograms: no evidence of pathology; condyles were well centered in the fossae and translated well. • Lateral Cephalometric Radiographs: reasonably good movement of the hyoid bone with advancement; moderate widening of the Posterior Airway Space (PAS) 4. Airway Acoustic Evaluation: • Acoustic Rhinometry (ARh): ARh is useful6-9 for estimating the location of obstructions in the nasal cavity. The obstructions may be in the form of turbinate hypertrophy and/ or septal deviation. ARh is performed

on all patients both pre- and postdecongesting. The data obtained will raise the level of suspicion or dispel the likely presence of turbinate hypertrophy and/or septal deviation both conditions contributing mightily to High Upper Airway Resistance (HUAR). Mindful that HUAR may contribute to increased

Right: Closed

Left: Closed

pharyngeal airway compliance and reduced efficacy of CPAP and MRDs, we make frequent referrals for EENT evaluation. • I believe that herein is a singular reason to acquire this technology. On

Acquired Centric

cross-sectional area and respiratory disturbance indices during sleep was investigated. Rivlin et al stated that there was a significant correlation between the number of apneas per hour sleep (AI) and pharyngeal cross-sectional area. Mohsenin found a significant correlation between pharyngeal cross-sectional area and Respiratory Disturbance Index (RDI) in males and females. 10, 11 • The results of this work show a significant relationship between pharyngeal cross-sectional area and AI; that is, the pharyngeal cross-sectional area can be a predicting factor for the severity of OSA.9 • Acoustic Reflection has been used by many competent clinicians to assess airway volume and has been found to be a cost-effective, non-invasive real-time technology with practical application in every-day assessment and management of patients pulmonary and sleep disordered breathing problems.12-17

Protrusive

numerous occasions, such a referral has concluded with vastly improved tolerance of CPAP that there was no need for the patient to obtain a MRD. Acoustic rhinometry has been shown to be predictive of tolerance of nasal continuous positive airway pressure7 and I feel that it particularly helpful in the severe non-positionally dependent severe apneic and the edentulous patient where sufficient advancement if often not an option without dislodgement of the MRD. BG’s ARh showed good volume on both sides (above the parallel lines) and the area under the curve on both sides is equivalent suggesting that there is neither turbinate hypertrophy nor septal deviation. An ENT referral does not seem to be indicated. Acoustic Pharyngometry (APh): The relationship between pharyngeal

The results of BG’s initial APh showed good baseline volume of 4.33 cm2. Baseline norms: female= 2.8cm2 ; male=3.0 cm2. At Residual Volume (RV), when the patient exhales thereby placing a negative load on the upper airway, we see a minimum xsec diameter of 1.47cm2 at the oropharyngeal juncture. We then proceeded to assess airway compliance or stability by testing the airway at RV both in the advanced and vertically depressed position and in both instances, there appeared to be a decrease in collapsibility. These results suggest that BG’s airway may likely respond to both advancement WWW.SLEEPGS.COM

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and depression. So, in the event, that we find that advancement alone fails to help improve BG’s airway stability, short of dismissing the him saying that “I have done all that I can”, I would choose to proceed with MRD modification and add vertical height and then retest.

Downloads Prior to Intervention with MRD.

You can see the significant mask leaks due to the extreme pressures with the persistent elevation of AHI. Also is shown the nasal triangle mask being utilized at this time. He was having pain on the bridge of his nose from having to tighten the mask so tight in an effort to reduce leaks. High mask pressure leading to discomfort and leaks, compelled BG to be changed to a full face mask as shown below. Despite a change of masks, leaks

Figure 1: BG: Initial Acoustic Pharyngometry (APh) Evaluation

persist and so do the elevated respiratory indices. 09/23/09: Dental Sleep Consultation I informed BG that I felt that he would be a candidate for a MRD Therapy and that a TAP3 could be the best choice for the following reasons: 1. This is an extremely agreeable and motivated patient 2. Mandibular Range of Motion is good 3. Hyoid Bone Movement upon protrusion is good 4. Airway acoustics suggest that his airway should stabilize with BOTH advancement AND depression 5. MRD I chose the TAP3 for the following reasons:

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• It lends itself very nicely to Titration in a hospital/sleep lab setting in that it does not have to be removed to be advanced; this is a most attractive feature for the sleep laboratory technicians and I do anticipate that a follow-up Split-Night Oral Appliance Titration will be necessary • Design changes make this particularly good appliance for Hybrid Therapy • TAP3-mask connections • TAP3/custom mask fabrication

Figure 2: Download Prior to Beginning Hybrid Therapy; AHI=42.5

• TAP3/nasal pillow customization 6. We will utilize the Airway Metrics System™ to enable us to utilize the pharyngometer for our “Airway Bite” (construction bite)

Figure 3: Change to full face mask; AHI=41.7

• This is a systematic “jig system” developed to more easily determine the mandibular locus on both x- and y • More often than not, advancement

Figure 4: 10/6/2009; AHI=56.0

is sufficient18 however, when a severe non-positional apneic presents, a 3-Dimensional approach to airway stabilization most always provides a better outcome.19 • Studies have shown that some

patients subjectively feel that an increase in VDO is more comfortable.20, 21 • A simple, cost-effective system to facilitate precise 3-D repositioning of the mandible when utilizing APh (AIRWAY METRICS LLC, 256-9498839) 09/23/09: Impressions for TAP3 and Airway Metrics Construction Bite • Airway Bite taken: pharyngometerguided construction bite utilizing Airway Metrics system. • Airway bite “ 2 airway bite 4, 3” appeared to provide the best airway response • We can see from bite “3 bite 6, 3” that increased vertical might also be useful if advancement is insufficient for airway stability. TAP3 Is Delivered • BG instructed to wear TAP3 WITH his BiPAP • Instructed to advance 1-2 turns every 3 days • BG appointed to return with downloads from his BiPAP • Figure 8 shows position of the mandible after advancement had been maximized. Post-Insertion Titration and Downloads • You will find below, the results of successive downloads • Each download represents a change in A-P position; the patient has entered the number of “turns” added from the previous download • We are seeing a progressive improvement in indices with each incremental advancement until 10/20/09 when our airway begins to degenerate; our AHI has risen from 22.0 to 35.4 and a commensurate increase in % Time in Apnea; (the goal for this index is <1.0% of TST) Re-evaluate our airway to look for a direction • BG’s airway has shown improvement however, additional advancement appears to be having a negative effect • Recall that during our initial airway assessment, that APh showed that there was a favorable airway response not only to advancement but also to mandibular depression (i.e. increased VDO) • We will utilize the Airway Metrics


Vertical Titration Keys (VTK) to help us find an airway • The 6 mm VTK is placed and APh reading shows markedly improved airway caliper (Figure 10) when patient exhales to Residual Volume (RV) • Below, is a view of the graph showing airway caliper changes with successive increases in vertical • An additional 6mm appears to have a positive effect upon reducing

additional advancement at the present vertical height, we are compelled to explore this avenue • The decision was made to proceed with relining the TAP3 by resetting the advancement mechanism and then retest. • The Acoustic Pharyngometry in concert with the VTK System, took my assistant Tracey, approximately 5-7 minutes to complete including the construction bite • The reline was facilitated by use of a

Figure 10: 6 mm Vertical Titration Key (Airway Metrics VTK) in place; airway stability evaluated with Pharyngometer

several weeks or even months with some

Figure 6: Example of Airway Construction Bite: A. Bite Jig Chosen/APh shows good stability at position, B. 4, 3; bite record applied; C. Bite record completed

airway compliance; this may enable us to retrude the mandible while gaining more stability which would be more comfortable for BG as well • The airway appears to be favorably affected throughout most of its length, from the Oropharyngeal Juncture through the Hypopharynx • A minimal xsec diameter of >2.0cm2 when a negative load (Appendix: 1) is placed on the airway, in our experience,

Figure 8: Advancement Instructions Provided

most often is indicative of a very positive response.9,22 • Given the inverse response seen with

patients Figure 9: Successive Downloads with cumulative (titration) turns; improvement until 10/20/09 at which point, the airway stability degrades; we will consider adding vertical

Galetti Articulator (stoneless mounting) and took approximately 30 minutes to complete • We could have just as easily sent BG home with an ambulatory sleep monitor if he were not using his BiPAP and obtaining downloads • BG will advance incrementally as before but to stop with any discomfort • Goal: BG’s goal was to reduce his AHI to 0; my initial response to BG that I would be satisfied to reduce the Oxygen Saturation <90% of TST to <1.0% and the AHI to <15 events/hour BG reported increased comfort with the relined appliance • BG has been asked to provide us with downloads from his BiPAP as they become available • He will advance 2 turns at a time every 2-3 days or as comfort allows • Do not hurry the titration/ advancement process; it may take

As can be seen from the downloads above, we are seeing success • The combination of both advancement and the introduction of additional vertical support has stabilized the airway nicely • After this article was written, I received another download from BG; the AHI=0.1 • BG’s sleep physician has now changed BG back to nasal triangle mask and we are considering nasal pillows • With the TAP3, we can connect the nasal pillows (Fisher & Paykel Nasal Pillows) DIRECTLY to the appliance allowing us to remove the (annoying) straps Very Recent Letter from Referring Doctor Opposite page is a copy of a very recent letter from the sleep center who is managing BGs case with me. This can be a very satisfying part of your practice. When otherwise, as a Dentist, do you have the opportunity to participate in someone’s health care at this level? WWW.SLEEPGS.COM

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SUMMARY: We have successfully assisted BG with airway stabilization. Our goal was augment his BiPAP, not replace it. BG is resting well and has noted a significant reduction in his excessive daytime sleepiness and with the reduced pressure of 17 cm of water pressure and a near total elimination of leaks, he is doing well. It is unlikely that we could have easily achieved this end result without the use

Figure 12: Comparison of varying increased in vertical upon airway; 6mm provides a minimum xsec diameter of 2.33 cm2

of Acoustic Reflection to aid the process. It is a technology which is widely used by both medical and dental professionals who are treating patients with sleep disordered breathing. Many patients are sent to dentists for CPAP-intolerance because they cannot breathe adequately with the CPAP applied. Acoustic Rhinometry is extremely useful to rule out High Upper Airway Resistance (HUAR). Even if the decision has been made to move to a MRD, HUAR must be eliminated

Figure 14: Original TAP3 with vertical increase of 6mm; advancement mechanism was reset.

Figure 15: I will close this space with acrylic if we are successful.

because the Bernoulli Effect due to HUAR will obtund the efficacy of the oral device, no matter which one is chosen. IT IS NOT AN OPTION, it is a MEDICAL NECESSITY. Acoustic Rhinometry can greatly assist the medical sleep specialist to predict those patients who may be more prone to be CPAP-intolerant.7 Dentists are not often asked to assist with life-threatening illness as we are in assisting patients with OSA and the consequences of not being able to

assist the CPAP-intolerant are serious. Acoustic Pharyngometry is currently used by more than 30 Diplomates of the American Board of Dental Sleep Medicine. The comments here may, to some, may seem anecdotal, nonetheless, if we do not avail ourselves of ALL technology in our efforts to help such patients and we fail, if we do not succeed, the worst case scenario is not the loss of tooth but potentially the loss of life. Implicit in accepting such patient is that we will do all that we can to help. The Evidence-Based literature says that the mandible will likely be advanced a minimum of 80% of maximum protrusive range of motion before airway stabilization is achieved. There are good studies suggesting that increased vertical height may reduce airway caliper.23,24 What we are doing with this technique is NOT what was done in such studies where opening was more hinge axis rotation than bodily depression of the mandible; quite another matter! Indeed RCTs are needed and we can argue Evidence-Based this and Evidence-Based that but in the meantime, there is a subset of patients, probably obese males and women with Polycystic Ovary Syndrome (as I have often seen) require additional vertical height. Until such time that EBM literature satisfies cynical critics, I would suggest that if you are not seeing a sufficient improvement in Respiratory Indices with “Advancement and Pray”, you may want to add some additional technology to your treatment protocol before you say to your patient that “I have done all that I can”. What choice do we have? With Gratitude: I would like to thank Tracy Devoss, my clinical assistant, for her help in managing the gathering and cataloging of acoustic data in our effort to help patient BG. Her dedication to detail greatly facilitated our efforts in this and many such cases.

Figure 13: BG with relined TAP3 (+6mm).

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BIBLIOGRAPHY 1. Ernst E. Assessing the evidence base for CAM. Complementary and alternative medicine: challenge and change 2000:165. 2. Ernst E. An evidence-based approach to acupuncture. Acupuncture in Medicine 1999;17(1):59-61. 3. Pless B. How to Read a Paper: The Basics of Evidence Based Medicine.: By Trisha Greenhalgh.(Pp 184;{pound}


14.95 paperback.) BMJ Publishing Group, 1997. ISBN 0-7279-1139-2. British medical journal 1998;4(1):80. 4. Aschengrau A. Essentials of epidemiology in public health: Jones & Bartlett Publishers; 2003. 5. MCARDLE N, DEVEREUX G, HEIDARNEJAD H, ENGLEMAN HEATHER M, MACKAY THOMAS W, DOUGLAS NEIL J. Long-term Use of CPAP Therapy for Sleep Apnea/ Hypopnea Syndrome. Am. J. Respir. Crit. Care Med. 1999;159(4):1108-14. 6. Clement PAR, Gordts F. Consensus report on acoustic rhinometry and rhinomanometry. Rhinology 2005;43(3):169. 7. Morris LG, Setlur J, Burschtin OE, Steward DL, Jacobs JB, Lee KC. Acoustic rhinometry predicts tolerance of nasal continuous positive airway pressure: A pilot study. American Journal of Rhinology 2006;20:13337. 8. Wheeler SM, Corey JP. Evaluation of upper airway obstruction-An ENT perspective. Pulmonary Pharmacology & Therapeutics 2008;21(3):433-41. 9. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Otolaryngology - Head and Neck Surgery 2004;130(1):58-66. 10. Viviano J. Normalizing the Pathological Airway. 11. Viviano J. Acoustic reflection: review and clinical applications for sleep-disordered breathing. Sleep and Breathing 2002;6(3):12949. 12. Hoffstein V, Zamel N, McClean P, Chapman K. Changes in pulmonary function and cross-sectional area of trachea and bronchi in asthmatics following inhalation of procaterol hydrochloride and ipratropium bromide. Am. J. Respir. Crit. Care Med. 1994;149(1):81-85. 13. Izci B, Riha RL, Martin SE, Vennelle M, Liston WA, Dundas KC, et al. The Upper Airway in Pregnancy and PreEclampsia. Am. J. Respir. Crit. Care Med. 2003;167(2):13740. 14. Jan M, Marshall I, Douglas N. Effect of posture on upper

airway dimensions in normal human. Am. J. Respir. Crit. Care Med. 1994;149(1):145-48. 15. JARREAU P-H, LOUIS B, DESFRERE L, BLANCHARD PW, ISABEY D, HARF A, et al. Detection of Positional Airway Obstruction in Neonates by Acoustic Reflection. Am. J. Respir. Crit. Care Med. 2000;161(5):1754-56. 16. Martin S, Marshall I, Douglas N. The effect of posture on airway caliber with the sleep-apnea/hypopnea syndrome. Am. J. Respir. Crit. Care Med. 1995;152(2):721-24.

20. Ferguson K, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 2006;29(2):244-62. 21. Hoffstein V. Review of oral appliances for treatment of sleep-disordered breathing. Sleep and Breathing 2007;11(1):1-22. 22. Kamal I. Lung volume dependence of pharyngeal crosssectional area by acoustic pharyngometry. OtolaryngologyHead and Neck Surgery 2002;126(2):164. 23. Isono S, Tanaka A, Tagaito Y, Ishikawa T, Nishino T. Influences of head positions and bite opening on collapsibility of the passive pharynx. Journal of applied physiology 2004;97(1):339. 24. Ayuse T, Inazawa T, Kurata S, Okayasu I, Sakamoto E, Oi K, et al. Mouth-opening Increases Upper-airway Collapsibility without Changing Resistance during Midazolam Sedation. Journal of dental research 2004;83(9):718-22. APPENDIX: Residual Volume (RV) By having the patient exhale to RV, a negative load is placed on the airway. Although not necessarily predictive of how much and where the airway may collapse during sleep, it has been shown to correlate with collapsibility of the asleep airway.9, 22

17. Van Surell C, Louis B, Lofaso F, Beydon L, Brochard L, Harf A, et al. Acoustic method to estimate the longitudinal area profile of endotracheal tubes. Am. J. Respir. Crit. Care Med. 1994;149(1):28-33. 18. Marklund M, Franklin KA, Sahlin C, Lundgren R. The effect of a mandibular advancement device on apneas and sleep in patients with obstructive sleep apnea. Chest 1998;113(3):707. 19. Marklund M, Persson M, Franklin K. Treatment success with a mandibular advancement device is related to supine-dependent sleep apnea. Chest 1998;114(6):1630.

design@sleepgs.com

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Pharyngometry

Simple, fast, reliable, non-invasive radiation, and reimbursable. By Professor Jeffrey J. Fredberg, PhD - Harvard University

Q. What makes acoustic reflection technology so accurate? A. Quite simply, the accuracy of this noninvasive approach stems from the two facts that the signal-to-noise ration is remarkably high, even in the doctorâ&#x20AC;&#x2122;s office, and the laws of acoustics are highly reliable. Taken together, this combination makes for a high-accuracy quantitative diagnostic device. We established long ago, and it has been widely validated by others since then, that the variability that is observed, which is modest, represents true physiological variability of the dynamic structures of interest. Q. What were your goals when you originally developing these systems, and how did you intend them to be used? A. We were originally focused upon developing this noninvasive technology to study the small airways of the lung periphery. The technology was thought to be particularly well suited to infants and young children because it requires no subject cooperation. Q. Did you ever think the Acoustic Pharyngometer would have so many applications with sleep medicine? Why do you think it has been adopted so well in this field? A. At the beginning, as described above, not at all. In time, however, it became increasingly clear that the main value of the technology would lie in otolaryngology and sleep medicine. Acoustic Pharyngometry has probably been adopted so well because it is simple, fast, reliable, and uses nonionizing radiation. It is also quantitative, inexpensive and reimbursable. These reasons, taken together, define a niche that cannot be matched by any other screening technology for seep www.thesleepmagazine.com

disordered breathing. Q. The Acoustic Pharyngometer has proven to be highly predictive of sleep disordered breathing problems as well as predictive of oral appliance efficacy, what are your thoughts on this? A. The pathophysiology entails airway geometry and airway stability. These physical factors are inescapable determinants of upper airway function, and Acoustic Pharyngometry measures and quantifies them quite easily. The same information can certainly be obtained by CT or MRI imaging, but only at much greater cost. Q. How can you see equipment being useful in the dental field? A. In dentistry, the value proposition is simple and revolves around mandibular advancement devices. Instead of guessing, the dentist can use Acoustic Pharyngometry to titrate the amount of mandibular advancement in order to optimize the balance between therapeutic effect on the one hand and patient comfort on the other. The latter is known to impact patient compliance. The patient who leaves the device on the night-table gets no benefit. Q. Do you have any advice for people first learning how to interpret the volumetric readings? A. The best approach is simply to play with the device on yourself. The display is intuitive, and after a few minutes the information becomes virtually selfexplanatory Q. What kind of validation was done during the development process? A. Our original validations used twoaxis radiographic projections, while later validations by others used MRI and CT. Compared with these more costly

modalities, all published studies concur that the Acoustic Pharyngometry is no less accurate. Q. What are the benefits of using acoustics versus something like an endoscope? A. Endoscopy is an indispensable tool, but is invasive and often requires sedation and/or anesthesia. Acoustic Pharyngometry can be used to rule in or to rule out those patients for whom endoscopy might be indicated. Q. In the study David Gozal did he was talking about Diagnosing kids for sleep apnea with the Pharyngometer. What do you think about it? A. Acoustic Pharyngometry is not yet widely used in children. Solid experimental evidence from multiple studies support the idea that Acoustic Pharyngometry is dramatically underutilized in this important patient population. In this population, airway dimensions during wakefulness have been shown to correlate with sleep disordered breathing. Q. What universities are using the Eccovision? A. Over 500 systems are in use worldwide, including those at U Louisville, Harvard U., Case Western Reserve, U Toronto, Albert Einstein, Yeshiva U, U Padova, U Turin, U de Bari, Southern U of Portland, Queenâ&#x20AC;&#x2122;s U., Catholic U. of Korea, Central Hospital of Sweden, Johannes Gutenberg U., U Mainz, U Calgary, U Pennsylvania, Korea University College of Medicine, U Verona.


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Using HST in a Sedated Apnea Management (SAM) Program. Providing a safe atmosphere for those patients scheduled for surgery.

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s the use of home sleep testing to diagnose obstructive sleep apnea continues, many hospitals and sleep centers are beginning to see a utility for it in screening those pre-surgical candidates that have a moderate to high pretest propensity for sleep apnea. In the past, sleep centers were not in a position to screen surgery patients due to the high costs and delayed access to sleep services. Now, with HST, the patient can pick up the portable device during their pre-admit testing (PAT) process and return it the next day for download and those results can then be sent to the surgery department for the anesthesiologist and surgeon to put forth a postoperative care plan that will reduce the risk of sleep apnea when the patient is sedated. It is well known that sleep apnea can be a complicating factor in the administration of general anesthesia. It is also known that when the anesthesiologist is aware of sleep apnea in the patient undergoing surgery and takes appropriate measures to maintain the airway, the risks of administering anesthesia to people with sleep apnea can be minimized. General anesthesia suppresses upper airway muscle activity, and it may impair breathing by allowing the airway to close. Anesthesia thus may increase the number of and duration of sleep apnea episodes and may decrease arterial oxygen saturation. Further, anesthesia inhibits arousals which would occur during sleep. HST can rapidly diagnose these patients efficiently and cost-effectively

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By Randall Haupt, RPSGT and give specific lengths and severity of sleep apnea along with the nadir of blood oxygen saturation associated with these respiratory events. At our facility, we worked with the PAT team, surgery department, anesthesiologists, the sleep specialist, and surgeons to come up with a policy to screen all pre-surgery patients for sleep apnea. A detailed history (Height, weight, BMI, neck size, and medical conditions) coupled with specific questions about their sleep can be accomplished with little effort and time by the screening nurse. If the patient is a likely candidate for sleep apnea they are sent to the sleep center to be educated on the use of the Embletta® portable sleep device. The Embletta® is preprogrammed with the approximate sleep and wake time of the patient so the patient does not have to start the unit by pressing a button. In the morning, the patient returns the device for download and a registered sleep technologist scores the study and prepares it for interpretation by the sleep specialist. A final report with recommendations is sent to the surgery department, the patient’s primary care physician, and a copy is mailed to the patient allowing for future treatment if warranted. Incorporating a SAM protocol into your sleep center’s practice will open new revenue streams and referral sources. “Using HST to screen high risk patients is something that hospital-based sleep centers as a minimum should do to

provide a safe atmosphere for those patients scheduled for surgery. It is costeffective and we now have the ability to rapidly diagnose patients with sleep apnea that was not previously available to us.” Says Dr. Manoj Majmudar, the Medical Director of the Sleep Disorders Center at Jennie Stuart Medical Center. Furthermore Dr. Majmudar says that “HST is the future of sleep medicine. With companies like Embla® designing better sleep diagnostic equipment it is accurate to say that more sleep-related services will be driven to the comfort of the patient’s home.” Sleep centers should consider investigating other referral sources that can maximize the use of HST versus shying away from it. Anesthesia patients and inpatients in the hospital provide numerous opportunities to capture those patients that need a sleep study and treatment for OSA but are being missed. The more people that are diagnosed with sleep apnea in-turn equates to the more people that can be treated with sleep apnea. This translates into increased referrals to the sleep center for CPAP titration. Using HST to diagnose the roughly other 90% of those undiagnosed with sleep apnea can dramatically increase the in-lab volume with PAP titration studies. Like it or not, HST is here to stay and sleep center have to embrace it and make it work to their advantage. Rest Assured! Randall L. Haupt, RPSGT Director, Sleep Disorders and Neurodiagnostics Center Jennie Stuart Medical Center Hopkinsville, KY Phone: 270-887-6883 Fax: 270-887-6884


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Bookshelf SM

Dental Management of Sleep Disorders

Ron Attanasio and Dennis R. Bailey

Book Excerpt Sleep disorders can no longer be thought of in simple terms as having a poor night’s sleep. There are currently a large number of different sleep disorders that may affect one’s quality of life. In addition, there is a difference between the sleep state and the wake state. Sleep is not simply an altered state of consciousness, that is merely a difference of being asleep or being awake. Sleep is a totally separate behavioral and physiological state that is unique and well documented, and it is defined as “a reversible behavioral state of perpetual disengagement from and unresponsiveness to the environment.”5 As such, sleep is composed of a combination of rapid eye movement (REM) and non-rapid eye movement (NREM)

Dennis R. Bailey, DDS

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he dentist’s role in the management of sleep disorders has grown significantly in the past 10 years. Accordingly the demand for a comprehensive text that applies to the doctor who is just entering this field as well as those with experience has been a well defined need. By the end of 2009 just such a text will be available. “Dental Management of Sleep Disorders” by Ronald Attanasio and Dennis R. Bailey, both of whom have active practices involving dental sleep medicine, will be available from Wiley-Blackwell. This text can be ordered directly from the publisher or from TMData Resources. The text is designed to be a comprehensive presentation of sleep medicine that is relevant to the practicing dentist as well as information that is dentally oriented. The book is divided into three sections:

1. Overview of Sleep Medicine 2. Assessment of the SleepRelated Breathing Disorder Patient 3. Management of the SleepRelated Breathing Disorder Patient

associated with well-defined and variable brain activity.6 Sleep disruption and the specifically recognized sleep disorders In addition there are two appendices not only may have a major impact on an for the dentist: one on abbreviations individual’s of terms for well-being, medicine Approximately 50–70 million people sleep health status, and the other in the United States are chronic a glossary of and quality of terms for sleep life, but may also sufferers from sleep disorders, who medicine. render significant have impaired health and daily This text consequences functioning issues as a result of will be a good on the various resource for those disorders areas of public the dentist who health, such as is involved accidents, mortality, morbidity, work and other with and practices in the field of sleep daily performance, cognitive function, and medicine no matter what level. utilization of health care. WWW.SLEEPGS.COM

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here are lots of people out there promising to deliver new patients to physicians. That’s true for physicians in general practice and to a lesser extent it’s true for physicians who are trying to build their sleep apnea practice. But in nearly every case, what’s being offered isn’t new patients - it’s a tool such as a website or a computer program or a internet key word buying program that is supposed to create the new patients. And you only get new patients to the extent that the website, program or key words are effective. Now there’s an alternative to these techniques. Instead of investing in a system to deliver new patients, you can simply ask for the patients themselves. It’s a new external marketing program called 1-800-SNORING. 1-800-SNORING is being offered under auspices of some serious names in medical industry – 1-800-DENTIST®, The Full Breath Corporation and Sleep Group Solutions. Designed on the proven model of 1-800-DENTIST®, the program will feature broadcast advertising to reach out to millions of snoring and sleep apnea sufferers. These messages are expected to make a huge impact because there are no other advertisers competing for attention in this arena. Once their attention is captured, their calls to the toll-free 1-800-SNORING number will be fielded by a specially trained US call center and they’ll be carefully screened to make sure they’re an ideal prospect to be converted into a new patient. Then they’ll be matched with a member physician who is best able to satisfy the caller. And personally introduced to the physician’s front office staff via a threeway phone call.

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our program requires. SGS seminars are taught by industry leaders, many are diplomats of the AASM and AADSM. The courses are designed to give physicians the knowledge and protocols needed in order to immediately begin implementing the treatment of snoring and sleep apnea in their practice. Initially 1-800-SNORING will debut in the Los Angeles metropolitan area reaching millions of patients. Later it will be available nationally to sleep apnea specialists across the country. “There are millions of people out there who suffer from sleep apnea and who need our help. But they don’t know where to turn,” says Fred Joyal, CEO of 1-800-DENTIST®. “But 1-800-SNORING and its members will make it easy to for them to find help. It’ll only be a phone call away.” About 1-800-DENTIST®

Founded in Los Angeles in 1986, 1-800-DENTIST® is the nation’s leading free resource for consumers in search of a dentist. Offering both online and on-the-phone services 24 hours a day, 1-800-DENTIST® has matched over 6 million Americans with independent dentists. For more information, visit 1800dentist.com.

“We truly believe that this new program is going to deliver a lot of prescreened, high quality leads to member physicians,” says Rani Ben-David president and founder of Sleep Group Solutions (SGS). “That’s why SGS is partnering with 1-800-SNORING to ensure doctors in our program are ready with the proper education, hands-on training and instrumentation.” SGS is the industry leader in providing continuing education to physicians related to the treatment of sleep apnea. Physicians interested in joining the 1-800-SNORING program are encouraged to attend an SGS seminar to become familiarized with the best practices and consistent protocols that

About Sleep Group Solutions (SGS)

SGS is a private medical equipment and education company and is rapidly becoming an industry leader in the field of airway diagnostics for Sleep specialist, ENT, Primary care, Cardiologist, Pulmonologist, orthodontics, dental sleep medicine, otolaryngology and pulmonology. SGS employs a team of motivated trainers and representatives to work hands-on with physicians in the field. SGS also provides Home Sleep Testing. www.sleepgroupsolutions.com 1-866353-3936 About Full Breath Corporation Dr. Bryan Keropian, the dentist and inventor behind the Full Breath Solution, has dedicated his life to developing a snoring solution as well as an alternative CPAP solution for those intolerant to CPAP. After years of research, treatment is now available to you in a state of the art facility by caring staff and doctors.


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The Emergence of a Health Centered Practice Ortho-TMJ-sleep connection. By Brock Rondeau, DDS

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rior to the recession which started approximately in September 2008, the most popular courses were those promoting cosmetic dentistry including crowns, veneers and lumineers. Patients wanted straight white teeth and when employed, they could afford to pay for these elective services. However, when an increasing number of patients became unemployed or had their hours reduced, their priorities changed. Discretionary dollars are now being spent on the essentials such as food, mortgage, automobile, clothing, etc. When the unemployment rate exceeded 10% and even higher in some areas, most dentists saw a significant decrease in their incomes. Dentists have fewer dollars to spend on expensive cosmetic courses where the return on investment is no longer a certainty. Napoleon Hill, a billionaire, wrote a book several years ago entitled, â&#x20AC;&#x153;Think and Grow Rich.â&#x20AC;? He stated that one of the keys to becoming successful was to find out what people want and give it to them. I believe that everyone wants good health and research has shown that healthrelated services and dental practices are doing well in this recession. Years ago, I decided that parents want early treatment utilizing functional appliances which help to modify the growth of their younger children. The majority of the orthodontists in my area did not offer this service. They preferred to wait until all the permanent teeth erupted. Since functional appliances were not utilized to widen the arch to make room for all the permanent teeth, many times they opted to extract some permanent teeth. Parents do not want extractions and prefer the early treatment approach with functional appliances. Once I offered this early treatment option, my practice continued to grow. We have patients traveling 100 miles or more to our practice when this treatment is not

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available in their area. Some orthodontic clinicians, in an effort to correct overjet problems, prefer to wait until age 17 and possibly refer the patient to have the lower jaw surgically

A

B

C

A. Constricted Maxilla B. Maxilla Expanded in 6 months C. MX Schwarz Appliance Midline Expansion Screw

advanced. Parents consistently informed me that they did not want their children to be subjected to a surgical procedure and fixed braces for 2 years at age seventeen. They much preferred the early treatment approach with functional appliances which orthopedically reposition the lower jaw forward non-surgically. My practice has grown substantially since starting to treat children and adults with functional appliances approximately 25 years ago. As my orthodontic practice evolved, I realized that an alarming number of patients who had been treated orthodontically with bicuspid extractions, ended up with the condyles posteriorly and/or superiorly displaced in the glenoid fossa with subsequent TM dysfunction. Our practice is now attracting a large

case finishing as their best option following Phase I Jaw Stabilizing treatment. This initial treatment involves utilizing a daytime repositioning splint to try and recapture anteriorly displaced discs and a nighttime appliance to stop parafunctional habits such as clenching and bruxing. It has been estimated that 70% of all malocclusions are Class II and approximately 80% are Class II skeletal patients with normally positioned maxillas and retrognathic mandibles. Overbite 6 mm.

Rick-A-Nator

Class II Molar Overbite 6mm.

First Molars Erupting

Rick-A-Nator Cemented

A

B

A. Pre-treatment retruded mandible B. Functional appliance 9 months later. Straight Profile

number of patients with TM dysfunction and a large percentage select orthodontic

These patients traditionally have narrow maxillary arches, moderate to large overjets and deep overbites.1 Routinely, these patients have internal


Straight Profile Retrognathic Profile • Headaches • Under-developed lower jaw

Insert Rick-A-Nator • No Headaches • Normal upper & lower jaw

derangements (problems within the jaw joints), evidenced by posteriorly displaced condyles and anteriorly displaced discs. Condyles that are posteriorly displaced frequently compress the nerves and blood vessels in the bilaminar zone distal to the condyle. Functional appliances are effective as they reposition the lower jaw forward which results in the condyle moving downward and forward away from the nerves and blood vessels. The ideal functional appliance to be used to correct deep overbites is the Rick-ANator. The diagnosis of an internal derangement can be made with a diagnostic device called a JVA (Joint Vibration Analysis). This device measures the vibrations in the TM joint when the patient opens and closes. A normal joint has no noise and is painless. In the early stages of internal derangement (Stage 1 and 2), there are different patterns of vibrations and different levels of pain. The JVA is an excellent device to measure different vibrations to assist the clinician in establishing the degree of seriousness of the internal derangement by evaluating the soft tissue. The diagnosis can also be made utilizing a tomogram x-ray, which is the hard tissue evaluation. This measures the position of the condyle in the fossa. If the condyle is down and forward, there is frequently no internal derangement. If the condyle is posteriorly displaced, there is an internal derangement routinely. When these patients open their mouths to talk or to chew, their jaws clinically click. This click occurs as the condyle goes over the posterior rim of the disc upon opening and is, in fact, recaptured, indicated by the click on opening. The treatment of choice for a patient

with a retrognathic profile, in order to improve their appearance, is to reposition the lower jaw forward using a functional appliance such as a Twin Block (removable appliance) or MARA (fixedfunctional appliance). The literature is clear that if the disc can be recaptured with the functional appliance that moves the mandible forward, most patients have a significant reduction in the signs and symptoms of TM dysfunction. Our treatment objective for these patients is not only to improve their facial esthetics but also to improve their TMJ health. The problem with the extraction of the upper bicuspids with subsequent retraction of the upper incisors is that sometimes the TM dysfunction does not manifest itself until the patient is much older. This makes Twin Block Appliance

After

Before Upper Block

Mara Appliance

After

Before

to snoring and sleep apnea.2-5 Snoring is caused by the tongue falling back and partially blocking the airway. Obstructive sleep apnea (OSA) occurs when the tongue falls back and blocks the airway5 for 10 seconds or more, over 35 times per night (in a 7 hour sleep cycle). Patients with underdeveloped lower jaws are extremely susceptible to OSA6 and snoring as the tongue is retruded when the mandible is retruded.5 When orthodontic clinicians elect to extract the bicuspids and then retract the upper incisors, the mandible and tongue

Bicuspid Extraction

Unhappy Patient TMJ Dysfunction

Lower Block

it difficult for the clinician years later to determine the cause of the problem. The problem is compounded by the fact that TM dysfunction can also be caused by trauma, whiplash injury, general anesthesia, and the extraction of wisdom teeth. Bicuspid extractions also contribute

Mandible Retruded Due To Extraction of Upper Bicuspids

remain in a retruded position at the end of treatment. When patients grow older and become less active, many put on weight. In some cases, this increases the amount of fat in the neck and this further restricts the size of the pharyngeal airway which increases the incidence of OSA7-10. The treatment of choice for patients with retrognathic mandibles is to advance the mandible with a functional appliance, preferably a fixed appliance such as the MARA Appliance11-13. This WWW.SLEEPGS.COM

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Retrognathic Maxilla & Mandible

Mandible Retruded due to Retractive Orthodontics Mandible Retruded Due To Extraction of Upper Bicuspids

results in the mandible coming forward and moving the tongue forward, thus reducing the likelihood of snoring and OSA. By advancing the mandible with the functional appliance, the condyles are moved down and forward away from the nerves and blood vessels in the bilaminar zone and this also helps to eliminate or prevent TM dysfunction. OSA is a medical condition that is becoming increasingly more prevalent in the U.S. and Canada due to the increase in obesity. Fifty-two percent of all Americans, age 40 years and older, snore. Approximately 20% of these have

A

B

A. Underdeveloped Mandible before treatment B. Mandible advanced Mara Appliance 7 months later

obstructive sleep apnea14-17. The Wall Street Journal stated that now the housing construction was starting to include two master bedrooms in new houses. The reason, I suspect, is that 27% of all couples over the age of forty sleep apart due to snoring problems. Dental practices with 2,000 active patients will have at least 400 children, 70% of whom have a malocclusion. These patients need to be treated with functional appliances in order to eliminate

Mara Appliance Advanced 5 mm

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or prevent OSA in the future18-20. SUGGESTIONS TO TRY PREVENT SNORING & OSA

AND

1. Treat the children early with functional appliances. 2. Establish a normal patent airway as soon as possible by the removal of adenoids and/or tonsils21-24. 3. Eliminate and/or control allergies which will stop mouth breathing and encourage nasal breathing. 4. Encourage orthodontic clinicians to develop arches with functional appliances instead of extracting permanent teeth. 5. Utilize functional appliances such as the Twin Block, Rick-A-Nator or MARA Appliance to reposition the lower jaw and tongue forward to open up the airway. Conversely, do not refer patients for the extraction of permanent teeth including bicuspids. 6. Utilize functional appliances to move the lower jaw forward non-surgically in children and young adults in an effort to open up the airway. Conversely, discourage orthodontic practitioners from waiting until age 17 to surgically advance the mandible. If you have 2,000 patients in your practice, approximately 35% will snore and 20% have obstructive sleep apnea. This provides you with an excellent opportunity to increase your income while providing a valuable health service to your patients. In my opinion, the health centered practice of the future will provide the following services for their patients: 1. Children will be treated with a nonextraction, non-surgical philosophy, utilizing functional appliances to reposition the lower jaw and tongue forward. 2. Adults will be treated with oral appliances to help eliminate the serious risks associated with snoring and obstructive sleep apnea. Dentists and staff who dedicate their practices to helping patients achieve healthy temporomandibular joints and eliminating snoring and sleep apnea, achieve a tremendous feeling of satisfaction. I would encourage all of you to consider changing your practice to one that is more health centered. The dental profession has an opportunity to significantly improve the

health of our patients and we need to take our responsibility seriously. BIBLIOGRAPHY 1. MD F, Kryger M. Gender and obstructive sleep apnea syndrome, part 1: clinical features. Sleep 2002;25(4):409. 2. Shapira IL. SLEEP APNEA. J Am Dent Assoc 2004;135(5):550-. 3. Arnett G, Gunson M, Mclaughlin R. Three-Dimensional Facial Treatment Planning. Distraction Osteogenesis of the Facial Skeleton 2007:1. 4. Muzaffar A, FRACS J. Craniofacial anomalies I: Cephalometrics and orthognathic surgery. Selected Readings Plastic Surg 2001;9:1â&#x20AC;&#x201C;50. 5. Lowe A. The tongue and airway. Otolaryngologic Clinics of North America 1990;23(4):677. 6. Deberry-Borowiecki B, Kukwa A, Blanks RHI. Cephalometric analysis for diagnosis and treatment of obstructive sleep apnea. The Laryngoscope 1988;98(2). 7. SCHELLENBERG JB, MAISLIN G, SCHWAB RJ. Physical Findings and the Risk for Obstructive Sleep Apnea . The Importance of Oropharyngeal Structures. Am. J. Respir. Crit. Care Med. 2000;162(2):740-48. 8. Schwab R, Gupta K, Gefter W, Metzger L, Hoffman E, Pack A. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am. J. Respir. Crit. Care Med. 1995;152(5):1673-89. 9. Schwab RJ, Pasirstein M, Kaplan L, Pierson R, Mackley A, Hachadoorian R, et al. Family Aggregation of Upper Airway Soft Tissue Structures in Normal Subjects and Patients with Sleep Apnea. Am. J. Respir. Crit. Care Med. 2006;173(4):453-63. 10. Schwab RJ, Pasirstein M, Pierson R, Mackley A, Hachadoorian R, Arens R, et al. Identification of Upper Airway Anatomic Risk Factors for Obstructive Sleep Apnea with Volumetric Magnetic Resonance Imaging. Am. J. Respir. Crit. Care Med. 2003;168(5):522-30. 11. Rondeau B, London O, Seminars R. How Early Orthodontic Treatment Can Prevent Temporomandibular Dysfunction, Snoring, and Sleep Apnea: Two Different Treatment Philosophies. 12. Yassaei S, Bahrololoomi Z, Sorush M. Changes of Tongue Position and Oropharynx Following Treatment with Functional Appliance. Journal of Clinical Pediatric Dentistry 2007;31(4):28790. 13. Papadopoulos M. Clinical efficacy of the noncompliance appliances used for Class II orthodontic correction. Orthodontic treatment of the class II noncompliant patient: current principles and techniques 2006:367. 14. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults. N Engl J Med 1993;328(17):1230-35. 15. Ancoli-israel S, Kripke DF, Mason W, Kaplan OJ. Sleep Apnea and Periodic Movements in an Aging Sample. J Gerontol 1985;40(4):419-25. 16. Berry DTR, Phillips BA, Cook YR, Schmitt FA, Gilmore RL, Patel R, et al. Sleep-Disordered Breathing in Healthy Aged Persons: Possible Daytime Sequelae. J Gerontol 1987;42(6):620-26. 17. Berry DTR, Phillips BA, Cook YR, Schmitt FA, Honeycutt NA, Arita AA, et al. Geriatric Sleep Apnea Syndrome: A Preliminary Description. J Gerontol 1990;45(5):M169-74. 18. Bondemark L. Does 2 yearsâ&#x20AC;&#x2122; nocturnal treatment with a mandibular advancement splint in adult patients with snoring and OSAS cause a change in the posture of the mandible? American Journal of Orthodontics and Dentofacial Orthopedics 1999;116(6):621-28. 19. Bernhold M, Bondemark L. A magnetic appliance for treatment of snoring patients with and without obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics 1998;113(2):144-55. 20. Marklund M, Franklin KA, Persson M. Orthodontic side-effects of mandibular advancement devices during treatment of snoring and sleep apnoea. Eur J Orthod 2001;23(2):135-44. 21. BAILEY BJ. Problematic Snoring and Sleep Apnea: The Place for Surgery. Arch Otolaryngol 1984;110(8):491-92. 22. Leach J, Olson J, Hermann J, Manning S. Polysomnographic and Clinical Findings in Children With Obstructive Sleep Apnea. Arch Otolaryngol Head Neck Surg 1992;118(7):741-44. 23. Stewart MG, Glaze DG, Friedman EM, Smith EOB, Bautista M. Quality of Life and Sleep Study Findings After Adenotonsillectomy in Children With Obstructive Sleep Apnea. Arch Otolaryngol Head Neck Surg 2005;131(4):308-14. 24. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for Treatment of Obstructive Sleep Apnea in Children. Arch Otolaryngol Head Neck Surg 1995;121(5):525-30.


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A.W.A.K.E. Support Group for Patients With Sleep Apnea A Win, Win for Dental Sleep Professionals By Gy Yatros, DMD

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.W.A.K.E. groups are a great opportunity to promote your dental sleep practice in your community. These programs are designed to be a support group for patients with sleep apnea. The coordinators for these meetings are usually eager to find speakers for these get togethers. The meetings are very informal so don’t be afraid to get involved. Typically you will be asked to give an overview of dental sleep medicine and then have Attendees experience frustration some time due to lack of success with their answering current treatment - they truly questions want help for their problem. from the group. I have found the participants of these meetings to be some of the best patients and referral sources in our practice. These people are taking their time to attend because they truly want help for their problem. Many times they are experiencing frustrations and lack of success with their current treatment. Often this meeting is their first exposure to the alternative of dental sleep devices for their apnea. It is rewarding to give hope to someone who felt like they were losing the battle with their affliction. Getting involved with the A.W.A.K.E groups also is great for networking. Even if you don’t want to speak at your first meeting they will gladly have you attend. Generally there are many health care professionals present, including physicians, CPAP company representatives, nutritionists, and others

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involved in the treatment of sleep apnea. This is a great opportunity to meet and educate the other health care providers in your community. If you have a couple of extra hours then please get involved in these groups. It is truly a win/win/win situation for you, the patients, and the health care community. • The ASAA A.W.A.K.E. Network is composed of hundreds of mutual-help support groups in nearly all 50 states for people affected by sleep apnea. The Network, founded in 1988, is an integral part of the American Sleep Apnea Association (ASAA) and since 1990, the two have been partners in assisting patients, their families, and the healthcare community concerned with sleep apnea. Committed to the belief that the ASAA A.W.A.K.E. Network must be patient-centered, local A.W.A.K.E. members plan and implement each group’s activities so that they meet the needs of each individual group. Meetings, led by the A.W.A.K.E. coordinator, are held regularly and guest speakers are often invited to address the group. Topics may include advice on complying with CPAP therapy, legal issues affecting those with sleep apnea, weight loss, and new research findings. To hear more of Dr Yatros lectures visit: www.sleepseminars.com


Whoâ&#x20AC;&#x2122;s Looking at Our Kids? Did you know that more than 3% of children suffer from sleep apnea and more than 10% suffer from snoring?

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hen we look at our children, do we typically evaluate them for obstructive sleep apnea? Is snoring in children just noisy breathing? Are we misdiagnosing and mis-medicating our children? It is time to start paying more attention to our little ones, and saving them from a life of sleep apnea and many other related disorders. As a society, we are changing, obesity is on the rise and the incidence of adult-type diseases are creeping into our youth. Our medical system is not keeping up with the research, and our children need our awareness now more than ever. It is estimated that upwards of 3% of our children are suffering from obstructive sleep apnea (OSA), and the incidence appears to be on the rise. This may be attributed to the reduction in the number of adenotonsillectomies in children or possibly the prevalence of obesity and general ill-health.[2] For a look into what causes OSA in children, an article from the International Journal of Pediatric Otorhinolaryngology states that all obstructive sleep apneas in children are pathological in nature. The definition of OSAS in adults is not valid for children. Children snore when their upper airways are too narrow, with lower than usual negative pressures. Children who snore are usually suffering from adentonsillar hypertrophy. In adults, the most common anatomy that contributes to snoring is the soft palate and the uvula.

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By Shandra Cipriano Snoring in children may not be as loud as adults, due to the volume of the muscles and lungs. The most prominent symptom that is usually paired have a very serious effect on the childâ&#x20AC;&#x2122;s with pediatric snoring is mouth breathing; intellect and behavior. These symptoms this posture may in the long run, cause have frequently been misdiagnosed as abnormal development of the maxilla and [1] attention deficit hyperactivity disorder the mandible. (ADHD). Recent studies have shown that Snoring is only one telltale symptom, chronic poor sleep results in difficulty children with OSA may also appear with focused attention, low threshold to to be very express negative emotion, irritability, restless during easy frustration and difficulty modulating the night, impulses and emotion.[5] Parents usually frequently identify their children with ADD as changing poor or restless sleepers. Children who sleep positions have been diagnosed with ADD wake to those up more often than their peers and poor promoting sleep is a common feature of ADD airway that can be made worse with the use of patency and hyperextending stimulant medications such as Ritalin and Dexadrine.[5] In essence, we are the neck. [3] medicating our sleepy children into a Nocturnal state of excitement, then asking them to enuresis, sleep fall asleep as usual. We are setting these walking, loud gasping respirations, and children up for years of confusion and paradoxical chest movements may also be failure. typical for a child. Recently, researchers have been able to During the day, the most common predict prevalence of ADHD in the basis symptoms reported are mouth breathing, of sleep patterns alone with a success frequent respiratory tract infections, rate of 70%. This is extremely important recurring ear infections, hearing and information when one considers that a lack speech problems, as well as a myriad of sleep alone can of behavioral disturbances. If sleep apnea is diagnosed and treated induce symptoms of ADHD in Children may adequately in early childhood, most normal adults.[4] suffer from children will be cured. What this means poor school is that there is performance, such a strong correlation between sleep daytime sleepiness, hyperactivity and and ADHD symptomology, that we can inattentiveness. These symptoms have actually start improving the behavior of been shown to be reversible, once the OSA these children simply by addressing their has been treated. sleep habits. Children with sleep apnea do not get How much sleep do children really sound sleep, they are also receiving less need? Each child is different, however, in oxygen to the brain a night; this can


general from about age 2-5, children need an average of 12 hours of sleep per night, some will even benefit from a nap during the day; school age children, age 6-12, need about 10 hours of sleep; teens and preteens need about 9 hours of sleep. [5] There is also new research that suggests that OSA may lay the groundwork for serious long term health problems such as high blood pressure and heart disease that do not generally show up until adulthood. Researchers believe that sleep apnea may hasten the development of these conditions by promoting a systemic, inflammatory response that causes changes in the blood vessels and the regulation of blood pressure.[2] What does this mean to us? We are responsible for asking the right questions. As dentists, you may see these children as much or more than any other physician in their lives. You can make the difference in a child’s life by simply asking the parents a few simple questions while they are in your office. You will identify the possibility of a sleep disordered breathing issue and progress into a full examination if needed.

• Does your child seem tired or irritable during the day? • Does your child have difficulty staying awake? • Does your child have trouble paying attention at home or school? • Does your child have frequent emotional outbursts?

A physical evaluation can be performed when the answers to these questions suggest sleep disordered breathing. A physical assessment should include an evaluation of the child’s growth pattern children with OSA are frequently reported to have delayed growth and impaired weight gain.[3]

Other physical observations should include:

• Mouth breathing? • Hypertrophied tonsillar and adeniod tissue? • Hyponasal voice? (Can be indicitive of nasal obstructions) • Retrognathia, micrognathia or midfacial hypoplasia?

• Tongue size? • Narrow arch? • Dark circles under the eyes? • Forward head posture?

Once predisposing factors are identified, treatment of OSA in children can involve several modalities. Since the most common cause of OSA in children is tonsillar hypertrophy, the most common treatment is adenotonsillectomy. The use of CPAP or BiPAP have been shown to be effective, however compliance may be an issue due to inconvenience and discomfort.[2] Arch expansion, using functional orthodontics is also a very common and effective mode of therapy for children with OSA . If sleep apnea is diagnosed and treated adequately in early childhood, most children will be cured. Some children may experience a return of symptoms during their physical development, but there will still be an opportunity for improvement once again and for normal development if sufficient treatment is

given early enough.[1] Moral of the story? Start today by screening the children in your office, you will save the lives of our future. Works Cited: 1. Baisch, Alexander, Sadik, Haneen. Obstructive Sleep Apnea and Snoring in Children, International Journal of Pediatric Otorhinolaryngology(2009) 2. Kuppersmith, Ronald, MD. Pediatric Obstructive Sleep Apnea, Baylor College of Medicine, Department of Otolaryngology-Head and Neck Surgery (1996) 3. Muzumdar, Hiren, Arens, Raana. Diagnostic Issues in Pediatric Obstructive Sleep Apnea, Division of Respiratory and Sleep Medicine, Children’s Hospital at Montefiore, Albert Einstein College of Medicine (2007) 4.Gruber, Robert. Instability of Sleep Patterns in Children with Attention Deficit/Hyperactivity Disorder, Journal of the American Academy of Child and

Adolescent Psychiatry (2000) 5. Green, Alan MD FAAP, Sleep Deprivation and ADHD (1997) 6. Monhan, KJ, Rosen, CL, Utility of Non-invasive Pharyngometry in Epidemiologic Studies of Childhood Sleep Disordered Breathing, American Journal of Respiratory of Critical Care Medicine (2002)

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Confirming Nasal Airway Patency Observed on Panoramic and Posterior-Anterior Cephalometric Radiographs Using An Acoustic Rhinometer By Jorge Landa, DMD, Alfred Rich, DMD, and Matthew Finkelman, PhD of Tufts University

T

his study aims to confirm the nasal airway patency observed in standard dental radiographs through analysis of the anterior nasal cross-sectional area and nasal volume with acoustic rhinometry. Method: Participants were chosen from the patient population under consideration for interceptive orthodontic treatment at Tufts University’s Pediatric Dentistry Clinic. A total of 55 Caucasian subjects, of both sexes (males=28, females=27), and ranging from age 6-9 years (mean= 7.33) were enrolled. Utilizing the Image J program, the subjects’ panoramic and PA cephalometric radiographs were analyzed for radiolucent anterior nasal cross-sectional area. The subjects were then examined with the Eccovision Acoustic Rhinometer, which measured anterior nasal crosssectional area and nasal volume. The data were grouped together, and the areas and volume gathered from the radiographs and rhinometer were analyzed for any correlation. The statistical analysis was performed using the SPSS program. The data was further divided into right and left nasal side, and a Pearson Correlation Matrix was created for 8 predictor variables (right and left panoramic area, right and left cephalometric area, right and

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left rhinometer area, and right and left rhinometer volume). Results: Values in this correlation matrix ranged from 0.712 to 0.988; all were statistically significant at the 0.01 level (2-tailed test). Conclusion: A very strong

correlation was found between the anterior nasal cross-sectional area calculated from the radiographs, and the anterior nasal cross-sectional area and nasal volume from the rhinometer. Background and Rationale Dimensional changes of the oromaxillary structures in conjunction with airway obstruction can best be explained by Moss’ functional matrix theory. The theory established that bones grow in response to the functions of the surrounding soft tissue and spaces.12 Subtelny also noted that maxillary

intermolar width was narrower in the mouth breathers and was associated with a higher prevalence of posterior cross-bite.19 Muscular pressure exerted during prolonged mouth breathing, resulting from nasal airway obstruction, can affect occlusion and interarch relationship by altering growth patterns. Ozbek’s research also described an association between dental malocclusions, vertical growth, and obstruction of the upper airway.13 Throughout Marks’ studies, children with open mouth postures resulting from chronic allergies, demonstrated structural changes including high palatal arches and nasal septum deviance.10 The appearance of nasal septum deviations occurs in 60% of children and 80% of adults. They can occur from trauma to the nose at an early age or during complicated birth. The deviated septums are key contributors to upper airway obstruction and to malformations of the maxilla.18 According to Scott’s Nasal Septal Growth Theory; the expansion of the cartilage in the nasal septum provides a source for the physical force that displaces the whole maxilla in an anterior and inferior direction. This sets up fields of tension in all the maxillary sutures. The bones then secondarily, but


virtually simultaneously enlarge at their sutures in response to the tension created by the displacement process. If we apply Scott’s theory to a patient with a deviated septum, it is justified to correlate the septal deformity with subsequent maxillary malformation.22,23 Chronic obstruction of the nasal cavity is a prevalent problem that presents with multiple causes. The conditions that predispose patients to nasal obstruction can pose challenges to the health care providers in charge of treating the patient. The most common causes of upper airway obstruction include nasal polyps, enlarged lymphoid tissue around Waldeyer’s ring, mucosal swelling, and abnormalities of the septum all commonly associated with hyperplastic adenoids or allergic rhinitis. 21 Sassouni showed that children with allergic rhinitis had large lower face heights and steep mandibular angles leading to a characteristic long and narrow face with midface deficiency.15 Chronic allergic rhinitis can cause structural changes at the cellular level that manifest as hypertrophy of the lining of the nose. The normal ciliated columnar epithelium diminishes as mucus accumulates, clogging the epithelium, and damaging the cilia further with bacteria and viruses. The hypertrophic response of nasal tissue leads to reduced airway patency from obstructed nasal passages.17 The resultant altered breathing mode has been shown to change dental and facial “normal” growth.4, 9 Another negative sequela to mouth breathing is an increase in the child’s cavity potential now and throughout their lifetime.16 Trask studied siblings who suffered from rhinitis and compared them to a set of siblings who did not have airway complications. He found the rhinitis sufferers had an increase in palatal height, a smaller angle between the mandibular plane and the mandibular incisors, increased

overjet, retrognathic mandibles, and increased lower facial height.20 In Linder-Aronson’s published report, he noted that mouth-breathers with prolonged airway obstruction exhibited cross-bites, narrow upper arches, long upper lip, and shorter mandibular arch length.8 Malocclusions are either hereditary, functional, or a combination of both. Parents pass down certain skeletal and dental characteristics to their children through genetics. It is also well documented that abnormal functions, such as airway obstructions, thumb sucking habits, or chronic allergies can lead to mouth breathing. The open mouth postures adopted through this abnormal manner of breathing can alter the way in which teeth and faces grow. In patients who are still growing, obstruction of the upper airway can lead to excessive vertical facial growth, dental malformations, and aberrant oromaxillary development.1,17 Children between the ages of 6-9 years are particularly vulnerable to oromaxillary changes associated with existing or evolving nasal airway complications. These patients are prime candidates for growth modification via interceptive orthodontic appliances. Further investigation is needed to determine the impact of growth modification through orthodontics on nasal airway obstruction. Regardless, a successful case must begin with accurate documentation of the dental

and medical history. Resolution and post-treatment retention can only be achieved if the clinician treats the primary etiology of the malocclusion as well as the airway obstruction. It is possible that children who undergo correction of malocclusions with appliances such as braces or palatal expansion, yet have continued airway obstruction, will have higher rates of dental relapse after their orthodontic treatment is complete.3 Therefore, in the process of diagnosing and correcting the dental malocclusion, the airway status is of keen interest to pediatric dentistry. A valid visualization and evaluation of the nasal airway, turbinates and nasal septum, can be performed through routine examination at the dental office via panoramic radiographs. Analyzing PA cephalometric radiographs, commonly recorded at the onset of orthodontic record keeping, can enhance further diagnosis.7 According to a recent study by Corey et al, the acoustic rhinometer has shown reliability in noting changes in the dimensions of the nasal cavity in post-surgical cases.2 The rhinometer can be used, when available, to document nasal cavity dimensions pre- and post-orthodontic treatment in the developing child. The dentist can properly treat a child with nasal airway obstruction and subsequent dental malocclusions by working closely with the patient’s pediatrician and an otolaryngologist. A thorough medical questionnaire WWW.SLEEPGS.COM

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and clinical examination is important to understand the etiology of the problem. An accurate referral to the ear nose and throat specialist should include diagnostic information that is readily available to dentists from the standard initial radiographic exam. The cephalometric and panoramic radiographs are very instrumental, but a more objective standard is necessary to establish norms and baselines that limit human error from interpretation. Currently, dentists and orthodontists rely on subjective visual assessment of the airway extraorally, and by analyzing panoramic radiographs and noting apparent structural and anatomical abnormalities. Once again this current modality of analysis lacks a standardized norm and is subject to human error and thus imprecise. While some recent studies have attempted to bridge this knowledge gap, there is a need to investigate a comprehensive diagnostic tool that is non-invasive and can be coupled with standard dental imaging to formulate the best objective assessment possible. This is where we believe the use of the Acoustic Rhinometer by dentists and orthodontists can serve the greatest benefit to their patients. The acoustic rhinometer was developed in 1977, and has been used to measure nasal airflow and volume by the medical profession. Some of the earliest descriptions and applications of rhinometry where provided by Hilberg. Acoustic rhinometry is non-invasive and uses sound waves to calculate the nasal airway5. ImageJ is a public domain Java image-processing program similar to NIH Image. The program, released in 1997, is utilized to calculate statistics, such as area and pixel value, from uploaded images.14 Through the use of the acoustic rhinometer and the standard radiographic images that are taken during the diagnostic process, we

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can bring a better level of care to all children. By augmenting the details of the referral, the dentist can stimulate cooperation with the otolaryngologist and thus affect their willingness to work together on the patientâ&#x20AC;&#x2122;s dental treatment. The combination of information gathered from the assessment of the radiographs and the added information from the acoustic rhinometer results in a more thorough treatment plan that accounts for the airway as a significant influence. The use of acoustic rhinometry as an adjunct to radiographic examination will provide an objective and non-invasive method to assess the nasal volumetric dimensions. The technique is easy to understand and is not imposing on practitioners or patients. The crosssectional area and volume of the nasal cavity can be assessed using the acoustic reflections from sound waves emitted from the rhinometer. The computer generated graph of nasal area versus nasal cavity distance plots waves which correspond to particular anatomical landmarks of the nasal cavity.6 Prior confirmation of the accuracy of these anatomical markers has been confirmed through CT and MRI investigations.5, 11 The previous studies have provided us with adult norms that can be used for comparison with the readings gathered from the acoustic

rhinometer, and a determination can be made as to the patency of the airway. Currently we possess little data on child or adolescent norms, and for this reason continued studies involving the acoustic rhinometer in this age group are indicated. The need for a definitive and noninvasive evaluation tool conventional to the dental exam can be fulfilled by the acoustic rhinometer. This comprehensive evaluation method will be instrumental in making multidisciplinary intervention to correct craniofacial abnormalities and nasal airway obstruction. The purpose of this project is to confirm the nasal airway patency observed in standard dental radiographs by analyzing the anterior nasal cross-sectional area and nasal volume derived from acoustic rhinometry. Determining the airway status of the patient can better aid in the diagnosis and treatment planning of a dental or orthodontic case. Materials and Methods The study was conducted at Tufts University School of Dental Medicine in the Department of Pediatric Dentistry. The patients were selected from the existing patient population, and were identified to have the following strict criteria: Caucasian males or females between the ages of 6-9, must have consent from the parent or guardian, must have panoramic and


PA cephalometric radiographs taken within the previous 30 days before examination, and submit a nasal health questionnaire provided by the examiner. The subject recruitment was limited to Caucasian patients

due to anatomical and dimensional differences in the oromaxillary

complex between ethnic groups and races. Consent was provided only after the guardian was presented with all risks and benefits in a thorough information session. The nasal health questionnaire was used to establish a history of: allergic rhinitis, recent upper respiratory infections (URI), trauma to the head and neck, perceived nasal obstruction, and any surgical or steroidal intervention to a nasal problem. Any patients with a history of using nasal drops or steroids, trauma to the head or face, recent URI, allergic rhinitis, or nasal

operations were grouped under the label Abnormal Airway. The remaining subjects were deemed to have Normal Airways, and grouped as such. Ultimately a total of 55 Caucasian subjects, of both sexes (males=28, females=27), and ranging from age 6-9 years (mean= 7.33) were examined. For each participant, a panoramic and PA cephalometric radiograph was recorded as part of their initial dental and orthodontic exam, and was not taken for the purpose of this study. The initial assessment of the radiographs was purely subjective, and performed by the same examiner for all subjects. The purpose was to gather one examinerâ&#x20AC;&#x2122;s interpretation of the degree of clarity in each anterior nasal area. This clear area is consistent with the radiolucent area in between the nasal septum and the turbinateâ&#x20AC;&#x2122;s as viewed on the panoramic and cephalometric radiographs. Subjects from both groups, abnormal and normal,

were mixed in together to ensure that the examiner was blind to the classification, and the subsequent objective analysis commenced. The ImageJ program was designed by the National Institutes of Health (NIH), and has been recognized as a

useful tool to evaluate radiographic images that require analysis and calculations.14 Image J was used in conjunction with the panoramic and PA cephalometric radiographs to calculate the anterior nasal twodimensional area. The shape of the anterior nasal space (radiolucent area) was outlined by one examiner and the program then determined the area, in terms of pixels (Fig. 3 and 4). The measurement was repeated three times on both left and right nasal regions for each subject, and for each radiographic format. The mean measurement per side per subject was calculated for the panoramic radiographs and separately for the cephalometric radiographs. The mean measurements per subject were then used for statistical analysis. Each subject was evaluated using the Eccovision acoustic rhinometer manufactured by Sleep Group Solutions. The acoustic rhinometer measured the anterior nasal crosssectional area and nasal volume. The anterior end of the inferior turbinate and the nasal valve defines this area; the measurement was recorded in centimeters squared (Fig. 6). This measurement coincides with the anterior nasal area measurement obtained from the panoramic and cephalometric radiographs. The nasal volume, from nasal opening to soft palate, provides additional information about the threedimensional capacity of the nasal airway that is not readily available from analysis of the two dimensional standard radiographs. The external nosepiece was properly fitted, as described by Kamal, with tight yet minimal pressure at the nare opening.6 Vaseline was applied WWW.SLEEPGS.COM

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to the rim of the nosepiece, and it was positioned passively as to not obstruct or deform the nasal opening. The patient was asked to breathe normally through the nose (Fig. 5). The test was then performed as the patient briefly held their breath as instructed by the examiner in the following manner: the patient was asked to take a normal breath through the nose, let some air out, and briefly hold their breath for 1-2 seconds while the data were recorded by the rhinometer.6 These measurements were repeated two times for each nasal side of the patient. The recorded volume (in cubic centimeters) and area (in centimeters squared) was tabulated, and the mean of the acoustic rhinometer readings per subject was calculated for use in the data analysis. The subject data was organized primarily by the responses to the nasal health questionnaire (abnormal and normal). Furthermore, the data were classified using a unique identification number. The means of the rhinometer readings and the ImageJ calculations was also organized for each patient. The statistical analysis was performed

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using the SPSS version 16.0 program. The data were analyzed for left and right radiographic measurements and rhinometer readings (Tables 1 and 2). A Pearson correlation matrix was formulated to investigate the relationship between

the eight co-variants of left and right radiographic calculations and the values provided by the acoustic rhinometer. To ensure validity, the data were compared to the reference values for acoustic rhinometry reported by Straszek et al. for the child population ages 4 to 13.18 The patients and their guardians were informed of the data that were accumulated, and of the role of the

airway with regards to craniofacial development. If needed, a referral to otolaryngologist Dr. Arnold Lee at Tufts Medical Center was provided to the patient. Data and Results

The Normal group had an average rhinometer nasal cross section area of 0.42 cm2 and nasal volume of 3.85 cm3. For this group, the mean panoramic and cephalometric nasal cross sectional area was 20,647.68 and 11,143.38 pixels respectively. The Abnormal group had an average rhinometer nasal cross section area of 0.25 cm2 and nasal volume of 2.26 cm3. For this group, the mean panoramic and cephalometric nasal cross sectional area was 8879.90 and 3851.53 pixels respectively. Tables 1 and 2 also list further data for both groups including ranges and medians. Table 1. Compiled data from the 26 subjects in the Normal Airways group. Normal Airways Table 2. Compiled data from the 29 subjects in the Abnormal Airways group.


A Pearson correlation matrix (table 3) was calculated to assess the strength of the relationship between the left and right rhinometer area, rhinometer volume, cephalometric area, and panoramic area. Values in this correlation matrix ranged from 0.712 to 0.988; all were statistically significant at the 0.01 level using a 2-tailed test. The strongest correlations were observed between left cephalometric area and left panoramic area (Pearson correlation = 0.988), right cephalometric area and right panoramic area (0.988), right rhinometer volume and right panoramic area (0.957), and left rhinometer volume and left panoramic area (0.952). Table 3. Pearson Correlation Matrix (N= 55) **. Correlation is significant at the 0.01 level (2-tailed). Discussion Chronic obstruction of the nasal airway is a common problem for many children. Allergic rhinitis, nasal septum deviation and hypertrophic turbinate mucosa are amongst the many causes for the occluded airways. The relationship between chronic airway obstruction and anomalies in craniofacial development has been well documented by prior studies. The more common presentations are narrow and high palatal vaults, long and slender faces, increased mandibular plane angles, open mouth postures, a variety of crossbites, increased caries and excessive incisor overjet. 1,8,9,10,13,15,16,17,21

The patients with nasal airway

obstructions often present at the dental or orthodontic office to seek treatment for their malocclusions. It is important for the clinician to understand the role of the airway in craniofacial development, and immediately assess the nasal airway status of the patient. The current standard of care for an initial visit at the dental office includes a review of the patientâ&#x20AC;&#x2122;s medical history, comprehensive intraoral and extraoral exam, and a radiographic exam based on age and chief concern. Further evaluation criteria are needed to determine an objective baseline prior to developing a treatment plan and commencing treatment. In some cases, referral to an otolaryngologist is appropriate, and can be facilitated by the presence of sound clinical evidence of nasal problems uncovered during the dental visit. The panoramic and PA cephalometric radiographs commonly recorded at the initial encounter are excellent tools for evaluation of the anterior nasal region (Fig. 1 and 2). The radiolucent area in between the turbinates and the nasal septum represents the patent area of the anterior nasal airway. Hypertrophic turbinate mucosa or septal deviations appear radio-opaque, and ultimately cause the anterior nasal airway space

to appear smaller or occluded. The dental clinician can make a subjective assessment of the patientâ&#x20AC;&#x2122;s nasal airway status after thorough examination of the recorded radiographs. In order to formulate a dental and orthodontic treatment plan that accounts for all the causative factors, an objective measurement of the anterior nasal airway area and volume is highly beneficial to eliminate human errors common to subjective interpretation. The objective measurements serve as a baseline for monitoring changes during and post-treatment, and can lead to a referral to the otolaryngologist for intervention if necessary. The aim of this project was to confirm the nasal airway patency observed in standard dental radiographs, by analyzing the measurements of nasal crosssectional area and nasal volume from the acoustic rhinometer. Our statistical analysis established a strong positive correlation between each pair of measurements. The largest values were observed by correlating the left cephalometric area with the left panoramic area, and the right cephalometric area with the right panoramic area. In the course of analyzing the subjective assessments and all the objective measurements, a data point or statistical divide was identified that distinguishes normal and abnormal nasal airways. The normal airways group had a range of nasal volumes from 2.78cm3 to 4.57cm3, and nasal cross-sectional area ranging from 0.32cm2 to WWW.SLEEPGS.COM

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0.50cm 2. The mean normal nasal volume and mean normal nasal cross-sectional area for 6-9 year old Caucasian subjects in this study were 3.85cm3 and 0.42cm2 respectively. The values are in close agreement with those referenced from Straszek et al. for this population.18 Those values were 0.33cm2 and 3.51cm3 for normal nasal cross-sectional area and nasal volume respectively.18 The abnormal group presented with nasal volumes ranging from 1.54cm3 to 2.68 cm3, and their nasal cross-sectional areas were between 0.12cm2 and 0.34 cm2. The mean abnormal nasal volume and mean abnormal nasal crosssectional area for 6-9 year old Caucasian subjects in our study were 2.26cm3 and 0.25cm2 respectively. This evidence can help the dental clinician identify those patients who have airway abnormalities that need to be addressed before treatment commences if a positive outcome is to be expected. The ImageJ measurement for anterior nasal area observed on panoramic radiographs was 8879.90 pixels for the abnormal group, and 20647.68 pixels for the normal subjects. Additionally, the ImageJ measurements for anterior nasal area observed on PA cephalometric radiographs were 3851.53 pixels for the abnormal group, and 11143.38 pixels for the normal subjects. These reference values can be used in place of the error-prone subjective assessment, and thus add a greater degree of certainty when distinguishing between normal and abnormal nasal airways. The clinical relationship between airway patency and orthodontic retention warrants further investigation. As does the effects of orthodontic treatment on nasal airway obstruction. Having a more profound knowledge about the effect of partially obstructed airways on dental intervention will help us improve our dental care for all children.

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Conclusion A very strong correlation was found between the anterior nasal cross-sectional area calculated from the radiographs, and the anterior nasal cross-sectional area and nasal volume from the rhinometer. The acoustic rhinometer can be a very instrumental and reliable adjunct during the course of treating a dental or orthodontic patient. By noting the nasal health status of the patient in detail before and throughout treatment, the dentist or orthodontist can properly account for the role of the nasal airway in diagnosis, treatment planning, and outcomes assessments, and make a proper referral to the otolaryngologist for treatment if need be. Acknowledgements The authors would like to thank Stanley Alexander, DMD, Chairperson of the Department of Pediatric Dentistry at Tufts University, and Arnold Lee, MD of the Otolaryngology Department at Tufts Medical Center for their guidance and expertise throughout the project. They are grateful to Sleep Group Solutions (SGS) for contributing the acoustic rhinometer. They would also like to thank Dr. Dan Tache and Mr. Rani Ben-David of SGS for their dedicated and professional assistance in all matters related to the acoustic rhinometer. And finally, many thanks to all the residents, faculty, staff, and patients at the Department of Pediatric Dentistry at Tufts University School of Dental Medicine in Boston, Ma for their support and contribution. About The Author Jorge E Landa, DMD is a Pediatric Dentist from South Florida. He graduated from Tufts University School of Dental Medicine in 2007. Dr. Landa completed his specialty training in pediatric dentistry at Tufts University and the Floating Hospital for Children in Boston, Ma. During

his time in residency, Dr. Landa was involved in organizing the dental component of the Tufts Medical Center Cleft Palate Team, and was the recipient of the prestigious Dr. Waldemar Brehm Scholarship in Early Orthodontics. Currently Dr. Landa is in private practice in Boca Raton and Aventura Florida. References 1. Bresolin D., et al. Mouth Breathing in allergic children: its relationship to dentofacial development. American Journal of Orthodontics. 83(4):334-40, 1983 Apr. 2. Corey JP., et al. Clinical applications of acoustic rhinometry (Nose and paranasal sinuses). Current Opinion in Otolaryngology & Head and Neck Surgery. Vol. 10(1): 22-25, 2002 Feb. 3. Grim D.L. Seeing the larger medical picture: airway enhancement for true orthodontic health. Journal of General Orthodontics. 6(3):5-8, 1995 Sep. 4. Shapiro G.G., Shapiro P.A., Nasal airway obstruction and facial development. Clinical Reviews in Allergy and Immunology. Vol. 2 Num. 3, 225-235. 1984. 5. Hilberg O., et al. Acoustic Rhinometry: evaluation of nasal cavity geometry by acoustic reflection. J. Appl. Phsyiol. 1989. 66: 295-303 6. Kamal I. Acoustic Reflectometry of the Nose and Pharynx. Brown Walker Press. 2004. 55-67 7. Kawashima S. Cephalometric comparisons of craniofacial and upper airway structures in young children with obstructive sleep apnea syndrome. Ear, Nose & Throat Journal. 2000 Jul. 8. Linder-Aronson S. The effect of adenoids on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the dentition. Acta Otolaryng Suppl 265:118-123, 1970. 9. LopatienÄ&#x2014; K., Babarskas A. Malocclusion and upper airway obstruction. Medicina. 38(3), 2002 Jan. 10. Marks, M.B. Allergy in relation to orofacial dental deformities in children: A review. Journal of Allergy 36(3):293-301, May-June 1965. 11. Min, Y.G. and Jang, Y.J. Measurements of cross-sectional area of the nasal cavity by acoustic rhinometry and CT scanning. Laryngoscope 105:757-9, 1994 12. Moss, M.L. The functional matrix. In Kraus, B.S. and Riedel, R.A., ed. Vistas in Orthod., Lea and Febiger. Pp. 85-98, 1962. 13. Ozbek M.M, et al. Oropharyngeal airway dimensions and functionalorthopedic treatment in skeletal Class II cases. Angle Orthodontist. 68(4):327-36, 1998 Aug. 14. Rasband W.S., ImageJ, U.S. National Institutes of Health, Bethesda, Maryland, USA, http://rsb.info.nih.gov/ij/, 1997-2006. 15. Sassouni V. et al. The influence of perennial allergic rhinitis on facial type and a pilot study of the effect of allergy management on facial growth patterns. Annals of Allergy 54(6):493-7, June 1985. 16. Stensson M., et al. Oral health in pre-school children with asthma. International Journal of Pediatric Dentistry, Volume 18 Issue 4 Page 243-250, July 2008 17. Smith R.M., Gonzalez C. The relationship between nasal obstruction and craniofacial growth. Pediatric Clinics of North America. 36(6):1423-34, 1989 Dec. 18. Straszek S.P., et al. Reference values for acoustic rhinometry in children from 4 to 13 years old. American Journal of Rhinology. 22, 285-291, 2008 19. Subtelny J.D. Oral respiration: facial maldevelopment and corrective dentofacial orthopedics. Angle Orthodontist. 50(3):147-64, 1980 Jul. 20. Trask G.M. et al. The effects of perennial rhinitis on dental and skeletal development: a comparison of sibling pairs. Amer. J. Orthod. Orthop 92(4):286-293, October 1987. 21. Weider D. Dental malocclusion and upper airway obstruction, an otolaryngologistâ&#x20AC;&#x2122;s perspective. International Journal of Pediatric Otorhinolaryngology. 67(4):323, 2003 Jan. 22. Scott J.H., The growth of the nasal cavities. Acta otolaryng. (Stockh.), 50, 215-223, 1959. 23Scott J.H., The cartilage of the nasal septum. Brit dent. J., 95, 37-43. 1953. 24. Netter F., Atlas of Human Anatomy. Saunders; 3rd edition (October 1, 2002).


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World’s Largest Sleep Diagnostics Company is Created Original Sandman Personnel Reunited Under Embla. by David Baker, President/CEO of Embla Systems

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roomfield, CO—Two of the largest, well-known sleep diagnostic companies in the world have come together today Embla® Systems (Embla), has acquired the Sandman® sleep diagnostic business from Covidien®. The combined entity will be the world’s largest company to focus entirely on sleep diagnostics with close to 1700 customers in the US and 2500 worldwide, offering market leading sleep diagnostic products, support and service. Embla® and Covidien® share similar histories; both started with a small group of dedicated individuals focused on customer service and leading technology solutions. Embla® (formally Flaga) was successful in Europe and well-known

for its research and flexible software applications. Sandman is a market leader in the US and Canadian markets and is recognized as one of the most easy to use and efficient products by sleep technologists. Embla® CEO, David Baker actually helped develop and launch the original Sandman® system, while working for a Canadian company in 1992. “We were incredibly lucky to meet some of the best sleep medicine doctors in North America. These doctors had faith in our team and pointed us in the right direction,” explains Baker. “They taught us the value of customer feedback, the most important concept I’ve learned in this business. Customers are the best source for product

innovation, your best sales people, and the only reason a company can sustain success.” Members of the same team that created Sandman® and helped restructure Embla®, are now working together on Sandman. “There is no question there needs to be a renewed investment in the Sandman® product and technical services,” explains Baker. “We intend to make that investment to create the best sleep diagnostic company in the world”. “We have the right team in place to deliver market leading technology and service to all our customers, both Sandman® and Embla®, and look forward to the opportunity this merger will provide to all.” New innovative technology for a more accurate and easy assessment of sleep.

The History of Embla In 1988, Embla Systems began in Europe under the name Flaga hf, though the company didn’t commence formal operations until 1993. The first employees were hired in 1994 and the first equipment was sold the following year. In 1999, Flaga formed a strategic alliance with US-based ResMed Inc., a company specializing in the development, manufacturing and distribution of therapy devices for sleep disordered breathing. The alliance positioned Flaga and ResMed with a complete product range, offering their customers both sleep diagnostics and associated therapy from one source. In 2002, Flaga acquired another sleep diagnostic firm, Medcare Diagnostics, in order to expand operations into North America. The name of the company was changed to Medcare Flaga. In November 2003, Medcare Flaga shares were listed on the main list of the Iceland Stock Exchange.

In April 2005, a new Flaga Board of Directors hired David Baker as the president of global operations. In 2006, the company changed its name to Embla­­ Systems. It was in the same year that Embla went through a major restructuring, moving the company out of Iceland to a new US headquarters in Denver, Colorado. It also opened new offices in Ottawa, Canada. The focus of the transition was to move the company “closer to our customers”. In mid 2008, in an effort to give itself more operational flexibility, the Flaga Group elected to remove itself from the Iceland Stock Exchange. In late 2008, due to the Icelandic banking crisis, Flaga Board of Directors, in conjunction with the Icelandic Bank, Kaupthing, moved quickly to restructure the company’s finances. The restructuring was complete in early December 2008. Embla is now in the strongest financial condition since its founding in the early 1990’s.

For product information, contact: Sleep Group Solutions

1-866-353-3936 Visit us online: www.sleepgs.com

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For medical professionals outside the field of sleep, understanding the complicated multi-page reports defining sleep is not easy. In fact, although the technology has changed with digital acquisition and elaborate software, the way sleep is defined has remained unchanged for decades. A new innovative method is now available that looks at sleep in a different way. Instead of breaking it up into 30 second epochs and arbitrary events, it looks at the whole continuum from Sleep Onset to Wake and creates an image of “Picture of Sleep” or sleep quality. It does all this using only one EKG signal. Dr. Robert Thomas, MD, a researcher in the Division of Pulmonary, Critical Care and Sleep Medicine at the Beth Israel Deaconess Medical Center (BIDMC) emphasizes that, “While sleep is a brain function, it’s also a full-body state.” CardioPulmonary Coupling (CPC) is a method of sleep analysis that represents “coupling” heart and breathing (rates); the dynamic relationship between breathing and heart rates is translated into a novel graph called a sleep spectrogram. “The CPC method makes it easier for us to distinguish obstructive sleep from central sleep apnea,” Thomas adds. Because central sleep apnea often requires a different type of treatment, such as drugs to modulate breathing control, this distinction is extremely important. CPC is currently available for use with Embla Systems’ RemLogic software platform and can be used with the traditional PSG systems or a portable monitoring device such as the Embletta. CPC can also be used in conjunction with any other system that can export data to the European Data Format (EDF).


A Letter from the President Achieving and maintaining the highest level of customer support in the industry.

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oordinating the merger of two of the world’s best known sleep diagnostics companies is truly the opportunity of a lifetime. Both systems have large installed bases in the United States. Both systems are well known for their high-end, easy to use PSG software. Sandman® is best known in North America. Embla, on the other hand is actually better known internationally with its “world standard” home sleep testing device, the Embletta®, that has over 1500 users worldwide. Together with the Enterprise™ Sleep Lab Management Software, we have the best combination of diagnostic equipment in the world. There are areas where the two companies compete, but there are many more areas where they compliment one another.

So, how are we going to do it? I have always believed that customer support is the single most important aspect of a successful sleep diagnostic company. As sleep medicine continues to become recognized as an important part of overall health and well being, we will work to provide exemplary support and communication. We will go above and beyond to ensure any previous

shortcomings are corrected, achieving and maintaining the highest level of customer support in the industry. In our new Embla-Sandman organization, we will employ a rejuvenated focus on product and technical support to reignite the passion for excellence, allowing our new organization to grow and flourish. My first task will be to visit with as many customers as I can to gain an understanding of their needs. I hope to discuss and share my vision for our new company at the same time as listening to your ideas and concerns. I also plan to create a “Sleep Diagnostic Forum” made up of Sandman and Embla customers. The objective of this forum will be to discuss how we move forward with three software platforms (Rembrandt™, RemLogic™ and Sandman®), two amplifier product lines, and the Enterprise Sleep Lab Management System. I believe we can achieve all this without major disruption to our customers. From a practical perspective we will quickly initiate cross training between the two technical support teams. This will ensure consistency and the effective transfer of intellectual equity. We will move quickly to make Sandman software compatible with new Embla PSG amplifiers in development. We

The History of Sandman In 1992, Melville Shipping was an Ottawa-based company that specialized in designing icebreakers. Apart from ship design, the company was also involved heavily in arctic ship research and ran numerous model tests on ships to evaluate the influence of ship size and shape on ice breaking performance. The research included a data collection and analysis system that was used to measure ship performance in ice and then correlate that to the performance of a model of the same ship in a model testing basin. A casual relationship with a sleep scientist in a local hospital brought the company to the healthcare market. The sleep scientist needed a flexible and powerful data acquisition system that would replace his existing paper system. Employing imagination and out of the box thinking, company engineers modified the ship data collection system

to measure sleep. The “fast” channels, such as propeller RPM and torque, were converted to EEG; the “slow” channels, such as ship motions (eg, roll pitch and heave), were converted to body position, saturation and respiration. Within a few weeks the hospital had a functional sleep digital data acquisition package. Melville Shipping saw the opportunity in the sleep market and created Melville Software. They continued to work on the “Sandman” software. In 1993, the Sandman system was released in the United States. Melville Software Ltd., was purchased by Nellcor in August 1995, amalgamated with Aequitron in 1997, purchased by Mallinckrodt in 1998, and purchased by Tyco Healthcare in 2000. In 2007, Tyco Healthcare became Covidien.

“We were incredibly lucky to meet some of the best sleep medicine doctors in North America. . . they taught us the value of customer feedback.” will also be working to integrate the Enterprise Sleep Lab Management System. with Sandman for a seamless lab management operation. In the near future, you will start to see an investment in support and an increase in communication from us. There will be challenges along the way, but I want to personally assure you, our customer, that I will do everything in my power to minimize negative impact on your business. We’re looking forward to seeing you all and we are already planning a big “Hard Rock” celebration at Sleep 2010 in San Antonio, TX! When I started Sandman I was the salesman, technical support manager and designer. Back then I was a phone call away – I still am, if you have any questions or concerns, I can be reached on my cell phone at 480-236-4705 or via email at David.Baker@Embla.com. Reducing the cost per patient study is the only true benefit. The business of running a sleep lab entails far more than collecting patient data. Over the last two decades the sleep diagnostic industry has focused on efficiency, accuracy and technology. Many sleep diagnostic vendors continue to develop PSG systems with features such as multi-colored graphs, semi-wireless capabilities, and an array of customizable options. In reality, while these may be “nice to have” few of these features have true benefit for today’s sleep lab because none of them change the reimbursement that can be charged for a sleep study. In fact, almost regardless of the proprietary system used, reimbursement is the same; therefore achieving the same quality of patient care, but reducing the cost per patient study is the only true benefit. The Enterprise Sleep Lab Management System, which interfaces with any PSG system, allows sleep labs to streamline workflow and optimize efficiency. The system allows sleep labs to move toward a paperless system; aids in completing accreditation documentation for their labs; and helps sleep professionals to run more efficiently. Talk to your Embla or Sandman sales specialist about how to go paperless today! Embla’s most valuable products is its industry experienced, high quality, responsive and reliable technical support team. Embla Systems’ vision and mission is to be

“Closer to the Customer”. WWW.SLEEPGS.COM

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patientcase

TMD, Fibromyalgia, Bipolar Depression & Undiagnosed Obstructive Sleep Apnea. By Dan Taché, DMD INTRODUCTION It is not unusual for the General Dentist or certainly, a dentist who seeks referrals of patients with TMJ and Orofacial pain problems, to see “Fibromyalgia” (FMS) listed in the past medical history part of the intake form. FMS is one of several syndromes considered part of what is currently termed The Functional Somatic Syndromes among which are included but not limited to: Chronic Fatigue Syndrome (CFS), Fibromyalgia (FMS), Irritable Bowel Syndrome (IBS), migraine/tension-type headaches, and Temporo-Mandibular Disorders (TMD).2 There is also a high prevalence of psychiatric and neurocognitive comorbidities overlapping with most of the aforementioned syndromes and depression, is perhaps the most common shared symptom within this subcategory.3 The diagnosis of fibromyalgia often unfairly and inaccurately prejudices the clinician into believing that the patients’ symptoms might be psychiatric or stress-related in nature. Being so biased is NOT evidence-based and may be an opportunity lost to add meaningfully to the long-term health of the presenting patient.4 It is useful to recall that the TMD/ FMS patient should be viewed as a biopsychosocial entity with multiple interacting variables and issues of sleep should be considered in the development of a differential diagnosis and treatment plan.

FIBROMYALGIA: BACKGROUND In 1990 The American College of Rheumatology (ACR), in the Criteria for the Classification of Fibromyalgia, defined such patients as having “chronic widespread pain” which must be present for at least 3 months”

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with tenderness of definable “tender points” located in the neck, trunk and extremities. Applying the criteria established by the ACR for the diagnosis of FMS, we find the prevalence in the United States to be break down as follows: 0.5% for men and 3.4% for women. The prevalence of FMS increases with the age of this population. The FMS patient, when offered treatment directed towards reducing peripheral nociception and inflammation, will often display a temporary or equivocal response to such treatment strategies. Because a well-defined etiologic explanation had not yet been revealed, there has been a tendency for most clinicians to dispel the seriousness of such a patient’s impairment. This was true, perhaps, because most researchers were looking for a peripheral explanation for the syndrome which had not proven productive. However, in 1989, Yunus conducted the first blinded, controlled study of skeletal muscle biopsy showing normal results.5 This research was repeated with similar results which helped further to dispel the concept of FMS as a peripheral pain problem but moreover to view it as a continuum of related, centrally-mediated phenomenon. This research was repeated with similar results which helped to dispel the concept of FMS as a peripheral pain problem but moreover to view it as a continuum of related, centrally-mediated phenomenon. There soon emerged a number of evidenced-based studies providing additional evidence which advanced the new paradigm of central sensitization through the mechanism of temporal summation. The recognition that FMS is likely a Central Sensitivity or Sensitization Syndrome6,7 an expression of dysregulation of the CNS is important.

Although the subjective and clinical manifestations may have origins in or be perpetuated by peripheral nociception it is generally considered “central” phenomenon.7-16 This paved the way for a further broadening of the understanding of the etiology of FMS when interest was redirected towards a better understanding of complaints of fatigue and sleep disturbance so common to patients with FMS.9,17,18 A landmark study published by Moldofsky and Smythe in 1975 was the first to describe alpha-delta sleep as a possible marker for fibromyalgia, but moreover, that “fibrositis complex” might be a consequence of non-restorative sleep syndrome. The results of this study, along with recent treatment outcome data on sleep interventions, suggest that sleep should be a primary intervention target for people with FM.19 FIBROMYALGIA and SLEEP. It widely recognized that complaints of sleep disturbance are highly prevalent among patients with FMS. The ACR criteria for the classification of fibromyalgia identify the presence of sleep disturbances in excess of 73% of patients.20 It is noteworthy, that of all of the symptoms associated with FMS which compel patients to seek treatment, are those which are sleep-related, fatigue being the most common.21 In an important contribution in 2007, Drs. Lineberger, Means,and Edinger, in an article entitled “Sleep Disturbance in Fibromyalgia” uphold the notion that “… it seems reasonable to speculate that sleep disturbance is mechanistically important to the etiology or symptom maintenance of the FM syndrome.” and “of all FM symptoms, sleep disturbance is among


the more common, and perhaps more etiologically significant.”22 Heretofore, FMS is largely considered a chronic pain condition and that the nonrestorative sleep has been characterized as a result of the FMS however, the concept of an etiologic role of sleep quality and sleep duration might play a causative factor intrigues many. FMS and the consequences of sleep disorders, share an interestingly similar litany of subjective complaints. An increasing number of studies showing strong correlation between fatigue, FMS, and Sleep Disordered Breathing (SDB) have emerged. Gold et al, in a descriptive study of 14 consecutive female patients diagnosed with fibromyalgia, were treated with nasal CPAP resulting in an improvement in functional symptoms ranging from 23% to 47%23; others have made similar observation.24 It is long appreciated that the physiological and neurocognitive consequences of SDB have very similar clinical manifestations which include: non-restorative sleep, fatigue, morning headache, lack of concentration, decline in libido, and mood disorders of anxiety and depression.24-28 Some studies have shown the prevalence of Upper Airway Resistance Syndrome (UARS) and Obstructive Sleep Apnea (OSA) in the FMS patient in excess of 70%.23,29 Considering the oftentimes discouraging and/or unremarkable results of our efforts to treat FMS, these findings beg the question: Could FMS be a manifestation of SDB?30 CASE STUDY: TMD, FIBROMYALGIA, BI-POLAR DEPRESSION, AND UNDIAGNOSED OBSTRUCTIVE SLEEP APNEA

Figure 1

This is SJ (Figure 1), a very pleasant 55 y.o. housewife who was referred to our

office in January of 2005. Her Chief Complaints (CC): 1. Jaw joint clicking 2. Fibromyalgia (arthritis/depression/ widespread pain/poor sleep quality/ fatigue): 25+ years 3. Awakens nearly daily with “terrible daily migraines” (bi-temporal) 4. Jaw soreness, most often associated with the migraines 5. Jaw clenching; she often finds herself awakening with her teeth clamped together and finds herself clenching during the day as well30 6. Poor sleep quality; frequently awakening with headaches and heartburn 7. Ear ringing 8. Bi-Polar Disorder31

examination she was taking Lexapro (20mg) and Wellbutrin XL (300 mg). Migraines: she has taken Endocet (7.5/325) for prevention for a number of years, and recently was prescribed Relpax which was helping somewhat; gabapentin was prescribed for both her pain and depression but made her feel more depressed. Amidrine, an OTC medication for headaches and fever also provides some relief in the past. Heartburn: Omeprazole (20mg) for her “heartburn” which became a problem shortly after she began awakening with her “migraines”. She related that although her migraine medications help at times, she continues to awaken nearly every day with headache, often quite severe.

PAIN DIAGRAMS (HEAD and NECK): (Figure 2: taken from patients’ pain diagram).

HISTORY OF PRESENT ILLNESS In addition to her jaw joint noises which are both new and alarming, she also finds it embarrassing when she is in public eating out. This new problem emerges at a time when she experiencing an escalation of her headaches and depression and these problems seem to be increasingly less responsive to both her migraine and depression medications. She is awakening more frequently both from sleep and upon awakening with “migraine” headaches. She denied aphasia, exertional pain, loss of consciousness, numbness and past brain imaging had been unremarkable32.

Figure 2

PAST MEDICAL HISTORY: Briefly, SJ has been under the care of several physicians for migraine and Bipolar depression for a number of years. Her protracted history of depression, widespread pain, anxiety, fatigue, and migraines are consistent with a diagnosis of Fibromyalgia Syndrome (FMS). She has had increasing problems with managing her thyroid function. Most recently, she has seen a corresponding increase in headaches as the depth of her depression intensified; she was referred to a psychiatrist who suspects that she may have “Bi-Polar Depression”. She is also concerned because she now often awakens with a “splitting headache” and notices that she has her teeth “clenched both during the night and during the day”. SJ reports that a sleep study was performed 6 years earlier was considered “normal”. MEDICATIONS Depression: At the time of her

CLINICAL EXAMINATION Blood Pressure/Pulse: 130/78/90 BMI: 27 Soft Tissue Exam: Malampatti Score: IV, Tongue Level: High, postured above occlusal plane of the teeth Range of Motion: Cervical, very restricted but with a soft end-feel; rotation, side-bending, flexion, extension are all markedly reduced by approximately 80%; hyoid crepitation is normal; moderate to severe forward head posture Mandibular: Maximum opening=47mm, Right lateral=10mm, Left lateral=10mm; no deviation or deflection of the mandible; protrusive range of motion=8mm Occlusion: Angle Class I; vertical overlap=2mm; horizontal overlap=2mm; excessive anterior wear with generalized wear facets of many of the teeth Muscle Palpation: the following muscles WWW.SLEEPGS.COM

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were tender to palpation: anterior, middle, and posterior temporalis, masseters (deep/ superficial), right SCM (clavicular/sterna) referred pain towards eye and behind ear when palpated, bilateral lateral pterygoids, bilateral posterior digastrics TM Joint Examination, Clinical & Doppler Auscultation: clinical examination and TM joint sounds suggest bilateral meniscal displacement with reduction; no sounds suggestive of adhesions Radiographs: Panoramic, bilateral TMJ tomograms, lateral cephalometrics radiographs were taken; TM joint films were within normal limits; lateral cephalometrics showed diminished posterior airway space (PAS) which increased with mandibular advancement CLINICAL IMPRESSION 1. Bilateral meniscal displacement with reduction 2. Nocturnal Bruxism 3. Myofascial Pain secondary to nocturnal bruxism 4. Fibromyalgia Syndrome 5. Possible Sleep Disordered Breathing 6. Tension-Type Headaches (TTH)33 My initial impression was that she was experiencing an escalation in her symptoms and degradation in the efficacy of her medications because of a problems associated with her nocturnal bruxism. Her pain was likely due to a combination of arthralgic pain from the meniscal displacement coupled with inflammatory muscle pain (myositis) and referred pain from active myofascial trigger points, namely the lateral pterygoid, masseter, anterior temporalis and posterior digastric muscles. The characteristics of her headaches appeared to be more consistent with a variant of migraine, specifically TensionType Headache which may have explained why medication had not helpful. The term tension-type headache (TTH) is a term (International Headache Society Classification) describing headache with both muscle contraction and psychological factors. Previous terms for TTH were muscle contraction headache, tension headache or psychogenic headache. Although research suggests that TTH is not caused by muscle contraction, it may be associated with pericranial muscle tenderness. The results of her previous

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Polysomongram (PSG) which was reported by SJ as “normal” was suspect and it was suggested that she return for another diagnostic PSG given the abundance of symptoms which seemed to be sleep-related. TREATMENT RENDERED: We provided her with a mandibular orthopedic repositioning appliance (MORA) to unload her TM joints because her greatest concern was the more recent “jaw clicking”, “tooth grinding” and “jaw soreness” all of which would be addressed by the appliance (Fig.3). SJ returned for several visits and reported a significant reduction of her chief complaints but would not return for nearly 2 years.

Figure 3 MORA with anterior repositioning ramp/curtain

2 YEARS LATER: FIBROMYALGIA SJ returned over 2 years later. Since her last visit to our office her depression had become less responsive to medication. Her neurologist had decided that she would undergo electroconvulsive therapy (ECT) to control the depression. ECT is indicated for the treatment of severe Bi-Polar depression and also for depression when accompanied by psychosis, suicidal intent, refusal to eat, mania, and/or schizophrenia which is not improving with medication. SJ reported that despite the ECT that many of her previous pain complaints persisted, most notably the fatigue, pain and depression. SLEEP SJ, acting upon our recommendation had returned for a sleep another sleep evaluation and a diagnostic PSG was again performed. This time, it was discovered that she had severe obstructive sleep apnea (OSA); AHI=61.6,

Table 1 Split Night PSG

Oximetry: mean SaO2: 91.6%/minimum SaO2: 86%. The Summary page of her Polysomongram (PSG) report is provided (Fig.4). Nasal CPAP was successfully applied reducing her AHI to 6.7 however, she reported eventual intolerance to CPAP oftentimes awakening and feeling unrefreshed and was still having headaches and jaw pain upon awakening. The results of the PSG are shown in Table 1. Table 1 shows that SJ has a severe level of OSA. It is noteworthy that during her split-night PSG, that her OSA was not being effectively managed even with her CPAP as evidenced by the residual AHI of 6.7 events/hour. As can be seen in the “CPAP Download” report taken from her AutoPAP download (Figure 4), that she was improved but not without problems. SJ was able to sufficiently reduce her AHI through additional tightening of the interface straps but the discomfort adversely affected her sleep quality probably resulting in increased sleep bruxism, hence her discomfort.

Figure 4 CPAP Download

SJ was told that a Mandibular Repositioning Device (MRD) might provide her with a possible alternative to CPAP therapy and was hopeful that we might be able to help her. ACOUSTIC REFLECTION ASSESSMENT: ACOUSTIC PHARYNGOMETRY (AP) / RHINOMETRY (AR) A clinical examination was performed which included the use of both Acoustic Pharyngometry (AP) and Acoustic Rhinometry (AR). AR and AP are unique Figure 5 Pharyngogram: corre-

sponding anatomical landmarks1


in that they are a real-time, non-invasive assessment which permits the clinician to assess the cross-sectional diameter of both the high upper airway (AR) and the oroand hypopharyngeal airway (AP) at any point along the airway (Fig. 5). Although the patient is awake and erect, the exam is performed at Residual Volume (RV) which is achieved by having the patient expire all available air, thereby placing a negative load on the airway which will mimic airway compliance when the patient is asleep. This information is useful not only in the management of OSA patients but is applicable to screening potential OSA patients as well34-37. In the case of our patient, SJ, the acoustic airway assessment showed that she had an airway which was of normal caliper but very compliant (collapsible). ACOUSTIC PHARYNGOMETRY

Figure 6 Acoustic Pharyngometry: Response to Mandibular Depression and Advancement

We can see from the details of the Pharyngogram (Fig. 6) airway stability is improved with BOTH mandibular advancement AND depression. This was a very favorable finding in view of the severity of the OSA. The circles show the area of the graph denoting the area occupied by the oral cavity. ACOUSTIC RHINOMETRY Assessment of the High Upper Airway, especially when we are dealing with severe levels of apnea, is important. Few if any Dentists are sufficiently trained to perform rhinometric exams, however, the need to be aware if the patient has significant High Upper Airway Resistance (HUAR) can be still critical to successful airway management38-42. The presence of HUAR has been shown to be a risk-factor

Figure 7 Acoustic Rhinometry: Septal Deviation/Turbinate Hypertrophy?

for UARS and OSAS and if untreated may preclude success with CPAP and/ or MRD therapy41,43,44. The AR graph displayed (Fig. 7) strongly suggests the presence of both turbinate hypertrophy and septal deviation (to the right). Note that we did decongest the patient and so no improvement of nasal patency. The inference here is that the obstruction is not likely mucosal due to inflammation but more likely, due to excessive bone deposition/enlargement of the turbinates and/or septal deviation. As a consequence of this finding, SJ was referred to an ENT for evaluation. We often find CPAP-intolerant patients who report an inability to breathe through as one of their chief complaints when delineating why they are having difficulty tolerating CPAP device. Unrecognized and untreated HUAR in the patient who is trying to be CPAP-tolerant will prove to be a significant obstacle simply because the patient cannot breathe through the nose; recall, this is nasal-CPAP. The answer often provided is typically to increase strap tension or an increase in the size of the interface. Larger interfaces can add to problems of claustrophobia and increased leakage because we are attempting to seal a larger surface area. If we are trying to treat a patient with an oral device alone, HUAR adds to the collapsibility of the airway because of the Bernoulli Effect which could frustrate the effectiveness of our therapy. Acoustic Rhinometry, as with pharyngometry, is a cost-effective, noninvasive and user-friendly technology which is available to BOTH Physician and Dentist. MANDIBULAR REPOSITIONING DEVICE THERAPY (MRD) MAD appliances have been shown to be effective in the management mild-moderate OSA45-50 but less so with severe OSA. Given the decreased effectiveness of oral airway appliances when attempting to control more severe levels of OSA, the decision was made to utilize airway acoustics to take advantage of the potentially favorable 3-dimensional repositioning as suggested by the initial AR assessment. (Fig. 6) Before we proceeded, SJ was informed of the guarded prognosis for a MRD cure because of the severity of her OSA and accepted the possibility that a “hybrid”

approach might be needed. THE AIRWAY BITE (Fig. 11) To potential benefit from a 3-dimensional mandibular repositioning warranted an AR-guided construction bite in lieu of the traditional George Gauge approach; we refer to this as an “Airway Bite”. With insights into how the airway responds, suggesting that we assess compliance changes on both x- and y-axes, we can REPOSITION THE MANDIBLE 3-DIMENSIONALLY for maximum response to the MRD. Specifically, acoustic reflection showed us that she has an unusually large airway (5.97cm2; minimal for females is 2.8cm2) and that if we build both vertical and advancement into her MRD that the airway response is significant, collapsing to a minimum of >3cm2. This is not absolutely predictive but suggestive of a good response. Mandibular advancement ALONE without taking advantage of how vertical displacement of the mandible favorably impacts her airway stability, would be counterintuitive when considering the high level of apnea (AHI=61.6), it is a risk that one should not take. We utilized the Airway Metrics® System which is a graduated “jig” system which incrementally repositions the mandible a specific amount both vertically and anteroposteriorly. The jigs

Pharyngometer Interface Remove Tongue Guide

Standard

Modified

Simulator Mouthpiece Interface

Figure 9 The Airway Metrics™ System was designed to fit the acoustics wave tube mouthpiece

fit easily into the pharyngometry wave tube and allowed us to find the optimal 3-Dimensional position to move the mandible. When we checked airway caliper WWW.SLEEPGS.COM

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and stability, the pharyngometer results suggested that airway compliance had been reduced sufficiently and that the minimal cross-sectional diameter of the airway approached 2cm2; this minimal diameter has been shown clinically to signal a stabilizing airway and we chose to record this 3-Dimensional position and proceed with fabrication of the MAD. Figure 10 is SJ’s Pharyngogram which shows that with the Airway Metrics™ (AM) jig in position, that when a negative load is placed on the airway by having the patient exhale all that he/she can, that the minimum xsec diameter is approaching 2.0 cm2 (red line). Clinically, this often means that the mandibular position is favorably affecting airway stability. This sort of data is very useful at any point in MRD treatment, particularly if advancement is not proving sufficient.

previously discussed with SJ. Shortly after we delivered the device, an ambulatory sleep monitor was provided to determine if respiratory indices had been sufficiently reduced (Table 1). Although the AHI was reduced appreciably (61.6 to 22.2), additional improvement is needed. Recall that our initial assessment showed that the airway would also likely respond to mandibular depression (adding VDO) as well so we decided to modify the TAP3®

Figure 13 Advancement Mechanism Detached and Connected to Plate Below

Table 1 Insufficient reduction of Respiratory Indices; MRD must be modified.

Figure 14 Advancement Mechanism Reattached with Acrylic to Maxillary Splint Component

Figure 12 TAP3® with 5mm VTK™ in place

Figure 10 A minimum xsec diameter of 2cm

2

Using the VTK System™ from Airway Metrics, you can rework the vertical of an MRD post-insertion as you will see. At this time, we fabricate our construction bite with the jig in place and proceed with fabrication of the appliance (Fig. 11). We decided to use the TAP3® appliance. Besides proven efficacy for management of mild-moderate OSA50,

Figure 11 The Airway Construction Bite

this appliance provides excellent options for hybridization if we are unable to sufficiently reduce respiratory indices (AHI) with the MAD alone as was

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by increasing the vertical height which would essentially depress the mandible. To facilitate the process, we employed Airway Metrics VTK™ as shown (Fig. 12). With the key in place, we retested the airway and confirmed that additional stability might be gained with increased vertical (Fig. 6). Resetting the TAP3® advancement mechanism (AM) for additional VDO is a simple procedure which was accomplished quickly in our office as can be seen in the photos below (Figs. 13-15). Note: Both the titration sequences and re-setting of the TAP3® mechanism were performed by auxiliaries and required less than an hour total time. The modified TAP3® (Fig. 15) was inserted but she was initially encouraged to wear the appliance in combination with her AutoPAP until there was some subjective improvement. We are seeing more interest in combination or hybrid therapy in the literature with encouraging results51. She reported a marked reduction in jaw joint noise, migraines, felt far more

refreshed upon awakening, less discomfort from the straps and generally began to experience an overall improvement in her quality of life, particularly the level of her fatigue which is often the predominant complaint of fibromyalgics. SJ did however report that she continued to have problems with her depression despite the rigor of Electroconvulsive Therapy which she had received prior to returning to me for treatment. Emerging evidence suggests that failure to control the OSA prior to

Figure 15 Addition of Vertical Is Complete (bracket);

performing ECT may compromise the success of the ECT52. POST-INSERTION PORTABLE SLEEP MONITORING. Following the vertical titration as described, SJ subjectively felt much improved. Her continued good progress was encouraging so we then


decided to test the efficacy of her TAP3® demonstrated, the TAP3® and most all Finally, a few personal comments alone and the results can be seen in regarding the management of patients who other MADs are easily modified to meet Table 2. The AHI was reduced the demands of such cases. We only need are referred to us for treatment of their considerably from 61.6 events/hr to technological insight to understand how obstructive sleep apnea. When patients 3.3 events/hr. The non-supine AHI the airway might respond. Having these such as SJ, come to us because of their was slightly more elevated as was insights makes the choice of which MAD CPAP-intolerance, as a Dentist, it is the oxygen saturation <90% of TST to use almost irrelevant. important that we take a sober look at just which also remained elevated. Among The case presented here is the what it is exactly that we are being asked other possibilities, this increase in exceptional case but we have many such to do. SPO2<90% TST might suggest that she “exceptions” as you will in your practice For many, these problems are lifemay be developing some central apneas, of Dental Sleep Medicine. Most cases altering and potentially life-threatening regardless; the need for a follow-up of mild-moderate OSA are effectively and because the OSA is not yet managed, PSG is obvious. In the meantime, her managed with MADs because mandibular their health is slowly declining as well. sleep specialist felt that given both the advancement therapy is effective if we Accepting such patients comes with a objective and subjective improvement give our patients time to adjust and for significant responsibility because we are in her condition, it was felt that SJ could the logical extension of the medical system the airway tissues to heal. Adjusting the continue as she was, alternating at her own which has not yet been able to help. In no MAD too quickly, will likely cause painful discretion between combination complications and acute bite therapy or the MRD alone. changes which may discourage However, it was recommended the patient and clinician from that she return for a follow-up additional advancement if the PSG to determine if additional patient continues in treatment at titration might improve the all. oxygen saturation <90%. Current The MAD titration process often literature clearly shows benefit to takes months, not weeks, to fully overnight, real-time titration PSG appreciate the beneficial effects to optimize the efficacy of the of employing these marvelous MRD48,53,54. So the decision to devices. Slow methodical remain with hybrid therapy was advancement and monitoring Table 2 Post-Insertion Portable Monitoring shows significant reduction of AHI from made at the present time. with consistent emphasis on 61.6 to 3.3 events/hr FINAL THOUGHTS: SLEEP and home stretching to reduce PAIN. One of my primary reasons myospasm and bothersome bite for presenting this case is because as a changes will pay good dividends. Patients way is that meant to denigrate the value clinician who treats pain, I too had many can be advanced significantly with of CPAP therapy, however, sadly, many patients with a history of unsuccessful marvelous results if time is allowed. Most people have intolerance to this therapy. attempts at managing their FMS and patients will need to be advanced between Consistent with the AASM Guidelines TMD symptoms. Through a series of 70-80% of maximum protrusion before the for the Management of Obstructive Sleep serendipitous events, I began to become airway will begin to stabilize. Apnea56 we offer them the alternative of aware that sleep disorders may be a Smoking, alcohol at bedtime, and Mandibular Advancement Therapy, “… “missing link” for some of these TMD/ obesity are habits often encountered to sleep-o-sleep-perchance to dream: ay, FMS patients, at least that has been my there’s the rub…” but the “rub” here might when dealing with OSA patients. They experience and more aptly put, that has are significant risk factors for failure and be a bit different than what Hamlet had in been my epiphany. In a recent publication, mind; it is “advancement”. That adjective, realizing success will require frank/honest Sleep and Pain.55 Drs. Lavigne, Sessle, conversation with our patients about these which describes what most of these oral et al, encourage the evaluation of the harmful habits. devices were designed to do, i.e. advance patient for sleep disorders when there is Regarding the severe apneic with the mandible, is sometimes insufficient at any evidence of sleep bruxism, another significant co-morbidities of their medical reducing severe levels of apnea or simply very common complaint amongst our condition, as seen in SJ’s case: it is because of painful side. The advance and FMS30 and TMD patients. This is advice unlikely that she would have succeeded pray approach as I call it, is simply not well worth our consideration. It is my without the use of the insights provided sufficient in light of the seriousness of hope that the reader may too have such an by currently available technology such the problem we are employed to control. awakening to the possibility that disorders Advancement alone is sometimes an as AR. I am not saying that this data is of sleep might be playing a significant PREDICTIVE but is a darned sight better insufficient effort when we are dealing etiologic role in many your pain patients than doing nothing at all. AR is nonwith such a serious medical problem. We as well. It is a possibility that warrants invasive, it is cost-effective because it need not allow the limitations inherent exploration, I can assure you. Our takes seconds for an assessment which can in the design of most Mandibular patients depend upon us to consider ALL be entirely delegated to an auxiliary and Advancement Devices minimize the possibilities. DOES provide data which will enable us options for treatment which we will offer TECHNOLOGY and RESPONSIBILITY to make essential design changes needed to our OSA patients. As has been shown WWW.SLEEPGS.COM

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for such complex cases. At the American Academy of Dental Sleep Medicine meeting in Baltimore, 2008, the opening speaker in her presentation on complications of MAD therapy, very responsibly, addressed the issue of utilizing changes in vertical dimension in order to enhance the efficacy of MAD therapy. Unfortunately, time did not permit the exploration of this aspect of MAD therapy in sufficient detail but kudos to her for broaching the subject. If memory serves me well, I cannot recall that the subject had ever been discussed prior to this presentation. The case of SJ hopefully will pique your interest in considering mandibular depression when you are presented with such cases and advancement alone is proving insufficient. Moreover, when such a case presents in your office where there is a Past Medical History of unsuccessfully managed FMS, consideration of including SDB as part of the Differential Diagnosis might prove a considerable decision. BIBLIOGRAPHY 1. Gelardi M, del Giudice A, Cariti F, Cassano M, Farras A, Fiorella M, et al. Acoustic pharyngometry: clinical and instrumental correlations in sleep disorders. Revista Brasileira de Otorrinolaringologia 2007;73:257-65. 2. Gold AR, Dipalo F, Gold MS, O’Hearn D. The Symptoms and Signs of Upper Airway Resistance Syndrome* A Link to the Functional Somatic Syndromes. Chest 2003;123(1):87-95. 3. Barsky AJ, Borus JF. Functional Somatic Syndromes. Ann Intern Med 1999;130(11):910-21. 4. Stowell AW, Gatchel RJ, Wildenstein L. Cost-effectiveness of treatments for temporomandibular disorders Biopsychosocial intervention versus treatment as usual. J Am Dent Assoc 2007;138(2):202-08. 5. Yunus M, Kalyan-Raman U, Masi A, Aldag J. Electron microscopic studies of muscle biopsy in primary fibromyalgia syndrome: a controlled and blinded study. The Journal of rheumatology 1989;16(1):97. 6. Yunus M. Central sensitivity syndromes: a new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness. Paper presented at, 2008. 7. Yunus MB. Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes. Seminars in Arthritis and Rheumatism 2007;36(6):339-56. 8. Wolfe F. The relation between tender points and fibromyalgia symptom variables: evidence that fibromyalgia is not a discrete disorder in the clinic: Annals of the Rheumatic Diseases; 1997. p. 268-71. 9. Yunus M. Towards a model of pathophysiology of fibromyalgia: aberrant central pain mechanisms with peripheral modulation. The Journal of rheumatology 1992;19(6):846. 10. Vierck C, Staud R, Price D, Cannon R, Mauderli A, Martin A. The effect of maximal exercise on temporal summation of second pain (windup) in patients with fibromyalgia syndrome. Journal of Pain 2001;2(6):334-44. 11. Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative Review: The Pathophysiology of Fibromyalgia. Ann Intern Med

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2007;146(10):726-34. 12. DeSantana JM, Sluka KA. Central mechanisms in the maintenance of chronic widespread noninflammatory muscle pain. Current pain and headache reports 2008;12(5):338-43. 13. Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. The Journal of rheumatology 2005;75(Journal Article):6-21. 14. Perrot S. Fibromyalgia syndrome: a relevant recent construction of an ancient condition? Current opinion in supportive and palliative care 2008;2(2):122-27. 15. Bennett R. Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensory processing in fibromyalgia. Paper presented at, 1999. 16. Bennett RM. Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensory processing in fibromyalgia. Mayo Clinic Proceedings 1999;74(4):385-98. 17. Inanici F, Yunus M. History of fibromyalgia: past to present. Current pain and headache reports 2004;8(5):369-78. 18. Yunus M, Masi A, Calabro J, Miller K, Feigenbaum S. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Paper presented at, 1981. 19. Hamilton NA, Affleck G, Tennen H, Karlson C, Luxton D, Preacher KJ, et al. Fibromyalgia: the role of sleep in affect and in negative event reactivity and recovery. Health psychology : official journal of the Division of Health Psychology, American Psychological Association 2008;27(4):490-97. 20. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The american college of rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis & Rheumatism 1990;33(2):160-72. 21. Lineberger MD, Melanie KM, Jack DE. Sleep Disturbance in Fibromyalgia. 2007;2(1):31-39. 22. Lineberger MD, Means MK, Edinger JD. Sleep Disturbance in Fibromyalgia. Medical Disorders and Sleep 2007;2(1):31-39. 23. Gold AR, Dipalo F, Gold MS, Broderick J. Inspiratory airflow dynamics during sleep in women with fibromyalgia. Sleep 2004;27(3):459-66. 24. Gold AR, Dipalo F, Gold MS, O’Hearn D. The Symptoms and Signs of Upper Airway Resistance Syndrome*. Chest 2003;123(1):87-95. 25. Halbower AC, Ishman SL, McGinley BM. Childhood Obstructive Sleep-Disordered Breathing*. Chest 2007;132(6):2030-41. 26. Guilleminault C, Tilkian A, Dement W. The sleep apnea syndromes. Annual Review of Medicine 1976;27(1):465-84. 27. Millman R, Fogel B, McNamara M, Carlisle C. Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure. J Clin Psychiatry 1989;50(9):348-51. 28. Thase M. Depression, sleep, and antidepressants. The Journal of clinical psychiatry 1998;59:55. 29. Dahan V, Kimoff RJ, Petrof BJ, Benedetti A, Diorio D, Trojan DA. Sleep-disordered breathing in fatigued postpoliomyelitis clinic patients. Archives of Physical Medicine and Rehabilitation 2006;87(10):1352-56. 30. Germanowicz D, Lumertz M, Martinez D, Margarites A. Sleep disordered breathing concomitant with fibromyalgia syndrome. Jornal Brasileiro de Pneumologia 2006;32:333-38. 31. Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M. Association of psychiatric disorders and sleep apnea in a large cohort. SLEEP 2005;28(11):1405-11. 32. Newman L, Lipton R. Emergency department evaluation of headache. Neurologic clinics 1998;16(2):285-303. 33. Dray A. Future pharmacologic management of neuropathic pain. Journal of orofacial pain 2004;18(4):381-85. 34. Kamal I. Acoustic pharyngometry patterns of snoring and obstructive sleep apnea patients. Otolaryngology-Head and Neck Surgery 2004;130(1):58-66. 35. Gozal D, Burnside M. Increased upper airway collapsibility in children with obstructive sleep apnea during wakefulness. American Journal of Respiratory and Critical Care Medicine 2004;169(2):163. 36. Jung D, Cho H, Grunstein R, Yee B. Predictive value of Kushida index and acoustic pharyngometry for the evaluation of upper airway in subjects with or without obstructive sleep apnea. Journal

of Korean medical science 2004;19(5):662-67. 37. Monahan K, Larkin E, Rosen C, Graham G, Redline S. Utility of Noninvasive Pharyngometry in Epidemiologic Studies of Childhood Sleep-disordered Breathing This article has an online data supplement, which is accessible from this issue’s table of contents online at www. atsjournals. org: Am Thoracic Soc; 2002. p. 1499-503. 38. Austin C, Foreman J. Acoustic rhinometry compared with posterior rhinomanometry in the measurement of histamine-and bradykinin-induced changes in nasal airway patency. British journal of clinical pharmacology 1994;37(1):33. 39. Hilberg O, Jackson A, Swift D, Pedersen O. Acoustic rhinometry: evaluation of nasal cavity geometry by acoustic reflection. Journal of applied physiology 1989;66(1):295-303. 40. Silkoff P, Chakravorty S, Chapnik J, Cole P, Zamel N. Reproducibility of acoustic rhinometry and rhinomanometry in normal subjects. American Journal of Rhinology 1999;13(2):131-35. 41. Morris L, Burschtin O, Lebowitz R, Jacobs J, Lee K. Nasal obstruction and sleep-disordered breathing: a study using acoustic rhinometry. American Journal of Rhinology 2005;19(1):33-39. 42. Clement P, Gordts F. Consensus report on acoustic rhinometry and rhinomanometry. Rhinology 2005;43(3):169. 43. Young T, Finn L, Kim H. Nasal obstruction as a risk factor for sleep-disordered breathing. Journal of Allergy and Clinical Immunology 1997;99(2):S757-S62. 44. REDLINE S, TISHLER PETER V, SCHLUCHTER M, AYLOR J, CLARK K, GRAHAM G. Risk Factors for Sleep-disordered Breathing in Children . Associations with Obesity, Race, and Respiratory Problems. Am. J. Respir. Crit. Care Med. 1999;159(5):1527-32. 45. Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Medicine Reviews 2004;8(6):443. 46. Dort LC, Hadjuk E, Remmers JE. Mandibular advancement and obstructive sleep apnoea: a method for determining effective mandibular protrusion. European Respiratory Journal 2006;27(5):1003. 47. Marklund M, Sahlin C, Stenlund H, Persson M, Franklin KA. Mandibular Advancement Device in Patients With Obstructive Sleep Apnea* Long-term Effects on Apnea and Sleep. Chest 2001;120(1):162. 48. Petelle B, Vincent G, Gagnadoux F, Rakotonanahary D, Meyer B, Fleury B. One-Night Mandibular Advancement Titration for Obstructive Sleep Apnea Syndrome. A Pilot Study. American Journal of Respiratory and Critical Care Medicine 2002;165(8):1150. 49. Rose E, Staats R, Virchow C, Jonas I. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnoea. The European Journal of Orthodontics 2002;24(2):191. 50. Pancer J, Al-Faifi S, Al-Faifi M, Hoffstein V. Evaluation of Variable Mandibular Advancement Appliance for Treatment of Snoring and Sleep Apnea*. Chest 1999;116(6):1511. 51. Wojciech T, Frédéric G, Pierre A, Pascal R, Nicole M, Jean-Louis S, et al. Microvascular endothelial function in obstructive sleep apnea: Impact of continuous positive airway pressure and mandibular advancement. Sleep medicine 2009;10(7):746-52. 52. McCall WV, Arias L, Onafuye R, Rosenquist PB. What the Electroconvulsive Therapy Practitioner Needs to Know About Obstructive Sleep Apnea. The Journal of ECT 2009;25(1):50-53 10.1097/ YCT.0b013e31817144a6. 53. Petelle B, Vincent G, Gagnadoux F, Rakotonanahary D, Meyer B, Fleury B. One-Night Mandibular Advancement Titration for Obstructive Sleep Apnea Syndrome . A Pilot Study. Am. J. Respir. Crit. Care Med. 2002;165(8):1150-53. 54. Campbell A, Reynolds G, Trengrove H, Neill A. Mandibular advancement splint titration in obstructive sleep apnoea. Sleep and Breathing 2009;13(2):157-62. 55. Lavigne G, Sessle BJ, Choiniere M, Soja PJ, Scanlon M. Sleep and Pain. Canadian Journal of Anesthesia-Journal Canadien d’Anesthesie 2008;55(3):198. 56. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman Jr J, et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 2006;29(2):240.


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Get Ready! Sleep Group Solutions is establishing sleep study groups around the country.

A

s you may have read in our earlier publications, Sleep Group Solutions is establishing sleep study groups around the country to help you enhance your sleep practices. Not only will adding sleep apnea treatment to your practice increase your bottom line, but it will also enhance your standing with your medical colleagues who treat these patients. Believe me, it won’t take long before your name gets out and the calls begin. Personally, I was very skeptical of the ‘sleep world’ for quite a long time. However, my eyes were opened to it through my TMD and neuromuscular training. As that aspect of

Dentistry is at the forefront of a new time - a time when dentists are diagnosing and treating systemic, chronic disease. my practice grew, I found that the link between occlusion and TMD had a lot of correlations with obstructive sleep

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By Mark Levy, DDS

apnea. What I then learned was that almost 100% of patients diagnosed with obstructive sleep apnea - at any level, were being treated with (or at least prescribed) a C-PAP machine. But I then found that there was a dental sleep medicine field out there so I did my homework, did a lot of continuing education, and met with several sleep physicians before deciding that there really was a need for well trained dentists to be involved in sleep medicine. So, why the need? A recent study from Johns Hopkins University found that men 40-70 years of age with severe sleep apnea were TWICE as likely to die over an 8 year period as their peers who did not suffer from the condition. As you may have learned already, the majority of sleep apnea sufferers (6075%) do not use their C-PAP machines. This is mostly due to discomfort or inconvenience. The issues with poor fitting masks, dry mouths, the noise, etc., leave a majority of sleep apnea patients choosing to NOT use their C-PAP machines. There simply had to be a better solution. Fortunately for sleep apnea patients (and for us), in January of 2006, the American Academy of Sleep Medicine published a paper that stated that mild or moderate obstructive sleep can be treated with an oral appliance and that this should be considered first line therapy. This should have been major news in the dental practice management world, but for some reason, it is only

beginning to seep its way into the dental community - and very slowly at that, but things are changing! For instance, the Ohio State Dental Board Scope of Practice Committee recently responded to an information request stating that:

• Dentists may write orders for a sleep study for a properly screened, atrisk patient. • Dentists may offer patients a home sleep test provided that a board certified sleep specialist interprets the findings. • A dentist treating obstructive sleep apnea with oral appliance therapy is an acceptable practice. Although this truly is a ‘green light’ for some of us, there are some challenges that face dentists who incorporate sleep dentistry into their practice. First of all, most sleep patients consider (and rightly so) that their disease is something that their medical insurance should cover in its entirety. We as dentists have rarely if ever had to deal with medical insurance submissions nor have we dealt with this mind set. In addition, some sleep specialists are reluctant to include us or to recommend oral appliance therapy. We have to be careful not to “step on toes”. It is very important to develop close working


relationships with sleep centers and recognized as the “canary in the sleep physicians. After all, this disease mine”. We now know of the links has traditionally been treated by sleep between periodontal disease and the physicians who run sleep labs and inflammatory response. The link prescribe C- PAP almost exclusively between oral infection and heart disease, as treatment for stroke, and certain patients. These cancers is in the obstacles are news and in the not the least bit minds of the public. insurmountable, Dentistry is at and Sleep Group the forefront of a Solutions is new time - a time prepared to guide us when dentists are through. But with diagnosing and recent statements treating systemic, American Academy of Sleep Medicine positively chronic disease. published. . . “that mild or moderate identifying dentists obstructive sleep can be treated with Dental sleep as legitimate an oral appliance and that this should medicine is a providers of sleep natural response be considered first line therapy”. medicine therapies, to this trend and I see big changes coming our way. incorporating the treatment into your Oral disease is fast becoming practice can have a positive impact on

the health of both your practice and that of your patients. What does this mean for you? You can position yourself to be the frontrunner in your community to treat these patients. The first step is getting the training you need. There are many sources now for training in dental sleep medicine and many excellent support groups. That’s where we can help. Sleep Group Solutions is working to provide support and training to dentists interested in incorporating sleep medicine into their practice. We are organizing and facilitating study groups through out the country with the goal of enhancing dentists’ ability to increase this aspect of their practice. This is an exciting time in the dental world! Contact us to get the name of your closest study group leader.

To hear Dr. Mark Levy lecture REGISTER TODAY FOR THE SLEEP GROUP SOLUTIONS SEMINARS

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patientcase

Oral Appliances For The Treatment Of Obstructive Sleep Apnea Team approach is often necessary. By Robert L. Horchover, DDS

Background: Obstructive sleep apnea (OSA) is a disabling condition, which reduces the sufferer’s ability to work effectively due to somnolence during the day. It can be life threatening, resulting in nocturnal anoxia and cardiac arrythmias. OSA is due to intermittent cessation of airflow at the upper airway level of at least 10 seconds duration. Severe cases may stop breathing for 2-3 minutes. It is a rare condition with a prevalence of up to 4 percent in middle-aged adults. OSA can be due to central apnea where the neural drive is transiently abolished. In obstructive apnea, the neural drive remains but there is occlusion of the oropharyngieal airway. Therapeutic approaches range from weight reduction, improving nasal patency, avoidance of alcohol and sleeping in the supine position and may include surgical procedures to increase the airway space. Continuous positive airway pressure (CPAP) at night is a common therapeutic modality but not always tolerated by the patient. Objective: This essay reviews current practices using airway dilators. Case Study. A 37-year old father of three had tried unsuccessfully to use continuous positive airway pressure (CPAP) for more than three years, followed by palate surgery (uvulopalatopharyngoplasty) which had produced little improvement. He had severe daytime symptoms that caused him to fear for his job, and his obstructive sleep apnea (OSA) disqualified him for life insurance. The patient received a custom oral airway dilator with 1 mm adjustability. He was fitted with a titanium connector, which allows

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adjustments at 1 mm increments in both the anterior and vertical planes. The patient’s apnea-hypopnea index (AHI) was reduced from 48 to 14, as confirmed by overnight polysomnography. Additional fine tuning, amounting to a 1 mm change in the vertical position, was guided by overnight home pulse oximetry. It further reduced the AHI to 2.0. When he provided the polysomnographic confirmation of his 2.0 AHI to his insurance company, his life insurance acceptability status was restored. Nasal continuous positive airway pressure (nCPAP), surgery and oral appliances have been the three most common treatments for OSA, with

CPAP remaining the gold standard. The oral device has recently gained more universal acceptance in the wake of broader clinical experience and evidence based studies of effectiveness. These devices are referred to variously as mandibular advancement devices (MADs), mandibular repositioning devices (MRDs), anterior mandibular positioners (AMPs) and oral airway dilators (OADs). Whatever the name, they all increase the patient’s upper airway cross-sectional area by supporting the mandible in a slightly forward and open position during sleep. Oral Appliances to Treat Sleep Apnea made their appearance about 20 years ago; generally as modified night guards or orthodontic appliances. They were mostly fitted only on the upper teeth in a single, non-adjustable position. Most of them were bulky and often required severe mandibular positioning, tending to compromise comfort and earning them a poor reputation. Little information was available on the anatomical and physiological factors associated with the use of oral devices in managing OSA. Dental school curricula largely ignored this field and an information chasm existed between published dental and medical research on this topic. Although science and materials


were evolving in each profession, it has only been recent that dental and medical researchers and clinicians have begun collaborative efforts. Physicians and Dentists knowledge about treating OSA still spans a broad spectrum and needs improvement. Correspondence to: Dr. Robert Horchover, Sleep Group Solutions, ; E-mail: s1eep911@comcast.net Modes of action of oral airway dilators Oral airway dilators preserve the airway during sleep in a passive manner by reconfiguring the architecture in the oropharyngeal area at the base of tongue. This is in contrast to the constant air pressure supplied by CPAP. The retropalatal and retroglossal areas of the upper airway are the primary sites of obstruction in OSA. When an OAD supports the jaw in an anterior (protruded) and more open position, the tongue is shifted forward and the muscle tone of associated small muscles increases. These changes are preserved during sleep, maintaining an adequate airway for normal breathing1-3. Effective anterior positioning usually varies between 3-8 mm and the vertical opening range is 6-15 mm The entire device fits in the mouth, so it does not influence sleeping positions. It also allows breathing through the nose, mouth or a combination. Oral devices are effective for mild to moderate OSA, and in some cases of severe OSA3-5. Effectiveness is significantly influenced by airway architecture and is very difficult to predict. All effective OADs consist of upper and lower units that grip the teeth and are connected together

in a way that allows some level of adjustment for optimum airway opening while allowing the mandible some freedom in order to minimize the influence of grinding of teeth during sleep (bruxing). The rule of thumb is that a minimum of eight teeth per dental arch is required; however, individual anatomical variables may sometimes allow successful use in patients with edentulous maxillas. Two categories of oral airway dilator Pre-manufactured devices usually involve a single clinical appointment to fit and adapt the device to the patient’s mouth. Short-term devices are more completely premanufactured and require a single clinical fitting and modifying. They usually have an outer rigid shell with a thermal material inside the shell that adapts to the teeth after heating. A two-part putty can also be mixed and placed in the outer shell just before fitting over the teeth. These devices are economical but bulky, less durable and frequently cover the gums adjacent to the teeth, which are not desirable. Their effectiveness is often restricted by their limited adjustability. They generally last for about a year. Custom-fabricated devices require impressions of the teeth and usually a bite registration of the jaw-to-jaw relationship. They are sent to an outside laboratory where a trained technician hand-carves the device in a special wax to fit the teeth more accurately and in contour to

Fig. 1 Custom-fabricated oral airways dilator made of acrylic titanium connectors.

the dental arches before they are processed at high temperature in a dense acrylic. The connectors, usually pre-manufactured medicalgrade titanium or stainless steel, are embedded in the acrylic during the processing period. Custom devices provide more subtle and flexible adjustment increments. They are less bulky, more comfortable, more durable and more effective. They seldom cover any of the adjacent gum tissue. In addition to the laboratory costs, three to seven appointments may be required. Five years’ durability is common, and some show no signs of deterioration at 10 years. The patient’s care of the device and the passive/active nature of facial muscles (e.g., bruxism) during sleep affect any oral device’s longevity. The effectiveness of oral airway dilators (OAD) can compare with CPAP With appropriate patient selection, as in the case described above, opening the airway with an OAD can accomplish a similar goal as CPAP, and the physiological outcomes may also be similar. Research has demonstrated that an effective OAD can reduce blood WWW.SLEEPGS.COM

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pressure, prevent blood oxygen Efficacy must be confirmed by an desaturation and eliminate the more overnight polysomnogram after typical sleep disorder symptoms of final adjustments to the OAD are morning grogginess and daytime completed. Subjective reports of somnolence1-8. Cardiologists improved daytime alertness are have reported reductions in heart not reliable evidence of treatment arrhythmias, and patients have efficacy10. Side effects occur in noted a reduction or elimination of 1-3 percent of patients, and tend to nocturia. be a function of patient tolerance, Oral devices are not for every age, oral habits (bruxing, tongue patient. An adequate evaluation thrusting), device design, initial jaw should include a full medical position and diligence in following examination and polysomnography daily preventive procedures to document sleep apnea severity and and follow-up evaluations. screening for predisposing factors Contraindications for OADs include associated with neck and shoulder insufficient teeth to support the muscles, including mandibular range of motion, occlusion, dentition and the intra-oral anatomy, tongue size and architecture of the oropharyngeal junction. A device may then be selected to best meet the patient’s unique needs. Table 1. Comparison of OSA with CPAP Acoustic reflection pharyngometry can be a valuable tool for measuring OAD, periodontal problems, active upper airway baseline dimension temporomandibular joint disorders and determining whether and how and maximum protrusive distance much mandibular repositioning will less than 6 mm11. 9 enlarge the airway . Each person In a study of 100 unselected seems to have an anterior/vertical polysomnography subjects examined position that produces his or her by maxillofacial surgeons, 31 unique optimum airway. percent had an insufficient number of teeth; 16 percent had periodontal Prescribing the oral airway abnormalities that would require dilators treatment prior to OAD use; and 2 percent had significant Obstructive sleep apnea is a temporomandibular joint disorders11. serious condition and should be Potential problems with OADs may diagnosed by an overnight monitored include the development of occlusal sleep study. Oral airway dilator or skeletal changes. Orthodontists, evaluation and treatment is by in a study of 34 OAD users, reported referral from a physician10. OADs are occlusal changes after a mean a prescription device when indicated. treatment duration of 29 months.

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These patients, using the devices six to eight hours per night for at least five days per week, experienced changes in the anteroposterior position of the molars and in the inclination of the upper and lower incisors12. Complications generally are reversible when identified in the early stages. Long-term efficacy of OADs requires careful follow-up care.

Few data have been published regarding the longterm efficacy of treatment with OADs. A two-year and a four-year follow-up study both emphasize that the efficacy of OADs as well as that compliance may decrease over time. They recommend careful follow-up examinations for adjustments and repair and regular polysomnographic follow-up to ensure longterm efficacy13-15. Repeat polysomnography is advised if the patient gains weight or exhibits a return of excessive daytime sleepiness. In the last 10 years, advances in devices and positive airway pressure machines have greatly improved and given many a despondent patient hope. Insurance coverage for OADs has progressed from denials due to it being “experimental,” to routine processing of claims. The patient profile has also changed. Three years ago there were few patients under 50 years of age, and 80 percent were


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The Airway Metrics System allows you to quickly determine optimum airway positions • Simulate among over 50 mandibular positions - A-P & Vertical • Applicable for all oral devices • Patient placement • Repeatable • Simple Pharyngometry interface • Autoclavable • Connecting fork/handle for bite registration • Accessories for Vertical titration of some devices Snore Screener Manibular Positioning Simulator

The kits are available in three colors for organization of multiple work stations. Please visit www.airwaymetrics.com for complete details & special introductory offers! male. They were referred primarily due to CPAP intolerance. Today the male-female ratio is almost equal and it is common to see patients between 35-40 years with mild to moderate OSA who are otherwise healthy. OADs are very userfriendly, socially acceptable and portable. Public awareness is much higher and patients appear to be more motivated to address their OSA early with a focus on prevention. Conclusions Oral appliances (OADs) are indicated for selected patients with mild to moderate OSA who prefer them to continuous positive pressure (CPAP), or who do not respond to, are not appropriate candidates for CPAP or had failed treatment attempts with CPAP. Until there is higher qualified evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA but OADs are another option17.

References 1. Bian H. Knowledge, opinions, and clinical experience of general practice dentists toward obstructive sleep apnea and oral appliances. Sleep Breath. 2004;8: 85-90. 2. Tsai WH, Vazquez JC, Oshima T, Dort L, Roycroft B, Lowe AA, et al. Remotely controlled mandibular positioner predicts efficacy of oral appliances in sleep apnea. Am J Respir Crit Care Med. 2004;170:366-70. 3. Mehta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med. 2001;163:1457-61. 4. Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy reduces blood pressure in obstructive sleep. apnea: a randomized, controlled trial. Sleep. 2004;27: 93441. 6. Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest. 2004;125: 12701278. 7. Clark GT. Mandibular advancement devices and sleep disordered breathing. Sleep Med Rev. 1998;2:163-74. 8. Krieger J, Kurtz D, Petiau C, Sforza E, Trautmann D. Longterm compliance with CPAP therapy in obstructive sleep apnea patients and in snorers. Sleep. 1996;19:S136-S143. 9. Hoekema A. Efficacy and comorbidity of oral appliances in the treatment of obstructive sleep apneahypopnea: a systematic review and preliminary results of a randomized

trial. Sleep Breath. 2006;10:102-3. 10. Jung DG, Cho HY, Grunstein RR, Yee B. Predictive value of Kushida index and acoustic pharyngometry for the evaluation of upper airway in subjects with or without obstructive sleep apnea. J Korean Med Sci. 2004;19:66267. 11. American Sleep Disorders Association. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Sleep. 1995;18: 511-13. 12. Petit FX, Pepin JL, Bettega G, Sadek H, Raphael B, Levy P. Mandibular advancement devices: rate of contraindications in 100 consecutive obstructive sleep apnea patients. Am J Respir Crit Care Med. 2002;166:27478. 13. Rose EC, Staats R, Virchow C, Jr., Jonas IE. Occlusal and skeletal effects of an oral appliance in the treatment of obstructive sleep apnea. Chest. 2002; 122:871-77. 14. Rose EC, Barthlen GM, Staats R, Jonas IE. Therapeutic efficacy of an oral appliance in the treatment of obstructive sleep apnea: a 2-year follow-up. Am J Orthod Dentofacial Orthop. 2002;121:273-79. 15. Walker-Engstrom ML, Tegelberg A, Wilhelmsson B, Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 2002;121:739-46. 15. Loube DI. Technologic advances in the treatment of obstructive sleep apnea syndrome. Chest. 1999;116: 1426-33.

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Practicing Dentistry Vs. Treating OSA and Snoring Decrease your occupational stress - incorporate dental sleep medicine into your practice. By Gy Yatros, DMD DAY 1 (Operative Dentistry) 10:00 a.m. and I am already a half hour behind schedule. Our interoffice communicator beeps displaying the message “Mr. Reid is getting inpatient!” He was scheduled at 9:30 for an implant impression but I am running late on Mrs. Saindon who proclaims that she is still not numb and the nitrous oxide isn’t working! As I try to finish her crown preparation I can feel the tension building in my neck. My back is already in spasms because I have to literally stand on my head to work on her. She claims “I can’t be laid back” so I am forced to work upside down like an acrobat. I have to fight back the temptation to sarcastically ask “How do you sleep at night in this upright position?” But, as usual, I refrain from making the comment and silently amuse myself at the prospect of actually asking her the absurd question someday. Finally obtaining an acceptable impression on Mrs. Saindon, I am able to sit down to remove Mr. Reid’s healing abutment. It is then that I realize the necessary implant driver is missing. From the sounds of slamming doors echoing down the hallway from the supply room, it is apparent that my assistant is also aware of this dilemma. When she appears in the doorway and asks to see me for a moment, it is obvious that her disorganized and disheveled appearance is not helping Mr. Reid’s dwindling patience. Through a whispered conversation in the hallway, my assistant confirms that the implant driver has once again disappeared. Through much stress and creative engineering involving a pair of hemostats and a slightly modified hex wrench from Ace Hardware, I am able to free the healing abutment. Thankfully we do have the correct impression coping and the impression is successfully obtained just before noon. My thoughts turn to a peaceful and

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rejuvenating lunch but are quickly shattered by the beep of the office communicator. This time it reads “Ms. Reynolds walked in…wants to talk about her crowns.” The sickening, unnerving feeling that just consumed my body was very much an understandable Pavlovian reaction when considering my past experiences with this lady. I spent hours with her over the past months in an attempt to accomplish her esthetic goals. After numerous provisional restorations, refinements, try-ins; after hour phone calls and

remakes, her restorations were recently finished to her satisfaction. Knowing how my day was going and her psychological make up, I somehow doubted that she dropped by just to tell me how pleased she was with her new smile. Shortly thereafter I met with her and my fears were confirmed. After a lengthy and stressful conversation she was scheduled to redo most of the newly placed restorations. It is now 1:00 and my hopes for a peaceful lunch are abandoned. DAY 2 (Dental Sleep Medicine) 9:45 a.m. and the first two patients have already left. The consultation with

Mr. Parker at 8:00 took about 30 minutes and he has decided to come in next week to begin treatment. Mr. Pursiful who was seen at 9:00 to deliver his new appliance seemed pleased and his wife is excited that it may help his snoring. I have 15 minutes so I review Mr. Wright’s Embletta sleep report. He took the sleep recorder home to evaluate how well his oral appliance is working. The report’s results were favorable so his chart was given to the front office for letters to be sent to his referring physician. At 10:00 Mrs. Hunter arrives to begin her treatment. We first review her sleep study, medical history and history of her sleep disorder symptoms. I complete a dental examination as well as an oral airway evaluation. We utilize the pharyngometer to measure the collapsibility of the airway and to obtain a starting position for the appliance. Impressions are taken along with a protrusive bite record. We discuss the various appliances available and make a determination as to which one would best suit her particular situation. Possible side effects of the appliance are also discussed as well as the likely outcomes of treatment. Mrs. Kelly arrives at 11:00 for the one month check of her appliance. She is very happy that her snoring has decreased but she still feels tired, although improved. Her husband reports her snoring is tolerable now and he is very happy, however he is concerned that she still seems to have moments of difficult breathing. We instruct her on advancement of her appliance and she is scheduled for another appointment in 3 weeks. 11:30 a.m. I see Mr. Wade to begin his treatment. My assistant is in Op2 with Mrs. Klein, who is receiving instructions for the Embletta to take home for the


evening to evaluate her oral appliance therapy. I complete the initial appointment procedures for Mr. Wade and am sitting down to lunch by 12:30. I never sweated, used anesthesia, experienced back pain, saw any blood, hurt the patients, or had an increase in blood pressure the entire morning. Of course, not all days practicing dentistry are as stressful as DAY 1, but the practice of dental sleep medicine never results in such a day. Being a dentist has many unique and challenging aspects that can be mentally and physically draining. I have found an enjoyable and profitable refuge from the stresses of general dentistry by incorporating dental sleep medicine into my office. A typical day of seeing patients for the treatment of OSA and snoring is appreciably less stressful, but every bit as gratifying, as that of restorative dentistry. It is never back breaking, we donâ&#x20AC;&#x2122;t hurt our patients and there are seldom emergencies. Most importantly, the gratitude that I receive from helping these people with their life threatening disorder surpasses that of my restorative patients. After practicing dentistry for over 20 years, I have come to realize that making each day as enjoyable as possible is of vital importance to my health, the care I deliver to my patients, and my continued success. If you would like to increase your enjoyment in your occupation while also increasing your revenues and decreasing your occupational stress level, then I highly recommend incorporating dental sleep medicine into your practice.

You will be glad you did â&#x20AC;&#x201C; I am! To hear Dr Yatros lecture. Register for one of his Sleep Group Solutions Seminars

EPWORTH SLEEP TEST

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

___ ___ ___ ___ ___ ___ ___ ___ ___

The Epworth Sleepiness Test is a tool, not a diagnosis. However, if your ESS score is:

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros February 5-6, 2010 Orlando, FL

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros July 23-24, 2010 Denver, CO

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros March 12-13, 2010 Las Vegas, NV

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros September 24-25, 2010 Denver, CO

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros April 16-17, 2010 Phoenix, AZ

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros October 15-16, 2010 Las Vegas, NV

If you are still unsure about the test results, please contact:

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros May 14-15, 2010 Boston, MA

Sleep Group Solutions Dental Sleep Medicine Instructor: Dr. Gy Yatros December 10-11, 2010 Orlando, FL

or visit us online at: www.sleepgs.com

1-6 Obstructive Sleep Apnea is Less Likely 7-8 Your Score is Average 9 or Higher Obstructive Sleep Apnea is More Likely and You Should Seek the Advice of a Sleep Specialist

Sleep Group Solutions 1.866.353.3936 WWW.SLEEPGS.COM

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The Efficacy of Tonsillectomy and Adenoidectomy For treatment of pediatric obstructive sleep apnea/hypopnea syndrome: an updated systematic review. By Michael Friedman, MD, FACS, and Christopher Leesman, DO, of Rush University

O

f the approximately 250,000 pediatric tonsillectomy and adenoidectomies (T&A) performed in the U.S. each year, the majority are for treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS)1, 2. Although this procedure is widely believed to be effective, studies to date have revealed inconsistent success rates, ranging from 24-100%3-7. One factor that has made it difficult to determine the overall success of T&A is the lack of objective data. The majority of pediatric OSAHS patients are diagnosed clinically rather than by polysomnogram (PSG), the gold standard for objective diagnosis,1 and an even smaller percentage undergo PSG postoperatively to confirm success of treatment. Another complicating factor is the exclusion of obese children from many studies. In their 2006 systematic review of 14 studies, Brietzke et al reported an overall success rate of 82.9% but excluded studies that included obese children3. With over 31% of the U.S. pediatric population considered overweight and a similar percentage of obesity among pediatric patients undergoing T&A,8 we felt that including results from this population was necessary in order to provide an accurate reflection of the overall success rate. Study Design: Studies which met the studies as as

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following criteria were included in our meta-analysis: 1) study population consisted of patients <20 years old with abnormal preoperative PSG, 2) surgery was limited to T&A alone, and 3) pre- and post-operative PSG data were available for all patients. Both studies that included obese children and those that did not were reviewed. Studies which included patients with neuromuscular disorders, chromosomal abnormalities, and craniofacial syndromes were excluded, as these conditions are rare and can significantly alter surgical outcomes. Twenty-three studies, totaling 1079 patients, met criteria and were divided into four groups for analysis (Table 1 )4-7, 9-27.

children, those with severe OSAHS, or those <3 years old). Success for this group was 38.7%. Further analysis of the remaining 19 “uncomplicated” studies which excluded special populations yielded a success rate of 73.8%. Overall, the average AHI decreased from 18.6 events per hour preoperatively to 4.9 postoperatively, which equates to a 73.6% reduction (Figure 2).

The average reduction in AHI for complicated patients was nearly double that for uncomplicated patients at 22.0 vs. 11.7 events/hour, respectively (Figure 3). Results: Group 1 included patients from all 23 studies. Analysis of this group yielded a random-effects model estimate for treatment success (as defined by AHI <5) of 66.3% (Figure 1). Group 2 included 9 studies in which success was defined as AHI <1; the overall success for this group was 59.8%. Group 3 consisted of 16 studies in which success was defined as AHI <5; the success rate for this group was 63.3%. Group 4 included studies focusing on “complicated” populations (e.g. obese

Discussion: Our analysis suggests that for the treatment for pediatric OSAHS, T&A may not be as effective as previously thought. Overall success, as


defined as AHI <5, was only 63.3%. We suspect that this figure may overestimate success, as poor outcomes tend to be under-reported in the literature. While our analysis only evaluated objective measures, other studies have considered subjective metrics such as quality of life scores. Reliance on subjective data alone may lead to inflated rates of success. Given the long-term sequelae of OSAHS, treatment should be aimed at eliminating the disease, not just the symptoms. Although the rate of cure may not be as high as once thought, significant reductions in AHI following T&A have been demonstrated by several reports, including this one. Thus, while our study brings to light some of the limitations of T&A, this procedure remains a valid first line treatment for pediatric OSAHS. Certain populations, such as obese children for whom T&A has been shown to be less successful as an isolated treatment, may require additional therapy to achieve cure6, 12, 15, 18, 19 . Further studies are necessary to determine the effectiveness of multilevel surgery, turbinate reduction, nasal valve repair, tonsillar pillar closure, and orthognathic expansion in children with sleep apnea28-31. This study was limited by the significant heterogeneity among the studies analyzed. Due to the deficiency of large numbers of high-quality studies, we were unable to apply strict inclusion criteria. Guidelines recommending preand post-treatment polysomnograms for pediatric patients suspected of having OSAHS are necessary in order to help identify which patients are most likely to benefit from surgery and to identify those who suffer from residual disease postoperatively. Standard criteria for PSG interpretation are also paramount. ABSTRACT OBJECTIVE: Perform a review and meta-analysis to determine the objective cure rate of tonsillectomy and adenoidectomy (T&A) for pediatric obstructive sleep apnea/hypopnea syndrome (OSAHS). METHODS: A systematic review was performed to identify English-language studies that evaluate the treatment of pediatric (age 20 years) OSAHS patients with T&A using polysomnography as a basis of cure. Twenty-three studies fit the inclusion criteria and a meta-

analysis was performed to determine the overall success. Meta- analysis was also performed to determine the success in obese and comorbid populations vs cohorts of healthy children. RESULTS: The meta-analysis included 1079 children. The effect measure was the percentage of pediatric patients with OSAHS who were successfully treated with T&A based on preoperative and postoperative PSG data. Random-effects model estimated the treatment success of T&A was 66.3 percent, when cure was defined per each individual study. When “cure” was defined as an apneahypopnea index (AHI) of <1 (9 studies), random-effects model estimate for OSAHS treatment success with T&A was 59.8 percent. Postoperative mean AHI was significantly decreased from preoperative levels. CONCLUSIONS: Contrary to popular belief, meta-analysis of current literature demonstrates that pediatric sleep apnea is often not cured by T&A. Although complete resolution is not achieved in most cases, T&A still offers significant improvements in AHI, making it a valuable first-line treatment for pediatric OSAHS. *This submission has been a review of the following research article. Friedman, M., M. Wilson, et al. (2009). “Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome.” Otolaryngology - head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery 140(6): 800-808. Author information: • Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL (Dr. Friedman) • Department of Otolaryngology, Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, IL (Dr. Friedman and Dr. Leesman) Send correspondence to: Michael Friedman, MD, FACS 3000 N. Halsted St. Suite 400, Chicago, IL 60657 hednnek@aol.com 1. Weatherly, R.A., et al., Identification and evaluation of obstructive sleep apnea prior to adenotonsillectomy in children: a survey of practice patterns. Sleep Med, 2003. 4(4): p. 297-307. 2. Young, T., et al., The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med, 1993. 328(17): p. 1230-5.

3. Brietzke, S.E. and D. Gallagher, The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg, 2006. 134(6): p. 979-84. 4. Guilleminault, C., et al., Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey. Otolaryngol Head Neck Surg, 2007. 136(2): p. 169-75. 5. Mitchell, R.B., Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope, 2007. 117(10): p. 1844-54. 6. Tauman, R., et al., Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr, 2006. 149(6): p. 803-8. 7. Wang, R.C., et al., Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg, 1998. 118(1): p. 69-73. 8. Nutrition and physical activity: defining over weight and obesity. National Center for Chronic Desease Prevention and Health Promotion 2003; Available from: http://www.cdc.gov/ nccdphp.dnpa/obesity/defining/htm. 9. Bar, A., et al., The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome. J Pediatr, 1999. 135(1): p. 76-80. 10. Goldstein, N.A., et al., Clinical assessment of pediatric obstructive sleep apnea. Pediatrics, 2004. 114(1): p. 33-43. 11. Gozal, D., O.S. Capdevila, and L. Kheirandish-Gozal, Metabolic alterations and systemic inflammation in obstructive sleep apnea among nonobese and obese prepubertal children. Am J Respir Crit Care Med, 2008. 177(10): p. 1142-9. 12. Mitchell, R.B. and J. Kelly, Adenotonsillectomy for obstructive sleep apnea in obese children. Otolaryngol Head Neck Surg, 2004. 131(1): p. 104-8. 13. Mitchell, R.B. and J. Kelly, Outcome of adenotonsillectomy for severe obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol, 2004. 68(11): p. 1375-9. 14. Mitchell, R.B. and J. Kelly, Outcome of adenotonsillectomy for obstructive sleep apnea in children under 3 years. Otolaryngol Head Neck Surg, 2005. 132(5): p. 681-4. 15. Mitchell, R.B. and J. Kelly, Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children. Otolaryngol Head Neck Surg, 2007. 137(1): p. 43-8. 16. Nieminen, P., U. Tolonen, and H. Lopponen, Snoring and obstructive sleep apnea in children: a 6-month follow-up study. Arch Otolaryngol Head Neck Surg, 2000. 126(4): p. 481-6. 17. Nishimura, T., et al., Effect of surgery on obstructive sleep apnea. Acta Otolaryngol Suppl, 1996. 523: p. 231-3. 18. O���Brien, L.M., et al., Obesity increases the risk for persisting obstructive sleep apnea after treatment in children. Int J Pediatr Otorhinolaryngol, 2006. 70(9): p. 1555-60. 19. Shine, N.P., et al., Adenotonsillectomy for obstructive sleep apnea in obese children: effects on respiratory parameters and clinical outcome. Arch Otolaryngol Head Neck Surg, 2006. 132(10): p. 1123-7. 20. Shintani, T., K. Asakura, and A. Kataura, The effect of adenotonsillectomy in children with OSA. Int J Pediatr Otorhinolaryngol, 1998. 44(1): p. 51-8. 21. Stewart, M.G., et al., Quality of life and sleep study findings after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg, 2005. 131(4): p. 308-14. 22. Suen, J.S., J.E. Arnold, and L.J. Brooks, Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg, 1995. 121(5): p. 525-30. 23. Tal, A., et al., Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome. Chest, 2003. 124(3): p. 948-53. 24. Tunkel, D.E., et al., Efficacy of powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope, 2008. 118(7): p. 1295-302. 25. Walker, P., B. Whitehead, and T. Gulliver, Polysomnographic outcome of adenotonsillectomy for obstructive sleep apnea in children under 5 years old. Otolaryngol Head Neck Surg, 2008. 139(1): p. 83-6. 26. Wiet, G.J., et al., Surgical correction of obstructive sleep apnea in the complicated pediatric patient documented by polysomnography. Int J Pediatr Otorhinolaryngol, 1997. 41(2): p. 133-43. 27. Chervin, R.D., et al., Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg, 2007. 133(3): p. 216-22. 28. Friedman, M., et al., Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome. Laryngoscope, 2007. 117(10): p. 1859-63. 29. Guilleminault, C., et al., A prospective study on the surgical outcomes of children with sleep-disordered breathing. Sleep, 2004. 27(1): p. 95-100. 30. Guilleminault, C., et al., Sleep disordered breathing: surgical outcomes in prepubertal children. Laryngoscope, 2004. 114(1): p. 132-7. 31. Mora, R., et al., OSAS in children. Int J Pediatr Otorhinolaryngol, 2003. 67 Suppl 1: p. S229-31.

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The Full Breath Solution A new paradigm for the treatment of OSA done with NO MANDIBULAR ADVANCEMENT. By Bryan Keropian, DDS

C

ancer, Aids, and Obstructive Sleep Apnea are the most dangerous and destructive diseases on earth. Obstructive Sleep Apnea is reported to occur as much as 83% in women and 92% in men. This means every hour of every night there are multiple periods of no O2 to every cell in the body. These periods occur 5-100+ times an hour, for 10-90 seconds an episode. With insufficient oxygen, cellular regeneration is unable to transpire nightly during sleep. Poor cellular regeneration results in an individual being more susceptible to numerous pathologies anywhere in the body. This nightly cellular breakdown has a nightly destructive effect on the health of mankind. The co-morbidities for sleep apnea are numerous The most successful treatment for OSA is a CPAP. It is the number one treatment prescribed by the medical community. It is highly successful when it can be used. The big problem with the CPAP is the numerous difficulties patients have tolerating it and using it. The CPAP is not tolerated by up to 60% and estimated by some up to 83% of the users. With an inability to tolerate the CPAP, these patients find themselves at great risk in regards to their health and longevity. It is a major problem for mankind when medicine’s most effective treatment tool is rejected by 60% to 83% of the users. With the high rejection rate of the

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CPAP, the American Academy of Sleep Medicine has designated dental sleep oral appliances as the number one non-surgical alternative for the CPAP intolerant. There are numerous sleep appliances available to the public that are distributed through dentists. These are double arched appliances that gain success by opening the vertical dimension and advancing the mandible. Vertical opening can range from 2 mm to 15mm. The advancement can be as much as full forward prognathic extension. This forward movement can be up to ¾ of an inch. The problem presented by these appliances is that they can cause pain or malocclusion Another dental sleep appliance has been introduced to Dentistry at the end of 2006. It is called the Full Breath Solution Sleep Appliance (FBS). It is a single-arched sleep appliance, which fits over the maxillary or mandibular teeth. It presents a very different paradigm to treatment. Rather than pulling the tongue forward by advancing Posterior Tongue Restrainer (PTR) aka “tail”. This is the beginning form of the tongue depressor that provides the clinical success for the FBSL. It will be expanded posteriorly and inferiorly. Translingual Bar to restrain and inhibit the tongue from moving up and back.

the mandible, it works by utilizing a posterior bar and tail that restrains the tongue from moving upward and backward. Mandibular Full Breath Solution illustrating Posterior Tongue

Restrainer (PTR) and Translingual Bar The Full Breath Solution has it’s success based on four main factors: 1) The tail will be expanded to provide a tongue depressor similar to that used by an MD to view the pharyngeal airway. 2) There is minimal to no advancement with the bite being set at CO or 1-2mm anterior advancement. Treatment is successful in CO since the success of treatment is based upon restraint and depression of the tongue to open the airway, not advancement. 3) The patient can open his mouth and have complete freedom of movement. And with all the movement the tail still stays in the same position on the teeth and depressing the tongue. 4) The FBSL is small, very comfortable, and one arched. THE REAL SUCCESS OF THE FULL BREATH SOLUTION COMES WITH UTILIZATION OF THE TONGUE DEPRESSOR AND NO MANDIBULAR ADVANCEMENT AND WITH OPEN VERTICAL OPENING OF 1-2MMS

A

B

A. FBSL Viewed from underside. Wax added to start forming tongue depressor. B. Wax removed and acrylic added to tail. It is thinned on the superior surface in order that it not be so bulky and more comfortable. Viewed from the underside.

Tongue Depressor Created with Wax and then changed to Acrylic. The Mallampati Classification is a methodology that reveals the degree to which the tongue is blocking the airway. It classifies the size of the oropharyngeal opening. It is the key upon which I base my treatment to open the airway and gain success in the treatment of OSA


A

B

A. FBSL with wax added to form tongue depressor The four Mallampati Classifications can be viewed. Our goal is to establish a II or III Classification utilizing the tongue depressor on the Full Breath Solution. Mallampati IV - Closed Airway Soft Palate Airway blocked by posteriorized tongue

B. Wax removed and changed to acrylic. Tail thinned on superior to make tail smaller and more comfortable. Mallampati II Created with use of Full Breath Solution Lower Mallampati II oropharyngeal airway Translingual bar blocking view of tail depressing tongue and creating opening.

Tongue

and snoring. Our clinical success will be based on the Mallampati Classification we can attain. Tongue Depressor Created with Wax and then Acrylic Look at all these Mallampati II’s. This is what we can do almost every case utilizing the tongue depressor of the Full Breath Solution. All this success at opening the airway with NO MANDIBULAR ADVANCEMENT With the development of the tongue depressor philosophy, the utilization of Mallampati II - Open Airway

Tongue Depressor Creating Mallampati II

the Full Breath Solution Lower requires only that the tail be lengthened and thickened 2-4 times. It has taken more appointments on some patients. But 2-4 appointments is what has been our usual and customary. The following is a Dental CBCT scan illustrating the opening that can be achieved with the Full Breath Solution. The “tail” acts as the MDs tongue depressors and thus depresses the tongue and prevents it from going up and back. Result, the biggest airways dentistry can produce over and over. With the large intolerance rate of the CPAP there are two more key parts of the equation that provide dentistry with

Large Tongue Posteriorizes and blocks or minimizes the airway.

Oropharyngeal airway openings created by use of Full Breath Solution PTR (tail). the best treatment answers on the planet for Obstructive Sleep Apnea and CPAP intolerance. Those two answers are the Pharyngometer and NewTom CBCT radiology. The Pharyngometer is a computer with a sensor arm that has a mouthpiece that shoots out sound waves that measure the size of the airway. The airway can be measured in its normal position, with an open vertical, with mandibular advancement, and with wax in the mouth in various positions to restrain and inhibit the tongue. The practitioner can then see what is the best position to fit the oral sleep appliance in the mouth. When it comes to case presentation, it is one of the most effective tools in dentistry. It is tremendous at illustrating the OSA problem and solutions. This results in a high percentage of case acceptance. The second key is the dental CBCT, NewTom. You see the example in the CBCT displayed earlier in this article. It is an incredible tool to see the progress we are making. In the next edition of this Journal I

Mandibular Full Breath PTR (Tail) Restraining Tongue and Allows for open Airay will have an article that presents the clinical use of the pharyngometer and the role of the NewTom CBCT in the treatment of OSA and CPAP intolerance. The author Bryan Keropian, DDS, is the inventor and patent holder of the Full Breath Solution Sleep Appliance. He has 2 patents and 5 FDA certifications with the Full Breath. He is President of the Full Breath Corporation and he can be reached at the Full Breath Corporation at 818-344-7200. His email is BK@ cpapalternative.com. • Sleep 10:705-706,1997 Cardiac Consequences of Obstructive Sleep ApneaHypopnea Syndrome, Mt. Sinai Med. 2005; 72(1):10-2 • Sleep Med. 2006; 7(1):73-5 Clin. Exp. Hypertension. 2005;27(2-3);259-67 Risk Factors and treatment for Obstructive Sleep Apnea Amongst Obese Children and Adults, Mark Kohler, Medscape Abstract posted 2/5/2009 • Redline S, Adams N, Straus ME, et al. Improvement of mild sleep-disoriented with CPAP compared with conservative therapy. Am Journal Respiratory Critical Care Med. 1998:157:858-865. • Engelman HM, Kingshott RN, Wraith PK, et al. Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea/hypopnea syndrome. Am Journal Respiratory Critical Care Med. 1999;159:461-467. • Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by obstructive sleep apnea. 1993 American Journal of Respiratory and critical Care Medicine. • Clete A. Kushida, MD, PhD1; Timothy I. Morgenthaler, MD2; Michael R. Littner, MD3; Cathy A. Alessi, MD4; Dennis Bailey, DDS5; Jack Coleman, Jr., MD6; Leah Friedman, PhD7; Max Hirshkowitz, PhD8; Sheldon Kapen, MD9; Milton Kramer, MD10; Teofilo Lee-Chiong, MD11; Judith Owens, MD12; Jeffrey P. Pancer, MD13. Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005, An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No.2, 2006. • Seminar, Introduction to the Full Breath Solution Sleep Appliance, At the Center for Snoring and CPAP Intolerance, Aug. 2006, Bryan Keropian DDS WWW.SLEEPGS.COM

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patientcase 62

It’s Not All About You Team approach is often necessary. By J.C. Goodwin, DMD

A

s a relative new kid on the block practicing dental sleep medicine for only a year now, my head spins every day at what I am learning, how much there is to learn, how important (and often how difficult) it is to communicate, and how cool it is when it all comes together. I’ll share a case that illustrates how critical it is to have a solid working relationship with a sleep laboratory in order to achieve a successful outcome. A 79 year old patient was referred by a local sleep medicine physician to evaluate for possible oral appliance therapy (OAT). This man had been aware of heavy snoring and progressive apnea, as witnessed by his wife, for more than twenty years. Chronic headache pain, progressive daytime fatigue and a generalized sensation of “just feeling lousy” prompted him to seek evaluation and treatment. He stated that he often did not want to go to

events averaging 25 per hour. His respiratory arousal index was 13. The average oxygen saturation was 92% and the nadir was 89%. He was prescribed CPAP titrated at 11cm of water. The patient made multiple attempts to comply with his therapy including PAP-NAP desensitization and even psychological counseling to deal with a claustrophobia issue. He purchased multiple masks himself on-line. He gave up after nine months hence the referral to my office. My treatment protocol always begins with an interview. I allow them to ask questions, share past history, frustrations and expectations. Listening gives me the opportunity to gain perspective on the patient’s level of understanding and helps me determine what information they most need. A fifteen minute overview of basic Treatment protocol always begins PSG interpretation, OAT mechanics, with an interview. Listening limitations of therapy, etc., is often fourteen minutes more than they gives me the opportunity to gain have gotten at any other office and perspective on the patient’s level they are not only grateful, they of understanding and helps me are better able to make informed determine what information they decisions. They feel empowered. most need. Allow time in your protocol for this critical step. This patient’s level of sleep because he knew how bad awareness of his condition, the he would feel when he woke treatment option limitations, and even up. A polysomnogram (PSG) the mechanics involved was very high. resulted in a diagnosis of severe A retired engineer, he proved to be obstructive sleep apnea and very proactive in the problem solving severe central sleep apnea. His process, which encouraged ownership AHI was 63.6, with obstructive of his situation. We discussed, at length, events averaging 38 and central the fact that central apnea is not often www.thesleepmagazine.com

corrected with OAT, but that it was necessary to minimize obstructive events first in order to more accurately assess the true severity of his sleep breathing disorder. The possibility of co-therapy involving medical and dental treatments was discussed. On clinical examination there were no findings that would contraindicate the use of an oral dilator device, though a generalized tenderness of nearly all facial musculature was consistent with his report of “myalgia”. A rhinometer evaluation showed a patent nasal airway and pharyngometer assessment revealed a dramatic increase in airway volume with only a minor amount of protrusive movement. I am abbreviating the clinical steps involved in record taking for brevity as well as other medical history which was not contributory. His primary fear was the inability to open his mouth and remove the appliances quickly due to his claustrophobia and his history of frequent nocturnal emesis associated with GERD. Subsequently, a Dorsal type appliance was selected with the patient’s consent. He tolerated the device very well and we began a several week process of slow titration and frequent home sleep testing with an Embletta X-100. The results of the ambulatory sleep tests consistently showed an AHI


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of around 41.0 (down from 64) with with your sleep physicians and the no significant obstructive events noted. testing facilities through consistent (See figure 1) He was referred back to written communication and allow them the sleep lab for a PSG with the oral time to develop confidence in you and airway dilator in place. The laboratory your abilities. Communicate effectively was advised of my suspicion that there with your patients and be realistic with were few obstructive events remaining your expectations of clinical success. Be and of his CPAP intolerance. aggressive with your testing during the The second PSG revealed an AHI titration phase of your treatment process. of 32, which was half of the original Subjective assessment is better than no baseline, including 18 obstructive follow-up, but objective data is so much events, 138 central events and 32 more effective when making decisions hypopneas regarding efficacy which were of your therapy. Key Elements to mostly central Finally, in nature. Most refer complex Practice Dental Sleep significantly, there cases back for Medicine Effectively. now appeared a evaluation and preponderance of additional coCheyne-Stokes therapy if needed. Take the time necessary to: type events Many physicians not noticed on and sleep centers • Develop strong relationships with your the first PSG, have never had sleep physicians and the testing facilities through probably masked an opportunity to consistent written communication and allow them by the obstructive manage difficult time to develop confidence in you and your events. In a splitcases with a coabilities. night study the therapy option. sleep center then Some • Communicate effectively with your placed him on physicians are patients and be realistic with your expectations of oxygen with a understandably clinical success. Be aggressive with your testing nasal cannula and skeptical of the during the titration phase of your treatment the AHI dropped effectiveness of process. to 10. He is now OAT. A referral being managed to a dentist for • Assessment - Subjective assessment is very successfully definitive therapy better than no follow-up, but objective data is with the resulting in the so much more effective when making decisions combination of delivery of a regarding efficacy of your therapy. the MAS device “snore guard”, and supplemental and then declared oxygen, both of which he tolerates very successfully treated when “he says he well. snores less”, is not meeting the standard Improvement of his clinical symptoms of care the medical community has a has been slow to develop, probably right to expect of us. due to the cumulative and progressive nature of the systemic damage from We have an obligation chronic oxygen deprivation. Time will to do it right. tell. Incidentally, several letters were sent to every physician and caregiver Dr. Goodwin has been in private practice involved with this patient’s ongoing care in Prescott, Arizona since 1987. He is a acknowledging the referral, updating member of the ADA, a Fellow of the World them on progress, and advising them Congress of Minimally Invasive Dentistry, of the outcome of the therapy as well and a member of the American Academy of as thanking them for the opportunity to Dental Sleep Medicine on Diplomat track. have participated with their patient. He is certified in advanced dental laser I believe this case illustrates several surgery and is affiliated with the Centers for key elements needed to practice dental Dental Medicine. sleep medicine effectively. Take the time To hear Dr Goodwin’s lectures visit: www. necessary to develop strong relationships sleepseminars.com

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INTRO TO DENTAL SLEEP MEDICINE Presented By SLEEP GROUP SOLUTIONS

Featuring: Dr. Dan Tache , AADSM Diplomat This comprehensive 2-day seminar is designed to give you knowledge of treatment protocols, appliances and sleep in order for you to confidently begin treating sleep apnea in your practice immediately. This is a rapidly increasing market and dentists need to have a sound understanding of best practices in order to succeed treating this life threatening disorder. “Which Appliance Should I Use?” - Come learn why this is the least important question to be asking. Come learn the true secrets and pearls of knowledge from world renowned experts. The time for “just making snoring appliances” is over! Dentists have been placed on the front line to treat Obstructive Sleep Apnea by the physicians and the Academy of Sleep Medicine. It’s time to answer that call to action! FEATURED INSTRUCTOR: DR. GY YATROS Dr. Gy Yatros practices on Florida’s west coast and has been treating sleep apnea through his Dental Sleep Solutions business for several years. Dr. Yatros recently earned his diplomat credential with the American Academy of Dental Sleep Medicine. His approach to teaching makes the material simple to understand. Dr. Yatros will share his personal experiences, cases and advice with a goal of preparing all course attendees to go back to their practices and immediately begin implementing what they’ve learned.

For more information, visit: www.sleepseminars.com or

www.sleepgs.com


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12 Pearls To Create That Practice You Really Want. During our unstable economy, this is the best time to grow your practice. By Leonard J. Feld, DDS

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he exciting news is that during our unstable economy, is the best time to grow your practice. This is the time to expand your thinking, your care and your practice. Obviously this article will address sleep disorder dentistry. Tammy Balatgek DDS introduced this subject convincingly in a prior article in Dental Sleep Magazine. She states “now is the time to integrate sleep disorder dentistry into your practice and offer more comprehensive patient service and additional income to your practice”. She quotes Roger Lever, “it takes 6-12 months for economic trends to affect dental practices”. He addresses the need to create an environment for a “comprehensive case acceptance and increase patient services”. The following are some ideas that I am calling the 12 Pearls that can easily increase you practice value. Marketing is a subject that has been beaten to death by all the MBA’s who invited themselves into the dental world to create “business to aid or help the dentist who have been looked up as poor business people. All of them have something to sell us. Even if it might be of help, “we” end up resisting. Marketing is divided into two parts, internal and external. The first Pearl will discuss external and the following

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11 Pearls will address the internal marketing ideas. “Moving ahead in a tough economy” All the experts (MBA’s) agree that words or even print ads. The phone is in a downtime period, companies, your life-line for communication. The products and services that fare best and first call by a new patient is your first even gain market share all have one step in a comprehensive examination thing in common, they increase their and case acceptance. Is your phone marketing. David Olgilvy, 1949, the scripted, do you role play with your staff father of marketing and advertising, as or do you just assume they know how well as other marketing experts, point to answer the phone and communicate to the fact that businesses that promote your practice. The gathering of in downtimes do 2-3 times better when the economy turns around. You need to information can help in the addressing make yourself visible and recognizable. of the patients’ chief needs. The office must know why the patient is calling! This does not mean that you shouldn’t “Everyone must know the cut out needless spending and waste “patients name and why the of monies. However, this philosophy patient is there. The patient needs to be of moving ahead in a tough economy addressed by their name. A good way has been proven to be a business to indicate that you care is have the reality. Coca-Cola thought it owned the patient spell their name market and since it was or pronounce their name in the most recognizable PATIENT so that you can be correct name in the world, they in addressing them. Dale stopped marketing. Now Carnegie made a fortune it takes second place to with his book “How to Pepsi and the “New Pepsi make friends and influence generation”, all during people” and his marketing a time when business is systems said “the most down! Or is it? important thing to a “Know why the person is their name”. patient is “Gathering calling” Information” The telephone reception Prior to coming into the is the greatest internal office the patient is given marketing tool. It is either Reception a health questionnaire making your money or which includes an Epworth loosing patients. “You scale and some form of never get a second chance a general craniofacial questionnaire at a first impression” says Leonardo as well as the general medical and Da Vinci. It is easy to say you care, dental health history. This is now the however actions speak louder than

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time to start creating a separation of your office by addressing larger issues than changing silver fillings to white fillings or cosmetic and beautiful smiles. How about creating an atmosphere of increasing the quality of life and life threatening issues? Why the patients’ teeth or physical condition is the way it is? When the patient is brought in, blood pressure, pulse or 02 saturation is recorded as well as their height and weight just like the “medical model”. Gathering information prior to the doctors’ entrance is the key here again. This sets up the doctors’ visit and the patients’ perception of a doctor’s office that this is different. Dr. Carl Misch is the doctor I recognize as the world leader in Modern Dental Implantology, (after all if you have the #1, #2 and #3 best selling book in all of medicine, someone is listening to what he has to say). He says “being educated creates respect, knowing you know creates trust”. “Introduce by a handshake The doctor using the patients name must introduce himself by shaking the patients’ hand. This breaks down the white collar syndrome. Thank you Dr. Jack L. Haden. “Look for the signs This is now the patient’s time with the doctor. Were the patients’ hands cold and clammy or warm? “Cold hands, warm heart”? Not really, the cold hands indicate usually some form of nervousness or adrenal dystrophy. This may be your first physical sign of a sleep disorder or a TMJ dysfunction. You should have already had some patient info from the Epworth scale, size of the patients’ neck and their history. Does the face show signs of fatigue? Are there bags under the eyes and what color are they? Can you see a postural significance? Is the patient over weight? Are there signs of sleep depravation? “Make every effort to “achieve WOW! With the patient at eye level you need to go over their health history. This is very important! This communicates that you are interested in them and are taking time to get to know them.

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Asking questions about their health Ask Permission history involves them. The more you If you now see evidence or ask, the more they will tell you about signs of life threatening issues, now is themselves. Make notes as they talk to a good time to ask the patient if you you. Now you have the time to listen, could palpate them. If there are signs no excuses! Two ears, one mouth! and symptoms of sleep disorders or The hardest thing for me was to ask temporomandibular dysfunction to a question and shut up. For years my indicate a physical touching of the wife has said “God gave you two ears patient, you must ask for permission! and one mouth so you could listen and “I see some things in your mouth that learn”. We need to be more involved I think we should check”. “I would with the patient. This separates us again like to check a few muscles which are from previous dental experiences. important in opening and closing your Tom Peters in his second book “the mouth, are you okay with that?” pursuit of WOW” recommends that we Perception is reality make every effort to achieve a WOW You can now go over the experience every time our customer patients’ structure and your exam or patient turns the corner. This also findings. If you have indications for gives you more information for a more introduction of Acoustic Pharyngometry, involved examination. Joint Vibration Analysis or even “Now Ask the patient if you could Ambulatory Sleep studies, this should look in their mouth with an ice be introduced at this time. Bells and breaker in a joking manner by saying “I whistles - dog and pony show - external wouldn’t be a good dentist if I didn’t”. marketing - internal marketing – the Thank you Dr. Brock Rondeau! patients’ perception is reality, it is “Now look even deeper everything and what is truth to the After viewing the patients’ patient. This is a must! If you now have x-rays and now is the time to look in information that the patient has a sleep the mouth for dental pathology. Now disorder “a life threatening condition” look, I mean really look at the mouth we now order a Pharyngometerand the physical signs and symptoms of Rhinometer test. Again, Sleep Group why certain things are happening. Can Solutions can help you with that. the patient open If there is an to three fingers Taking the time to listen indication of a or only two? Do TMJ dysfunction, you see signs of we order a sleep disorders, Joint Vibration scalloped tongue, Analysis. I myself abfractions, use bioresearch attrition, tori, wear JVA equipment facets, exostosis, for that test. posterior teeth *Disclaimer- I with large fillings, do not represent crowns, root canals, posterior teeth any of these companies. By including missing or all possible patterns and signs a JVA and/or Acoustic Pharyngometry of sleep disorders or craniomandibular you now have set the stage for the close. dysfunction? Thank you Dr. Steve Now you are really different! Olmos! Are we still trying to fill Class V abfractions or find out if the Increase case patient has a life threatening disorder acceptance such as pooling, acid reflux, IBS, This pearl I have to give full credit to comorbid issues of sleep disorders or Dr. Brendan Stack of Vienna, Virginia. TMJ dysfunction. I suggest you check If you have a chance to meet one of the out Sleep Group Solutions at www. fathers of TMJD and take one of his sleepseminar.com and the www.AACFP. courses, it will change your life. The big org to learn about these things. question that will completely separate

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you from the rest of the flock: “have you ever had an examination done like this before?” I have never had a patient say “yes”. They all can’t believe the time and caring. The patient is now much more apt to accept treatment and if it is a large case they will ask if they can phase treatment because they want you to do the work. If you have found extenuating circumstances that may change their life or get them out of pain, you will get positive feedback to whatever you discussed. Your findings will be more accepted and you will increase your case acceptance because you know why things are happening. What separates you? My bakers dozen, my extra pearl for you. In summary, whenever I am asked by practitioners for help and what they should do first, I ask them

why should the patient come to you and why would they accept treatment from you? What separates you and why should the patient trust you? Have you taken the time to HEAR what they want and not what you think they need? Ask yourself these questions! Editorial may be you need to get the education that your dental school didn’t give you. They taught you how to change tires but they didn’t teach you how or why the tires wore out. • Sleep Group Solutions www.sleepseminars.com

• American Academy of Craniofacial Pain Institute for TMJD www.aacfp.org • Introduction to sleep and TMJ- Brock Rondeau Seminars www.rondeauseminars.com

• TMJD- Dr. Brendan Stack www.tmjstack.com • Implants- Dr. Carl Misch www.misch.com Leonard J. Feld, D.D.S. Diplomate: American Board of Craniofacial Pain American Board of Implantology International Congress of Oral Implantologists Masters: American EndodonticSociety Misch International Institute of Implantology Fellow: American Academy of Craniofacial Pain American Academy of Orofacial Pain American Academy of Implant Dentistry Deutches Gezelchaft Implantology American Congress Implant Prosthetics European Society of Oral Implantology Member: American Academy of Sleep Medicine American Academy of Dental Sleep Medicine American Academy Of Pain Management Part Time Clinical Professor U.S.C. Dental School

New Development from Golani Holdings Quick, accurate placement of the endotrachael tube. by Tamir Cohen, President Medical professionals such as paramedics, anesthesiologists and emergency room physicians must be able to perform endotracheal intubation. That is the insertion of a breathing tube into the trachea (windpipe) of a critically ill patient, or one undergoing surgery, to maintain the flow of oxygen to the brain and other vital organs. An improperly placed tube can deprive the patient of oxygen and rapidly lead to death.

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tudies show that an alarmingly high error rate - more than 8 per cent of all attempted endotracheal intubations are off course. In our most prestigious medical centers, highly trained anesthesiologists and emergency room physicians have difficulty intubating patients, with state of the art medical equipment at their disposal. Out in the field, it’s much more difficult. According to a study supported by the Agency for Healthcare Research and Quality (HS13628), paramedic intubation errors occur in 22 per cent of intubation attempts. And in selected

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ambulance systems, a disastrous 40 per cent error rate occurs. There are a variety of contributing factors. In the most favorable conditions Endotracheal intubation is a complex procedure which requires considerable skill and training to maneuver the breathing tube into the correct position. But in the pre-hospital setting, paramedics perform this procedure in uncontrolled, stressful, and chaotic settings -- such as a cramped bathroom floor or a mangled automobile after a crash. These patients are often critically ill or injured and it is extremely difficult

to identify basic airway structures. Further, most paramedics do not perform this procedure frequently. Given these factors, there is great potential for adverse outcomes. The solution to this problem is a new portable medical device developed and patented by Golani Holdings, called ARCD. Based on a technological breakthrough, Golani Holdings is developing a small device which quickly and accurately confirms the proper placement of the endotracheal tube. This allows for a successful intubation, avoiding potentially grave consequences. For more information, Contact: Tamir Cohen, President Golani Holdings. 16840 NE 19 Ave, NMB Florida, 33162 Office: 305-360-3613 Tamir@sleepgs.com


With Change Comes Opportunity! Providers need experienced medical billing services. By Pauline Bell, CPC, CANPC, CGS, CPRS - Bell Billing Services

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ith Change comes Opportunity! As the healthcare landscape continues to evolve at a rapid pace, we are faced with complex challenges. We must find new ways to improve our services to our patients while meeting the financial goals of the practice. Sleep apnea testing and treatment is one area in which there is a great need for more providers. The market is slowly opening up to providers that fall under the guise of General Practioners and Dentistry. Add to the number of patients with OSA comes the new CMS restrictions on therapy compliance resulting in patients who are intolerant of the CPAP therapy and are in need of alternative treatment. With the advent of Dental Sleep Medicine and oral appliances, new therapy options are available. This Opportunity brings the challenge - to be paid appropriately for the services rendered. Every service, the office visits, CT scans, x-rays, Pharyngometry, Rhinometry and oral appliance and the follow-ups--are all payable. There are codes for each service, assigned relative value units, and there are diagnoses which are payable for that service. Commercial medical insurance as well as Medicare will pay for every service, but only if the claim is properly sent. This means the type of service, place of service, and procedure/ diagnosis match must be correctly entered on the claim. Global dates and CCI edits must be followed. Most Dental practices are unfamiliar with billing medical claims. Most practices do not have the time to research the correct codes for each payor and the requirements of each payor. Does one payor require precertification while others do not? Which diagnosis codes does a payor recognize as “medically necessary” and which codes will be denied. What is the criterion that justifies a patient’s need for an oral appliance? To make a diagnosis of OSA, the patient

must meet the event thresholds of an Apnea-Hypopnea Index or Respiratory Distress Index. To qualify for CPAP therapy a patient must have either 15 or more AHI along with documented symptoms of excessive daytime sleepiness (780.53780.54), impaired cognition (331.83), mood disorders (296.90-296.99) or insomnia (780.52), or documented hypertension (401.0-405.99), ischemic heart disease (410.00-414.9), or history of stroke (V12.59). Oral Appliances have been medically approved for Mild ( AHI

5-15 and Moderate (16-30) Once the medical necessity has been determined, the services will be paid if properly billed. Using a billing service, which is experienced in filing medical claims, is imperative to getting the reimbursement you deserve. Find one that has filed claims for those services that you are providing. Use one whose staff is certified by either the American Academy of Professional Coders or American Health Information Management Association. Because it is customary for billing services fees to be a percent of the collections, the viability of their business depends on staying abreast of all policies and regulations that affect reimbursement issues, and getting you the maximum reimbursement for those services.

At Bell Billing, we use only AAPC certified coders. Currently our staff holds certifications in Internal Medicine, Family Practice, Dentists, Evaluation and Management Services, E&M Auditing, General Surgery, Plastic and Reconstructive Surgery, and Anesthesia and Pain Management. We offer full service billing and collection services generated on the provider’s system which allows the claims to be integrated with your current scheduling and billing application. We generate charges, post payments and appeal denials online. Claims are transmitted within 48 hours of the date of receipt of the service information. We average 95% + collection for our clients. We perform pre-transmission audits of all claims to insure that there are no procedure/diagnoses mismatches or other errors that would cause a denial. We log in securely, audit the claims for appropriate coding, and appeal any that have denied. We research all billing issues, and are specialists in billing for sleep apnea services. If the Provider does not have a current Medicare number or Medicare DME (durable medical equipment) number, we will assist in securing those provider numbers. Find a billing/consulting service which has a knowledgeable staff and one that will be a welcome support for your practice. Your expertise is patient care. Get the same expertise in your billing service. Bell Billing Services 1317 North 8th Street, Suite 200, Abilene Texas 79601 Phone: 325-676-0557 Fax: 325-672-9869 WWW.SLEEPGS.COM

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support for

sleep disorders A successful Patient Support Group is accomplished by the support of the Sleep Disorders Program. By William R. Beauchamp RRT, RPSGT, Daniel Ventimiglia Jr RRT, RPSGT

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he Tampa General Sleep to reducing injury, disability, and death Disorders program sponsors from sleep apnea and to enhancing the a successful sleep disorders well being of those affected by this support group. We provide facilitators, common disorder. In 1988 the AASA speakers, meeting room space, formed a network of sleep support light refreshments and monitor groups with the acronym A.W.A.K.E the discussions to ensure accurate (Alert, Well, And Keeping Energetic). information is expressed. The meeting is After careful research we decided to join open to the public and at no cost. There this network and started the local Tampa are sleep physicians and other sleep Bay Area AWAKE group meeting. professionals that The Tampa attend all meetings. The goal of the meeting is to make available General Sleep They are available free information, a place where persons of Disorders Program for private like circumstances can come together, and has grown into a questions and to get the message out that no one is alone six bed nationally open discussions. in this disorder in the effort to improve the recognized sleep The goal of the disorders program, quality of people’s lives. meeting is to make which has both the available free information, a place where American Academy of Sleep Medicine persons of like circumstances can come Accreditation and the Joint Commission together, and to get the message out that Disease Specific no one is alone in this disorder in the Certification. Our effort to improve the quality of people’s A.W.A.K.E. group lives. meeting has also In the early 90’s the sleep lab began its grown as we have. transition to a sleep disorders program. We have bi-monthly During its growth it went from a one meetings that have bed lab to a two-bed sleep disorders attendance from program. Our Medical Director, Dr 30-60 participants William McDowell Anderson M.D. had and are supported joined our team and with his experience from 8-12 vendors brought the idea of a patient support at each meeting. The group. He suggested we partner with a meetings consist of a mix of persons network known as the American Sleep who have been with us since the start Apnea Association (ASAA). The ASAA of this chapter of A.W.A.K.E. in the is a non-profit organization dedicated mid 90’s and people who have recently

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been diagnosed with a sleep disorder. Being an open meeting we have times that participant’s just show up to get information about a sleep disorder they are experiencing. We do our best to make everyone feel welcome. Participants are invited through many different sources. All patients who come through our sleep disorders program are either emailed or mailed a meeting flyer. Our working relationships with many of the local home care companies lets us provide A.W.A.K.E. meeting flyers with all new CPAP users to be distributed at time of set up. Advertisements are placed on our local hospital website and in local newspapers. Our partnerships with local physician practices have the meeting become a resource for both physicians and their patients. Physicians request their patients attend the meeting to take a look at new masks and to get information on new technology and OSA treatment options. The A.W.A.K.E. group meeting flyer is available out at all local sleep offices and clinics. There is some work involved to develop and maintain a successful support group. A successful support group must create


an atmosphere that the participants: 1. Feel welcome, can speak openly and ask questions. 2. Relevant, up-todate topics. 3. Speakers need to be experts and have the ability to speak to participants with various educational backgrounds. 4. Participants need to leave the meeting with applicable information that can improve the quality of their life. Our meetings are held regularly. Our A.W.A.K.E. group meets the third Thursday of every other month at 6:30 pm. This has not changed since the beginning and we want our patients to know that 10 years from now this meeting will still be meeting at the same date and time. We try to keep regular topics relevant to our participants needs. We have six meetings per year and discuss pertinent topics. We developed our topics by what we saw as the most common problems we see in our sleep disorders program. The main topic of discussion is based on mask fitting or compliance. The second common topic of discussion is the participants’ lack of understanding or knowledge of their sleep disorder. We have meetings to discuss insomnia, proper sleep hygiene, alternative treatments for OSA, weight loss, healthy eating, and exercise. Beginning in January we discuss exercise and its effects on sleep. We teach the participants how to start an exercise program and to obtain reasonable goals. The March meeting we discuss Insomnia and sleep hygiene. The May meeting is our yearly equipment checks and mask fitting. We encourage all the participants to bring in their sleep equipment and mask. The

July meeting is our general sleep disorders lecture. One of our sleep Physicians describes the most common sleep disorders. September is our OSA treatment options. We have an ENT and a dentist speak on their specialty. Our November meeting is one week prior to Thanksgiving so we have a dietician speaking on healthy eating and weight loss. The vendor support consists of local home care companies, national equipment manufacturer representatives and regional dental specialists. Our vendor support contributes greatly to the success of our A.W.A.K.E. support group meeting. They are readily available to assist patients with

specialized needs. The local home care representatives are available for face to face discussions with their patients to address issues such as equipment problems and mask fittings, talk to the patients about what to expect from a home care company, and insurance updates or changes. The national equipment manufacturer representatives bring the latest in CPAP technology. The patients have a chance to interact with the representatives, see the newest masks and get valuable mask fitting tips. Regional dental specialists are available for the participants to see other available sleep apnea treatment options. This meeting has proved to be beneficial for the representatives as they interact and gain valuable information from the end users of the product or services.

In order to have a successful support group you must create an atmosphere that the participants feel welcome and open to speak. Although some A.W.A.K.E. groups are completely patient organized we have had more success by operating as the leaders with participant feedback. We have a speaker at each group. Our speakers are professionals and well versed in their field of expertise. Our speakers consist of MD’s, Clinical Psychologist’s, Registered Dietician’s, Registered Exercise Physiologist and Dentists. Support group participants are able to share information and encourage each other. The invited speaker usually has a 25 minute presentation with as much time as needed for questions and answers. After the topic-speaker finishes one of our sleep physicians begins the open discussion of the meeting. The discussion may take some interesting turns, but we do our best to get the discussion back to the business of sleep. At this time, it may totally turn into participants offering support and relating personal experiences to each other or one of the vendors may have a new product or technology to speak about. Each meeting has the ability to take on its own character. We allow the meeting to go in any direction as long as accurate information is being expressed. Meetings vary in time from one to two hours. Once the discussion is over, the meeting is adjourned and the participants are encouraged to interact with each other as long as they like, as well as the opportunity to speak to the vendors and sleep professionals in attendance.

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Global Headquarters: 11001 West 120th Ave. • Broomfield,CO 80021 USA • Toll Free: 888.662.7632 • O: 303.962.1800 • F: 303.962.1810 • www.embla.com

Embla Enterprise™ Sleep Lab Management Software Customer Success Stories

ABOUT SLEEP CENTER A Sleep Center A is the largest sleep disorders center in its area with 14 private hotel-style bedrooms. Established in 1982, it has been providing the highest quality of care in its AASM accredited facility for years.

Business Issue: Sleep Center A was looking to take its business to the next level through the use of electronic charting and desired to implement new technologies to manage its occupancy rate and service level. Embla Solution: Embla installed the Enterprise System and interfaced it with its PSG Software. High speed scanners were used in connection with the Enterprise document management system to allow the center to quickly reach its goal of implementing fully electronic patient records. The standby list in Enterprise identified patients that can be called in the event of an appointment cancellation. Embla worked with a third-party service to automatically place reminder calls to patients before their studies. Benefit: The lab has noticed a consistent 4% decrease in unfilled beds since the implementation of Enterprise. On the basis of a $1000/ patient reimbursement rate, filling these additional beds translated to an additional $120,000 per year. Less the cost of service, an incremental return to the organization of $60,000 was realized. The Enterprise system paid for itself within a few months of purchase on based on the standby list feature alone. In addition, by going paperless the sleep center estimates an additional savings of $2,000 per year on paper charts and filing supplies.

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ABOUT SLEEP CENTER B Sleep Center B is a 14 bed accredited sleep center with multiple facilities in a large metropolitan area.

Business Issue: The sleep center was looking to schedule all sites from one location and needed a scheduling system capable of managing and distributing the schedule throughout its organization. The center’s reading doctors were located off-site and would drive to the lab several times a week to review studies. The center was looking for a solution to provide its referring physicians the convenience of securely accessing patient information and monitoring compliance outcomes remotely. Embla Solution: Embla installed the Enterprise System and interfaced it with its PSG Software. The Enterprise Multisite Module allowed the site to manage the schedule of multiple sleep labs from one central location and automatically push this data to the PSG software on the night of the study. The Enterprise Client was used in conjunction with terminal services to provide a remote access solution for reading and referring physicians. Benefit: Aside from making the job of their reading doctors more convenient, the remote access and centralization of lab information provided by Enterprise allowed Sleep Center B to reduce its clerical staff by two full time employees. This led to a savings of $60,000 annually, providing a complete return on investment after only four months of using the system. Sleep Center B has reported that Enterprise has been invaluable in the time saved by quickly locating information through the Enterprise Query Manager. Another huge benefit is that the referral tracking abilities of Enterprise

have allowed the sleep center to focus their marketing efforts so that they can ensure maximum growth for the center.

ABOUT SLEEP CENTER C Sleep Center C is a six bed AASM accredited sleep lab.

Business Issue: The sleep center was looking to reduce costs and transcription errors involved with using a dictation service. Embla Solution: Embla installed the Enterprise System with the Enterprise transcription system. Using this system, the center was able to automate the transcription process so that the interpretation reports are now generated automatically based on clinical parameters from the study and basic physician input. Benefit: Sleep Center C has projected that the transcription feature saves approximately $24,000 per year in dictation costs and dramatically reduces transcription errors.

www.thesleepmagazine.com European Representative : • Kon. Wilhelminaplein 13 / 2.09.05 • 1060 CM Amsterdam, The Netherlands • PH: +31 20 3460 130 • FX: +31 20 3460 121


So Who Are You? What Do You Do Anyway?! The proven power of television marketing. By Michael Wiegenstein, Executive Producer markets, a 30 minute show in morning prime time (8a-11am) can be purchased for under $200.00 -- and no, not channel 358, in most markets it is under channel 16. So for less than $1000.00 per month, hen I ask doctors the most you can have your own weekly TV important thing about their show. This is probably less than you pay practice, I get a wide variety for one quarter page ad in your local of answers. Some say it is their staff or newspaper. themselves. Some say it is the office or Now, I want you to think about that the location. Others believe it is their moment when the patient really becomes technology or thousands of hours of convinced you are the provider for them, advanced education they have taken. when they decide to Every so often, one says it actually choose you to Half empty? is the patient themselves. perform the therapy they The single most need. Most would agree important thing about it is during the 20-30 a health professional’s minutes they get to spend practice is no different with you personally from any other business: while you explain exactly letting people know “who what you do to treat their you are, what you do, condition, what training Half Full? and what benefit you you have had, and what bring to your consumer technology you have base”. Although there are specifically designed to a wide variety of ways to help diagnose and treat accomplish this including their concern. The only radio, print, direct mail, problem with that is online, internal and there is only one of you external marketing (and as a full service and one of them and they are already agency we do them all), I want to focus there. What if we got 10, 100 or even on the power of television. 1000 people in a room together, all We have found time and time again who needed services you provide and when it comes to ROI (return on allowed you to explain it to them? How investment) and the power to inform many would do business with you? and educate, very little comes close Television, unlike print or radio, to an effective television campaign. allows you to do just that. By educating We are not talking about 30 second potential clients, you begin to build commercials. They can be useful your reputation in that market area. As tools themselves, but it is hard to Dr. Tom Gonzales of Las Vegas, NV educate someone about what you says: “It is your opportunity to create do in 30 seconds. We are talking the public’s perception of you. The about 30 minute talk show format testimonials are the most powerful part “newsformercials.” of it. Because I focus on sedation, I get The greatest concerns most of you a lot of high fear, BIG dentistry patients have about this type of marketing through my show.” is cost. A half hour on TV must be I know what most of you are thinking expensive, right? Wrong. In most

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now… It wouldn’t work in your market, people are different there. I hear that from almost everyone in the beginning, but it doesn’t take long for them to sound like Dr. Roy Jolley of Little Rock, AR, a provider who wanted to focus on TMJ therapy in his practice: “The very first time I aired my show, we received 26 phone calls, made 21 appointments, and closed 18 cases. I highly recommend this form of marketing if you are serious about growing your practice.” Television marketing done right also comes with many peripheral benefits. It makes all your other marketing efforts work better and as Dr. Travis Perkins of The Nevada Implant Institute put it, “The patients from the show feel like they already know and trust you, even though it is their first visit to your office. The best part is that the show provides me patients looking for the exact type of dentistry I want to perform, custom made cases.” I can’t overstress the importance of educating and informing the community about what you have to offer in your practice. How many people who are fatigued, tired, not sleeping, snoring, have headaches or balance issues would ever consider seeing a Dentist for their symptoms? I guess that would depend on whether anyone has educated them. TRUST MEDIA GROUP “The Science of Information and Awareness” Michael Wiegenstein Executive Producer Trust Media Group www.TrustMediaGroup.net Contact Info: 760-578-9272 Email: Mike@TrustMediaGroup.net

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Screening All Patients . . . A Winning Strategy Initialize patient discussions of possible symptoms and problems. By Marty R. Lipsey, DDS

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hen we speak to Dentists who are interested in starting or growing their Dental Sleep Medicine practice, one of the most frequent initial questions we hear is “How can we get patients from medical doctors or local sleep centers?” While we certainly have ideas on how to develop these referrals, we would strongly suggest that every dental practice first develops a program to screen all patients of record and all new general patients for Sleep Disordered Breathing. In most dental practices snoring and other sleep disordered breathing problems are never discussed. We have found that your existing and new patients will welcome the idea of your screening for sleep health. When you put systems in place to do this, you will find that you not only open the door to find that you probably have a multitude of CPAP intolerant patients right within your practice, but also patients that should be referred to a sleep specialist or the appropriate medical professional for further evaluation and diagnosis. The added benefit here is that you also can start to build a referral relationship with your medical counterparts. You will, as well, begin to hear many stories of patient’s family members that are in need of evaluation for SDB. This is the perfect opportunity to invite those family members to become general patients of the practice. So you see, these screening systems are not only a way to grow your sleep practice, but your general practice and relationships in the medical community as well. The most important rule of implementing a screening program for

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sleep health is to screen every patient. Using a patient’s occasional mention of snoring or excessive daytime sleepiness to trigger your sleep screening is really no system at all. The best way to determine if your patients are candidates for sleep therapy is to screen every one. Even before you put the screening programs in place, make sure that every member of your team is educated. Your team cannot successfully educate your patients and help them to commit to any treatment or referral until they understand the problem, the solutions and the way to get there. Dental sleep medicine is a unique area of your practice and requires that you take the time to have your entire team on board. We often speak about helping everyone on the team to develop the medical mindset that is necessary to discuss and deal with these problems. Make sure that this is part of your program! If you have a new patient packet that you mail out to your new general patients, introduce the idea that you are screening for sleep health at the initial telephone contact and include the appropriate screening forms in your new patient packet. Some ideas of what to include are the Epworth Sleepiness Scale, the Fatigue Sleepiness Scale and Bed Partner Screening forms. For your recare patients, make sure that the hygienist or dental assistant has a standardized routine, with questions and checklist, so that every recare patient appointment follows your protocol in terms of screening for SDB. Our philosophy is that initial screening is just that - initial discussion of possible symptoms and problems that lead to a subsequent initial sleep consultation

appointment. The sleep screening at a new patient exam or recare appointment should lead to the offer of a followup initial sleep consultation. It is at the subsequent appointment where the situation is discussed and evaluated in more detail. Trying to do too much at screening time may lead to; (1) delays in treating other scheduled patients for the day, (2) rushing or incompletely explaining all the details of the sleep problem(s) and treatment options, and/ or (3) discouraging the patient from scheduling the proper and complete sleep consultation appointment because you have given them the impression that it may be secondary to their dental treatment or that you are really not focused on their sleep health, The bottom line is that attempting to do too much at the initial sleep screening shortcuts the patient in terms of fully analyzing the problem and providing the patient with all necessary information. Proper sleep screening is structured so that it introduces the critical initial information and is also a segue to the complete and subsequent sleep consultation appointment. In this manner, it is a win-win situation. The follow-up initial sleep consultation is really the appropriate time to do a more thorough evaluation, using your pharyngometer and other tools to gather information and to discuss the situation in greater detail. This is the dedicated sleep appointment where you have scheduled time to be more thorough. You now have the appropriate setting to help the patient understand the treatment options and will be more likely to have the patient commit to the next appropriate step in treatment or evaluation. Implementing a fully organized and across the board screening routine is the key to get to the initial sleep consultation appointment and a winning strategy for your dental sleep medicine practice!


Less Known But Common Symptoms Found in the Sleep Apnea Population Some of these associated symptoms are not appreciated by medical professionals unfamiliar with the many important physiologic functions By Steven Scheer, MD, DABSM

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here are several interesting symptoms associated with obstructive sleep apnea (OSA) besides the more commonly heard complaints of loud snoring and daytime sleepiness. Some of these associated symptoms are not appreciated by medical professionals unfamiliar with the many important physiologic functions served by a healthy and fulfilling sleep. In taking a dental history from patients who have a small oropharynx, macroglossia, retrognathia or other findings prompting a suspicion of OSA, dentists interested in Sleep Medicine might consider these interesting and fairly common associations. Nocturia Repeated urination at night is referred to as nocturnal polyuria or simply nocturia. Having to urinate more than once in the middle of the night meets the definition of nocturia. In persons with obstructive sleep apnea (OSA), nocturia is a fairly common occurrence. Severe OSA can cause a need to urinate every hour during the sleeping period. There is considerable evidence that atrial natriuretic peptide (ANP), a hormone produced by the heart muscle in increased amounts in persons with sleep apnea, is responsible. This hormone is essentially a natural diuretic produced by and released in tiny amounts by the heart and brain. Italian

researchers identified that nocturnal ANP production correlates with elevated urinary volumes overnight and that treatment of sleep apnea lowered both the ANP secretion and urine volumes. Patients successfully treated for sleep apnea appreciate that they need to awaken to urinate infrequently. Awareness of relief often comes the very first night of effective treatment. It should be noted that such conditions as diabetes, interstitial cystitis, prostatism, or the â&#x20AC;&#x153;too much to drink before bedâ&#x20AC;? syndrome can also cause nocturia. Morning headache Headache is among the most common of human complaints. Awakening with a headache represents an important subset. Chronic morning headache is considered to be a part of the sleep apnea syndrome. The more severe the apnea is, the greater the likelihood of waking with a headache. For some people, the headache is unusual in that it may go away just by walking around , by taking a morning shower, or after coffee consumption. When a sleep-related breathing disorder

is treated successfully, morning headaches generally disappear, supporting a causal role of the sleep disorder. Several hypotheses have been proposed to explain this relationship. Night-time fluctuations of arterial oxygen saturation along with high carbon dioxide (hypercapnia), associated intracranial vasodilatation, increased intracranial pressure and sleep fragmentation may all contribute but the exact mechanisms both of headache pathogenesis and its elimination by treatment remain controversial. Whatever is the mechanism, neurologists now often include a screening sleep study as part of the work-up for headache since they know treating the apnea problem may be fundamental to eliminating the headache. Dentists are aware of a surprisingly common second cause of morning headaches: bruxism, teeth grinding or clenching. The biting force in bruxism is often much higher than normal force for biting food. This constant and forceful movement of the jaw during sleep causes tension in the neck that can lead to headache on waking. Unfortunately, headache from this problem is difficult to address since most treatments focus on protection of the teeth rather than elimination of jaw muscle action. Night sweats WWW.SLEEPGS.COM

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Excessive sweating at night is known in the medical literature as sleep hyperhidrosis. We commonly refer to it as “night sweats”. These can be due to a warm sleep environment and of no medical concern, or they can be meaningful and indicative of pathology. Severe night sweats can be quite distressing and disrupt sleep patterns. A person or a bed partner can awaken drenched from the damp sleepwear or wet sheets. Night sweats can be caused by menopausal hormone changes, infectious disease such as tuberculosis or HIV, diabetes, medication side effects, and alcohol at bedtime. However, one of the commoner causes of night sweats in men and nonmenopausal women is sleep apnea. A hyperactive sympathetic nervous system (SNS) is believed to be responsible for this excessive sweating in apneic persons. Disturbance of the SNS can occur when an individual is exposed to a number of distressing stimuli. With sleep apnea, there is brain arousal from either low arterial oxygen or a “felt” airway resistance to breathing. The struggle to get proper oxygen causes a stress response much like “flight or flight”, leading to excessive sweat gland production. The SNS disturbance is further shown by elevated catecholamine production and excretion in the urine. The disappearance of night sweats by treatment of sleep apnea is one of the motivations for continuing the treatment. After treatment starts, there is evidence of reduced sympathetic activation because urinary catecholamine production is reduced dramatically when sleep apnea is eliminated.

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Erectile dysfunction

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It is well established that sleep apnea increases the risk of erectile dysfunction (ED) in men and that there is strong correlation between the severity of the two disorders. During sleep, men commonly experience erections during the rapid eye movement phase (REM), when a person dreams most vividly. One theoretic cause for ED is that sleep apnea disrupts REM. It is also possible that REM erections are essential for men to maintain sexual health and performance. Reduction in REM means fewer erections over the night, possibly causing ED. At Cornell University, researchers tested the correlation by studying ED in men symptomatic for sleep apnea. The study revealed that as many as eighty percent of the men who had abnormal or disrupted sleep from sleep apnea also had trouble achieving or maintaining erections. In another study at the University of Louisville using mice, Dr. David Gozal and co-investigators found that after one week of being exposed to chronic intermittent hypoxia (low arterial oxygen) similar to that found in humans with OSA, mice showed a 55 percent decline in their daily spontaneous erections. After five weeks of this lower blood oxygen exposure, the “latency to mount” period - the average interval before mounting a mate - increased 60-fold. Restless legs Restless legs just before bedtime and extending into the sleep period is a fairly common condition, occurring in roughly 10% of the general population, and probably closer to 15% of older adults. The condition can be hereditary, but at least 50% of persons have a precipitating cause, including iron deficiency, medication side effect, renal failure, and sleep apnea. Sleep physicians distinguish between the daytime phenomenon of having an annoying sensation that causes a need to

move, called “restless legs syndrome”, from the sleep –related phenomenon of periodic leg jerks, called “periodic limb movement syndrome (PLMS). For some, PLMS is inconsequential but for others and in particular for a lightersleeping bed partner, PLMS can be quite a nuisance and a cause of insomnia through the night. The co-occurrence of repeated nocturnal leg movements and sleep apnea events is well known to sleep specialists who commonly see patients’ leg movements caused by a brain arousal due to a lapse in breathing. Treatment of the breathing disturbance, with CPAP therapy or a dental appliance, can ameliorate the kicking disturbance. Summary Dental professionals are increasingly identifying sleep breathing disorders in their patients. It is important to be aware of many possible symptoms these individuals may have. In addition to the commonly known symptoms of excessive daytime sleepiness and snoring, dentists might inquire about nocturia, morning headache, erectile dysfunction and restlessness in bed both before considering the need for a sleep evaluation and after employing a mandibular advancing appliance to discern any symptomatic improvement.

References Hajduk IA , RR Jasani et al. Nocturia in sleepdisordered breathing. Sleep Medicine 2000; 1(4): 263-271 Provini F, R. Vetrugno, E. Lugaresi & P. Pontagna Sleep-related breathing disorders and headache. Neurological Science 27 (Suppl 2), 2006: s149s152Rains JC & SJ Pocet , Sleep and headache disorders. Headache: Jl Head and Face Pain, 2006; 46(3): S147 - S148Soukhova-O’Hare GK, D Gozal et al. Erectile dysfunction in a murine model of sleep apnea. Am Jl Resp & Crit Care Med, 2008; 178: 644-650


Dental Sleep Medicine. . . A Full Team Approach! Production time does not have to suffer as you add this specialty into your practice. By Sleep Group Solutions

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ental sleep medicine is the most rewarding field in dentistry; it is one of the only fields that you can practice standing up, and also practice with your mind instead of your hands. Beyond the physical rewards, there are also the emotional benefits that you receive from changing the lives of your patients and giving them back their health. The one aspect that doesn’t get much attention is the fact that as you implement this specialty into your practice, it is not the dentist that has to do all of the work. In this field, you can train your staff to take over much of the treatment; this is such a benefit in so many ways. As the doctor, you are the leader in your office. You are responsible for inspiring your staff to take on new challenges and for keeping up to date with the changes in the field. You are the catalyst that makes things happen in your office. In dental sleep medicine, this is still the case, however, once the ball is rolling, you can relinquish a majority of the responsibilities and your staff can absorb them. Your staff will become so empowered by the knowledge that they gain and use on a daily basis and they can save you valuable production time. This will give you more time to see more patients and increase your production, while working less! This being said, it is so important to train your staff, and train them well. Whether this means that they come to the seminars with you (best case scenario), or they read the manuals

that you receive, or you have frequent educational staff meetings, etc. Whatever the mode of training, the more that your assistants know, the more excited they are about the process. At Sleep Group Solutions, we offer a very discounted rate as an incentive to bring your staff to the seminars. We know how powerful it is for them to hear the exact same information that the doctor does. When you return to the

office, it isn’t just a “new bleach”, it becomes a mission for the entire staff. Dental sleep medicine requires a full team approach in the office; and it isn’t the doctor that is doing the lions share of the work. The assistants and administrative staff really take care of a majority of the pre and post work with your OSA patients. Here is a typical graph of time spent

with an OSA patient. The breakdown goes like this: Administrative staff: All paperwork, insurance, patient correspondence, billing, etc. Assistants: Initial records, testing in office, x-rays, pharyngometer/rhinometer, impressions, bite registration, delivery, adjustments and follow up. Doctor: Patient education, appliance selection, delivery and validation. The point in this breakdown is to illustrate how much happens between all members of the staff; and how much responsibility is bestowed on each member. It should also demonstrate how much time the doctor will have to be seeing other patients and increasing production. The goal in this article is not to discount the doctor’s abilities, at all, it is to hopefully give you a new outlook as to how important this field can be to your office. Also, it is to show you that, as the doctor, your production time does not have to suffer as you add this specialty into your office. You can delegate the responsibilities and create a way to produce more, with less effort and time on your part. Start today, working smarter, not harder! WWW.SLEEPGS.COM

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We allow people to live longer and feel younger.

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y journey into sleep came through the eyes of a TMD and Orofacial Pain practitioner. I knew that most of my TMD patients who were women were sleeping poorly and waking up exhausted with tight jaws, necks and shoulders. Unless I could give them deep restful sleep they would continue this pattern and continue to spiral downward. Moldofsky’s work on Fibromyalgia was very helpful as were discussions with Solberg and GrafRadford in the mid 80’s. I was often able to change brain chemistry pharmacologically as an adjunct treatment to reduce pain and discomfort. In the mid 80’s my patient Raquel Welch told me that after wearing my appliance at night she awoke rested and rejuvenated. I attributed this to the effect of decreasing pain and stress. Years later I learned that it probably had more to do with sleep fragmentation Around 1990 Wayne Halstrom spoke at NYU where I was running the TMD and Orofacial Pain Program. He showed me a picture of his Cadillac (his third) that he had wrapped around a highway divider. Miraculously he walked away unscathed but then learned that he had an unknown condition called Obstructive Sleep Apnea. He crafted the Silencer out of balsa wood in order to treat his own condition. Wayne was the first doctor to inspire me to devote a good part of my career to teaching, researching and practicing breathing related sleep disorders. I was lucky to be at NYU where David Rappaport was doing sleep research on RERAs and UARS using nasal cannulas instead of thermistors. This was the early 1990’s and we did a study with the Silencer on mild and moderate apneics. I worked with Wayne for about 10

By Michael Gelb, DDS years teaching the extra-oral Gothic Arch Tracer which I still feel is the best method to find the “bite”. I also taught TMJ diagnosis and prevention in Dental Sleep Medicine. John Remmers, who is a good friend, gave one of the best lectures ever on the role of the dentist in sleep diagnosis and treatment. He inspired me to do sleep testing and I soon owned a Remmers Recorder. Along the way Keith Thornton , another fabulous speaker and inventor , opened my eyes to airway management with the TAP. I have been fortunate to have worked with Ed Spiegel, Bob Talley and Dennis Bailey on the development of the NORAD which is a very useful chairside appliance for snoring and OSA. I have taught with my good friend Mark Abramson, the inventor of the OASYS. We have a course Feb 11-14th at Pebble Beach. Mark opened my eyes to nasal dilation and the role of the rhinometer One of my favorite people in sleep is Bryan Keropian. His use of the pharyngometer for screening is

unparalleled. Bryan’s Full Breath Solution is the best appliance for individuals with a large tongue base where nothing else will work. I currently have 2 practices, NYC and White Plains. I have 3 Pharyngometer and Rhinometers. I use them both for screening and optimizing mandibular position in airway titration. My NewTom is an incredible tool for sinus , turbinate, septum evaluation as well as mandible , soft palate and tongue

evaluation. By using Dolphin, NNT and Anatomage software I can isolate and measure the volume of the airway before and after treatment My clinical assistants and lab techs are the most sophisticated in the business Lisa, David, Kate and Wally. They are familiar with all our high tech equipment and can explain the results to the patient. I encourage you to train your staff and get them certified. It was John Remmers who I travelled to India with, who pounded into my head the importance of home sleep testing follow up. We must do follow up sleep tests on ALL our OSA patients. The impact we can have on people’s lives as dentists is profound. We allow people to live longer and feel younger. 90% of airway obstruction is behind the mandible and maxilla. We are the doctors of the jaws with the ability to co-manage the tongue and soft palate. We are part of a medical team which can successfully manage the airway. We have just completed a million dollar renovation with a conference room for in-office courses and hands on training in everything from home sleep testing to CT Scan to Pharyngometer and Rhinometer as well as insertion and fabrication of oral appliances in our lab. Happy Holidays

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The Impact We Have on People’s Lives is Profound

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Rhinometry Abnormal test results should alert the dentist to follow up with ENT. J.Brian Allman, DDS

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lectrodiagnostic instrumentation has catapulted positive airway pressure (PAP), surgery, oral appliance heath care diagnoses influencing treatment protocol therapy and nasal patency therapies. While the first three rather dramatically; dental sleep medicine is no are historically recognized “players”, the fourth, nasal different. In fact, rhinometry in particular, offers essential patency, is a relative newcomer. utility when screening prospective oral appliance therapy Nasal patency, as revealed in current literature, plays patients. a vital role in OSA therapy. Research shows that nasal Understanding the modern approach to treating airway resistance (NAR) can positively or negatively obstructive sleep apnea impact the efficacy of both PAP mandates abandoning the old and OA therapies. Higher NAR model of treating patients in negatively impacts OA efficacy a near vacuum and pursuing, and lower NAR improves OA cultivating and embracing a efficacy. Clearly, we must multi-disciplinary collaborative evaluate nasal patency as part medical approach to treating of our OA screening protocol. this insidious and deadly Not all patients pandemic condition. This referred for OAT will have had medical-dental model involves endoscopic examination to now a quartet of modalities rule out the possibility of nasal used both synergistically and blockage. It behooves the adjunctively. astute dental sleep medicine A four pronged approach physician to use rhinometry to to treating OSA patients easily, quickly, economically leverages the talents and and non-invasively evaluate expertise of aware dentists, nasal patency which can Figure 1 Barry C. lateral cephalogram ENTs, allergists and sleep directly influence OAT specialists providing the best outcomes. The four pronged prognoses for OSA sufferers. Abnormal test results approach can be likened to four spheres (of influence) should alert the dentist to follow-up with ENT referral each intersecting one another. The four spheres of for expert paranasal sinus evaluation. Close attention to influence include the following disciplines and therapies: this narrowest member of the OSA therapy quartet will

increase OA outcomes and put the ability to examine the initial few centimeters of our airway into the skilled hands of our dental sleep colleagues. The following case illustrates the utility of rhinometry in dental sleep medicine practice and should also raise concern for rhinometry non-users. In fact, the author welcomes all collegial discussion regarding the use of rhinometry (info@sleepgs.com). Barry C. presented to our office referred by a physician for an oral appliance to treat his OSA. Though prediagnosed with moderate OSA (AHI = 27) and a negative lateral cephalogram, routine pre-OAT rhinometry did reveal significant nasal blockage of his right paranasal sinus. An iCAT scan was subsequently obtained and upon examination a significant mass was revealed. Immediate referral to an ENT for evaluation was recommended prior to my initiating OAT. ENT evaluation confirmed a huge, antral choanal polyp on the right side with erosion of the medial, maxillary sinus wall. Further, diffuse maxillary and frontal sinus infection was noted on the patient’s right side. The surgeon’s recommendation was for bilateral endoscopic intranasal total ethmoidectomy, left endoscopic intranasal antrostomy and right endoscopic intranasal antrostomy with tissue removal. Due, in part, to our multidisciplinary medical-dental network, Barry’s surgery was performed successfully only nine days after ENT referral. Had rhinometry not been performed as routine screening protocol, OAT might have been less than successful despite my efforts monitoring OAT titration protocol for several months. My delay in identifying this obvious and undiagnosed nasal patency issue might have yielded much more dire consequences for this patient. While general dentists cannot utilize endoscopic procedures, thank goodness for rhinometry! Editorial note: In my opinion, electrodiagnostic equipment such as pharyngometry and rhinometry are not an option. Noninvasive and inexpensive testing of a patient’s airway is basic to modern dental sleep medicine. Read about the utility of pharyngometry in our next DSM Magazine. Brian.

Dental Solutions for Sleep Problems The Dentist’s Role in the Management of the Sleep Apnea Patient Presented by Chris J. Hansen, DDS and Dan Taché , DMD, D,ABDSM Course Description

Thursday Evening Dental Sleep Medicine Basics - A review of sleep, the pathophysiology of Sleep Disordered Breathing (SDB) & Obstructive Sleep Apnea (OSA). Portable Monitor Use In Dental Sleep Medicine Practice - Compare and contrast the various portable monitors and the information that can be gleaned from the reports. Q and A and distribution of portable sleep monitors. Friday Portable Monitor Review with Clinical Applications - Review of data from portable monitors and a review of the report with appliance adjustment. OSA Medical Management and the Trained Dentist - Medical diagnosis of Obstructive Sleep Disorders and the common co-morbidities of Sleep Disordered Breathing.

Oral Appliances in Management of OSA - oral appliance therapy in OSA management effectiveness of oral appliance therapy vs. other treatments. Oral Appliance Therapy Crash Course - Bite techniques and using the pharyngometer to find the optimal treatment position. Fees & Insurance- How to keep fees from being a barrier in treatment & how to encourage referrals. Q and A course wrap-up.

Course Objectives

• To provide a basic understanding of sleep medicine and to explore dentistry’s vital role in management of sleep disordered breathing of the patients who do not respond to customary medical treatment. • To explore the link between sleep-disorder breathing (snoring, , upper airway resistance syndrome and sleep apnea) and malocclusion, sleep bruxism, and TMD. • To provide a comprehensive, standardized approach to the management of sleep disordered breathing

• • •

using oral appliances. Using this information, participants will be able to effectively evaluate and treat patients with snoring and diagnosed with sleep apnea. To describe indications for the use of a variety of FDA approved Mandibular Repositioning Devices (MRD) and to determine which is appropriate each patient. To understand the use of airway imaging equipment (acoustic reflection) to evaluate the airway response to repositioning of the mandible. To recognize the essential role of the portable sleep monitor (PM) in the effective management of patient engaged in MRD therapy. To educate the dentist and support staff in order to make practicing “Sleep Dentistry” efficient and financially profitable. Develop an internal marketing plan for your practice. Learn effective methods of building strong relationships and communicating with sleep medicine physicians and sleep centers in your community.

For Course Information - Contact Sleep Group Solutions

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

1-866-363-3936 www.rondeauseminars.com â&#x20AC;˘ www.sleepgs.com

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Dental Sleep Clinics • Abidin, Michael D.M.D. • Abramson, Mark E D.D.S. • Adams, William C. DDS • Adelstei, Cindy, DDS • Agatep, Kathrina DDS • Ahler, John, DDS • Albert, Joe M., DDS • Aldrich, Dell DDS • Alfaro, David, DDS • Allman, J. Brian DDS • Alpher, Elliot DDS • Andrews, Victor DDS • Armstrong, Tom DDSh • Arthur, James C DDS • Arthur, Lisa DDS • Arturo, Garcia, DDS • Ashton McGregor, Catherine DDS • Aubin, Phillip DDS • Austin, David D.D.S. • Autobee, Thomas V., D.D.S. • Awayes, Adly T. DDS • Babiec, Daniel D.M.D. • Bach, Darin M. DDS • Bailey, Dennis D.D.S. • Bailey, Jeanne K. D.D.S. • Bailey, Jeffrey C. DDS • Balatgek, Tammy, DDS • Barron, Melody A. DDS • Bauer, Dale, DDS • Bauk, Marta, DDS • Baylin, Michael DDS • Beck, Jim D.D.S. • Belfore, Theodore R. DDS • Bennett, Terry D.D.S. • Bernstein, Allan K. DDS • Billard, Brian R. DMD • Blackwell, Courtney DDS & Miskuf, Michael DDS • Blumenstock, Norman D.D.S., MAGD • Bosma, Thomas S. DDS • Bowden, Sam & Laura D.D.S. • Branscombe, Gregg DDS • Brouhard, Gerald L DMD • Brown, Chris DDS • Brown, Robert J. DDS • Bryan, Gregory, DDS • Buske, Jeff DDS • Cadden, Brian, DDS • Cahali, Michael MD • Callender, Sam D.D.S. • Cashion, Tim & Cashion, Theresa DDS • Chai, Jesse DDS • Chao, John C., DDS • Chaves, John M. DDS • Cherin, Jack I., DMD

• Chomiak, Joe DDS • Choudry, Rashid., MD, FACS • Chu, Johnston D.D.S. • Clifford, Daniel E. DDS Clifford, Paul M DDS • Cobb, Daniel DDS • Cobbs, Charisse, DDS • Cody, Theresa DDS • Cohen, Eric, DDS • Cohen, Stanley, DDS • Cole, Stacy V. DDS • Collett, Miles B., DDS • Colson, Dana DDS • Cooper, W. Philip, DDS • Corbett, Jeffrey DDS • Coriz, Patrick, D.D.S • Corn, Jack, DDS • Cost, Nick, DDS • Creating Smiles • Crombie, Martin & Debra D.D.S. • Danchuk, Matthew DDS • Danchuk, Donald DDS. • David Rubis DDS • Davis, Vincent DDS • Davydon, Albert, DDS • Daya, Roger DDS • Dean, Robert, L., DMD • Dean, Ron DMD • Dean, Terecita L. DDS • Decker, Nathan, DDS • Delsor, Ted DDS • Demurjian, Gary DDS • Digiorno, Anthony DDS • DiLeo, Kevin, DDS • Doneskey, Jeffrey W. DMD • Donley, James, DDS • Doppke, Douglas, DDS • Dorrow, Stanley T DDS • DuHamel, James B DDS • Dwyer, Alicia, DDS • Ellis, Arian R. DDS • Eng, Lily DDS • Escoto, Mark J. DDS • Fareid, Behzad DDS • Farooqui, Shaqufta DDS • Farrell Fruge, Cecil Jr., DDS • Farris, David DDS • Feld, Leonard J. DDS • Ferro, Peter P. DMD • Fink, Larry DDS • Firouzian, Michael DDS • Fischer, Richard D., D.D.S. • Fong, Jack DDS • Foreman Glenn DDS • Frank A. Pettisani DMD

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Friedman, Mark DDS Fritzsche, Calvin A. DDS Frodel, Greg DDS Garcia, Arturo, DDS Garcia, Javier DDS Garcia, Maria Teresa, DDS Gelb, Michael L. DDS Gengle, Michael D.D.S. George, Thomas D.D.S. Geron, Phillip D.M.D. Gildner, Jerome DDS Gillum, Richard DDS Goad, Andrew L. DDS Goebbel, Martin, DDS Gole, Daniel R. DDS Gonzales, Bulmario DDS Goodwin, J. C., DMD Gordon, John A. DDS Gorman, Martin DDS Gotsis, Thomas M., DDS Greenburg, Jonathan DDS Grimmer, Bryan, DDS Guinn, James, DDS Hall, Phillip C. DDS Halsey, Wm, DDS Handley, Cheryl, DDS Handley Dental Center Hansen, Chris J. DDS Hatch, Stephan L. DMD Hayslip, Curtis O., DMD Herald, John DDS Herpe, Lynn DDS Hobbs, Edward DDS Hoefs, Michael D. DDS Hoffman, Steven M. DMD Hollenbeck, Thomas DDS Holt, Charles, DDS Hong, Sook DDS Horchover, Robert L. DDS Hughes, Timothy, DDS Hwang, Daniel, DDS Inouye, Randall N. DDS Isaacs, Mary R., D.M.D Isom, Blair DDS Jackson, Dan, DDS Janosik, Jeffrey M., DDS Jeppesen, John C. DMD Johnson, Bradley E. DMD Johnson, Douglas H. DDS Johnson, Jeff DDS Jolley, Roy DDS Jones, Marilyn K. DDS Kaniff, Alice A. DDS Kawakami, Alan P. DDS Kepp, Philip B., DDS Keropian, Bryan D.D.S.

• Kim, Chun K. DDS • Kincaid, Jeff, DDS • Kinzer, Craig A, DDS • Klein, Deborah DDS • Klemons, Ira DDS, PhD • Klockow, Gordon DDS • Koeppel, Ira D. DDS • Kohen, Michael, DDS • Kravitz, Robert S., DDS • Kulaga, Eugene DDS • Kurban, Andrew DDS • Kushner, Gerald DDS • Kwiatkowski, Kathy DDS • Laij, Khin DDS & Laij, Lily DDS • Landeros, James DDS • Langstaff, William N. DMD • Larson, Keith DMD • LaSelle, Thomas, DDS • Lauck, Rebecca J. DDS • Laurence, Peter, DMD • Lawson, Steve DDS • LeJeune, Kurt DDS • Leon, Steven DDS • Leone, Phillip A. DDS • Levy, Mark DDS • Liem, Edmund DDS • Light, Rick A. DDS • Lipsey, Marty DDS • Lockerman, Larry Z DDS • Loftus, Ronald J. DDS • Loriaux, Aubyn, DDS • Lowe, Alan DDS • Loye, James DDS • Luckman, Valencia DDS • Maggan, Manoj DDS • Magida, Edward A. DMD • Makaea, Pamela DDS • Mallonnee, Barbara DDS • Mansoon, Ahmed DDS • Marinkovich, Steven P. DDS • Martin, Charlie, DDS • Matriste, Lisa G., DDS • Mavandadi, Shahrad DDS • Maytesyan, Amik DDS • McMahan, John, DDS • Mc. Vicker Michael DDS • McCloy, Russell DDS • McMunn, Mike, DDS • McNaughton, Clifford, DDS • McVicker, Michael C. DDS • Medlock, James DDS • Mehrabani, Gita, DDS • Messing, Michael D.D.S. • Meyer, Nicholas DDS • Miskuf, Michael DDS

• Mitchell, Margarett, DDS • Mollick, lawerence, DDS • Montoya, Arthur, DDS • Moore, Michael DDS • Moore, Kent MD, DDS • Morales-Garcia, Patricia, DDS • Morejon, Orlando • Morris, John B., DDS • Murillo, Maricela, DDS • Naghaqmi, Resa, DDS • Nassery, Hamid, D.M.D. • Neal, Phillip, DDS • Nichols, Del DDS • Nigro, Carlos DDS • Nutter, David L., DDS • Ong, Lilian DDS • Pabst, Richard J., Jr, DDS • Packard, Mark DDS • Panczyk, Peggy DDS • Papir, Dori DDS • Patel, Hitesh K. DDS • Pecenka, Michael P. • Pearson, Murray DDS • Peters, Robert, DDS • Peterson, John DDS • Pham, Carol Huong DDS • Phillips, Douglas DDS • Pick, Douglas DDS • Planer, Angela DDS • Pribyl, Larry DDS • Queen, Brian DDS • Ramirez, German, DDS • Rawson, David DDS • Reichgott, Brian DDS • Reinmiller, Ronald DDS • Reynolds, Robert K. DDS • Robinson, Tim, DDS • Roeder, Gordon DDS • Rogers, Michael B. DDS • Romack, Deborah A. DDS • Rondeau, Brock H.M. D.D.S. • Rose, Steven DDS • Rosebury, Scott, DDS • Roskelley, Chad W. DDS • Roubal, Roger DDS • Rousseau, Robert DDS Lielais, John DDS • Rubis, David & Joseph DDS • Ryan, W. Ross DDS. • Saager, Norman D. DMD • Salisbury, Herbert DDS • Sambataro, Eugene D.D.S. • Sanchez, David, DDS • Saran, Baldeep K DDS • Satnick, David D.D.S. • Sauer, Eddy, DDS

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Sauer, Ina, DDS Savedra, Manuel A. DDS Schafer, Eric DDS Schantzer, Eric DDS Schwantes, Thiago, DDS Schapansky, Weldon K. DDS Scheer, William DDS Schlott, Warren James, DDS Schmidt, John DDS Schmidt, John, DDS Schumacher, Charles DDS, FAGD Segal, Marc E. DDS Shantzer, Eric DDS Shea, Michael, DDS Sherman, Ben K., DDS Sherrod-Jewell, Carole DDS Shirazi, David, DDS Shklovsky, Victoria DDS Shturman, Inna DDS Shudrack, Jaroslaw DDS Siegel, I Marc DDS Siegel, Jefrey S DDS PA Silver, Scott A. DMD Simmons, Dennis, DDS Simmons, Robert, DDS Simmons, William C. DDS Skowronski, Raymond D.D.S. Slabach, Dawne DDS Smith, Anna Ruth DMD Smith, B. Kent DDS Sofferman, Bruce DDS Stern, Gloria DDS Striebel, David J., DDS Soto, Rudolph M. DDS Sprinkle, Allen DDS Sreshta, Flavia D.D.S. Stack, Brendan C., DDS Stagg-Ruda, Claire DDS Steel, Marc D.D.S. Steinberg, Howard M. DDS Steinberg, Michael DDS Stern, Gloria DDS Sukel, Phillip P. DDS Sullivan, Frank DDS Sutter, Vesna S. DDS Sweeney, David F. DDS Sweeney, James E. DDS Szarko, James, DDS Szawlowski, Elizabeth, DDS Tache, Dan D.M.D. Tallents, Ross DDS Talley, Robert L. DDS Tatevossian, Steve DDS Taxin, Paul DDS Taylor, Tim DDS Thompson, Andrew F. DDS

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Tilley, Larry L. DMD Tobias, Luz DDS Tophan, LaNell DDS Tregaskes, Joseph DDS Troop, Michael, DDS Ueber, Robert, DDS Urban, Daniel P. DDS Uyehara, Kurt I. DDS Valen, David DDS Valen, David M., DMD Vali, Megan DDS Valladares, Carlos D.D.S. VanDyke, Schuyler DDS Viviano, John DDS Vo, Diane, DDS Wahib, Shokri DDS Walker, Thomas, DDS Wall, Judson B., DDS Walz, Jack DDS Warren, Donald DDSh Welch, Dane DDS West, Scott D.D.S. Wheeler, Larry DDS Whillock, Edward DDS Wiggins, Cynthia M. DDS Wilk, Steven J. DDS Wilks, Thomas, DDS Willet, Kent DDS Williams, James DDS Winber, Stephen M. DDS Winter , Daniel M, DDS Witek, Robert A DDS Wolfe, William D.D.S., N.M.D. Wood, Don C III DDS Wong, Nelson, DDS Wooten, David DDS Wyatt, Rebecca DDS Wyatt, Eric DDS Yatros, Gy DMD, OMD Zane, Neil DDS Zymantas, Kaz M., DDS


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