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Sleep Magazine THE

www.thesleepmagazine.com

BITE REGISTRATION FOR A FUNCTIONAL APPLIANCE! (David Walton)

6TH EDITION

USD $14.75

UNDERSTANDING SLEEP DISORDERS

IMPROVING EFFICACY OF NON-RESPONDERS TO MANDIBULAR ADVANCEMENT IN THE MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA (Daniel Tache, DMD)

Including patient education articles Share this article with your patients!

MEASURING AND COPING WITH EXCESSIVE SLEEPINESS!

(Gregory Carnevale, MD)

FUTURE HEALTH OF OUR PATIENTS DEPENDS ON

DENTISTS

Treating Snoring And Sleep Apnea with Oral Appliances

(Brock Rondeau, DDS, IBO)


2013 Dental Sleep Medicine Seminars Calendar 16 CEU PACE/AGD Approved!

These two day information packed seminars will help you jump start your dental sleep medicine practice!

May 2013 17th-18th: Detroit, MI 17th-18th: NYC, NY

June 2013 7th-8th: San Antonio, TX 14th-15th: Milwaukee, WI 14th-15th: Irvine, CA 21st-22nd: Boston, MA 22nd-23rd: Houston, TX 28th-29th: New York, NY

July 2013

September 2013

12th-13th: New Orleans, LA 12th-13th: Baltimore, MD 19th-20th: Chicago, IL 19th-20th: San Francisco, CA 26th-27th: Philadelphia, PA

August 2013

October 2013

2nd-3rd: Buffalo, NY 2nd-3rd: Portland, OR 9th-10th: Newark, NJ 16th-17th: San Diego, CA 16th-17th: Charleston, SC 23rd-24th: Rochester, NY

Sleep ApneaThe Hottest Niche in Today’s Dentistry

6th-7th: Cleveland, OH 6th-7th: Salt Lake City, UT 13th-14th: Orlando, FL 20th-21st: Irvine, CA 27th-28th: Washington, DC 4th-5th: Nashville, TN 11th-12th: Hartford, CT 18th-19th: Denver, CO 25th-26th: Ft. Lauderdale, FL 26th-27th: Eau Claire, WI

November 2013 8th-9th: Seattle, WA 15th-16th: Kansas City, KS 15th-16th: Los Angeles, CA 22nd-23rd: Dallas, TX 22nd-23rd: Philadelphia, PA

December 2013 6th-7th: Irvine, CA 13th-14th: Chicago, IL 13th-14th: Tampa, FL

16 CE’s

Our Seminars Include:

Meet the Instructors

Dr. Barry Freydberg Dr. Michael Hnat Dr. Dawne Slabach Mr. John Nadeau

Dr. Marty Lipsey

Dr. Michael Gelb

Dr. Dan Tache Dr. George Jones Dr. Vesna Sutter Dr. Jeffrey Horowitz Dr. Jerome Gildner Dr. Damian Blum Dr. Stacey Layman

Register Today!

SLEEP APNEA AND AIRWAY MANAGEMENT One Stop - More Solutions.

995 1-855-4SLEEPGS $395 (Prices and acceptance of new clients subject to change) Visit our website for further details and registration.

www.sleepgs.com

$

Doctor

Staff Member


Sleep Magazine 2013 Contents: THE

Putting the Passion Back into your Practice! Page 24 This is Why I Do It! Technology and Oral Appliances

Page 26

Implementing a Complete Sleep Solution Page 28 Bite Registration for a Functional Appliance Page 30

The Evolution of Dental Sleep Medicine Page 33 Dental Continuing Education

“I Want to Get Into Sleep Apnea Screening and Treatment But I Don’t Know Where to Begin,” Page 5

The Role of Staff in a Successful DSM Practice Page 10

Future Health of Our Patients Depends on Dentists Treating Snoring And Sleep Apnea With Oral Appliances Page 36

Case Studies

New to Treating OSA? What is Success? Page 12 OSA Education and Advocacy

Measuring and coping with excessive sleepiness Page 14 How Snoring Affects Your Partner Page 18

OSA is NOT Here to Stay! The Importance of Sleep Wellness

Non-Responders to Mandibular Advancement in the Management of Obstructive Sleep Apnea Page 40

Sleep Apnea Myths

Page 50

PSG versus Home Sleep Study-A patient case study Page 54 About US

Sleep Group Solutions Page 58

Page 20

Sleep Apnea ...A Matter of the Heart Page 22

WWW.SLEEPGS.COM++++PAGE 3


Sleep Magazine THE

President’s Letter

Welcome to our magazine

T

his magazine is a publication designed for medical and dental professionals interested in the latest information

on the screening, diagnosis and treatment of sleep disordered breathing problems.When we started Sleep Group Solutions (SGS) in 2005, the world of sleep medicine was quite different.We have seen the dental treatment of these problems become a much more acceptable option, and SGS is proud to have helped facilitate the diagnosis and treatment of thousands of new patients through our

Sleep$Group$Solutions

President Rani$Ben>David$ ranibd@sleepgs.com CEO Tamir$Cohen$ tamir@sleepgs.com Director$of$Marketing$&$PR Holly$Jordano$$$ holly@sleepgs.com Creative$Director Miguel$Valcarcel$$ miguel@visualmediaarts.com

medical/dental client network. It has been amazing to see the growth and heightened level of awareness of sleep apnea. New studies linking sleep apnea to cancer, dementia, stroke and other deadly health issues have given us all a huge wake up call. The dental sleep medicine industry is in higher demand than ever, and as a company, Sleep Group Solutions is now opening offices and resource centers across the globe. This is a global epidemic, and we are pleased to spread the knowledge around the world.

Rani Ben-David President Sleep Group Solutions “We understand that education is the key to success in this field. Knowing this, SGS has put together the most comprehensive series of CE seminars in

Editors Holly$Jordano,$John$Nadeau,$$ Dr.$Dan$Tache,$Dr.$Charles$Kravitz Tracy$Faulkner Contributing$Writers$ Dr.$Dan$Tache Dr.$Brock$Rondeau$ Dr.$Michael$P.$Hnat$ Dr.$Gregory$G.$Carnevale Dr.$Charles$Kravitz Dr.$Marty$Lipsey Dr.$George$Jones Dr.$Jeff$Horowitz Dr.$Michael$Gelb David$Walton John$Nadeau Holly$Jordano

the industry.We utilize over a dozen instructors who share a common goal of teaching attendees how to duplicate the success they’ve each personally achieved.” - Rani Ben-David The$magazine$has$no$medical$responsibility$and$the$articles$and$medical$opinions$are$the$writers$of$the$articles$and$can$not$hold$the$ owner$of$the$magazine$responsible$for$any$error.

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www.sleepseminars.com

Sleep$Group$Solutions$(SGS) $ $ Email:$info@sleepgs.com


Dental Continuing Education

“I Want to Get Into Sleep Apnea Screening and Treatment But I Don’t Know Where to Begin.” By Charles Kravitz, DDS

We hear that so often from dentists. Patients, both new and current, are asking their dentists in greater numbers to test them for sleep apnea.

The media, especially television through

appliances, is one story. But the fact remains that

advertisements for bargain oral appliances, is

the public is learning the signs and symptoms, and

building a greater awareness that sleep apnea needs

the dangers of sleep apnea. The articles in the social

to be treated. Unfortunately these purveyors of

media, increasing in volume over the last year, have

“do-it-yourself appliances” did not take the oath of

been providing excellent information and the public

Hippocrates (Above all, do no harm.) and we will soon

has been tuned into them. In many cases patients

be seeing reports of harmful effects. In the absence of

have more knowledge of sleep apnea than do their

professional observation, recording, and titration we

dentists. They are coming to the dentist explaining

can expect retreatment, orthodontic problems, and

their symptoms and their dentists are scurrying for

more unknown and undesirable side effects. Whether

answers.

the public is buying and using these uncontrollable flip the page to learn more... WWW.SLEEPGS.COM++++PAGE 5


Dental Continuing Education

So then. How does a dentist fast-

Where do they begin? SEMINARS

JUMP IN

WEBINARS

MENTOR PROGRAM

CONTINUING EDUCATION

Webinars

Training Seminar

Mentoring Program

The SGS webinars are a great way to get familiar with Sleep Apnea. The free webinars are available every week and can be joined at lunchtime or in early evening. The topics vary and include marketing to new and current patients, screening, protocol, and insurance systems and billing. Here is a calendar of 2013 webinars: www. sleepgroupsolutions.com

Sleep Group Solutions has a seminar schedule for 2013 with a two day accreditation seminar every week all across this country The dentist leaves the seminar with all the tools and information ready to step into his or her office the next day able to BEGIN to serving his or her sleep apnea victims. This accredited course, taught by doctors with years of intense private practice experience offers 16 units of CE credits.

A Mentoring Program is available for the dentist to stay in touch with his or her seminar instructor. The seminar program is analogous to your four years in dental school. You took the courses, you got your degree, and now you’re ready and eager to present basic services. You have some degree of clinical confidence, but you know you have to learn more about crowns and bridges, occlusions, advanced endodontics, and get more experience with oral surgery. So you take a one-year associateship with an older doctor who becomes your mentor, and you take some advanced courses. There is always more to learn. The advancements

Then you can move on to attending the two day course where you will learn how to implement sleep medicine in your practice and how to treat those patients successfully.

Continues!page!9 PAGE

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Looking for a Dental Sleep Medicine Mentor? Sleep Group Solutions can help! SGS has introduced many dental offices to dental sleep medicine through our seminars and in-office training programs. Ongoing technical support and customer service is provided to every client, however we are frequently asked by clients to be paired with a “mentorâ€? who can help them with various clinical and procedural hurdles that frequently come up. The SGS mentor program is a fee-based service that will pair new SGS clients (DDS ProtĂŠgĂŠ) with a mentor (a Dental Sleep Medicine expert). Mentorship Program includes: s 7EEKLY CALL WITH 3'3 MENTOR TO REVIEW CLINICAL QUESTIONS SET GOALS and ensure successful dental sleep medicine implementation. s 7EB COMMUNICATION WITH MENTOR VIA EMAIL 3KYPE OR WEBINAR s )N OFlCE hSHADOWv SESSION WITH MENTOR TO VIEW MENTORS CLINICAL protocols and techniques with dental sleep medicine cases. Up to 2 staff may also attend. s 0ROTĂ?GĂ? AND STAFF MAY ATTEND ANY SEMINAR FREE OF CHARGE AS A @REFRESHER COURSE

SLEEP APNEA AND AIRWAY MANAGEMENT One Stop - More Solutions.

Call 855-4-SleepGS to learn more about being paired with a Dental Sleep Medicine Mentor who can help pave the way to Dental Sleep Medicine Success!

www.Sleepgs.com

WWW.SLEEPGS.COM++++PAGE 7


Home Sleep Studies interpreted & diagnosed

An online nationwide network of Board Certified Sleep Medicine Physicians to interpret and diagnose sleep studies. Simply unload your patients’ home sleep study data to our network of “Analyzers”. Our Analyzers provide you with the most current American Academy of Sleep Medicine guidelines regarding diagnosis and treatment options including oral appliances -usually within 5 business days.

s !2%3 s %MBLA s -EDIA"YTE *R s 7ATCH 0!4    s !PNEA ,INK s -OST /THER $EVICES Learn how simple the process is. Log on today!

REPORTS Within

5

Business Days

InterpStudies.com 1-855-4SLEEPGS (Prices and acceptance of new clients subject to change)

www.sleepgs.com SLEEP APNEA AND AIRWAY MANAGEMENT One Stop - More Solutions.

Starting at

$69 per Study


From!page!6

Charles Kravitz, DDS

in technique and technology make it fun and challenging to keep up with today. And so it is with the study of sleep medicine. From the accreditation seminar you will emerge with all the basics. You will be able to do a proper sleep apnea screening, you will learn how to use all the equipment and how to work with a sleep physician, how to provide your patient with a correct oral appliance, how to make adjustments (titrate), and how to bill medical insurance and Medicare. As you learned in the general practice of dentistry that there is so much further you can go after dental school, you will see how much more there is to learn about sleep medicine. Every SGS instructor provides all the necessary basics in the seminars, yet each one of them is a fountain of knowledge in some other aspect of sleep science. Each time you open a book, turn on your computer, or speak with your mentor, an exciting new chapter in sleep medicine will be waiting for you.

Continuing Education There is an endless stream of information available to those who want to learn. Sleep Apnea and other sleep dysfunctions impact so much of our lives, from children’s learning disorders, thru stroke, heart disease, diabetes, and into dementia.

Conclusion The current need, and “buzz”, is in discovering, diagnosing and treating sleep apnea. It is reported that less than .5% of practicing Dentists are able to assist the more than 50 million people who suffer from sleep apnea. There is a growing public awareness of the hazards that come from a nocturnal stoppage of breathing. Your patients are becoming increasingly more concerned about the blockage of oxygen to the brain and other organs. As a Care Giver, think of how you can provide an underserved need.

Dr. Charles Kravitz received an early admission to Temple University School of Dentistry in Philadelphia after only 2 years of college pre-dental. He was President of his Freshman class, and he ranked eighth in his graduation class of 120. He took the big step of opening a solo dental practice directly upon receiving his Doctor of Dental Surgery degree. He developed this practice into a five dentist, three hygienist general dental practice in Philadelphia.This office became a showplace for practice management and dental school sources. It proved to be a training ground for many of Philadelphia’s future successful private practitioners.

“Action speaks louder than words but not nearly as often.”

~Mark Twain

WWW.SLEEPGS.COM++++PAGE 9


Dental Continuing Education

By Michael F. Hnat, DMD

In a few short years and with the help of Sleep Group Solutions, dental sleep medicine has become the special focus of my general dental practice. A primary catalyst in the rapid evolution has been the collaborative and concerted effort of my “entire� staff. Going forward from the day they all received the SGS in-office education and training, they were all committed to learn their integral roles in building this area of my practice.

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The most important “ingredients” to the successful and growing DSM practice are well-informed, caring and enthusiastic staff members in their interaction with the prospective sleep patients along with the medical and sleep-lab personnel. Your sleep patient may be an existing patient in your dental practice, a referred patient or an inquisitive phone caller. From their initial contact, that first time caller should easily recognize the knowledge and concern of the staff member. A well-written laminated phone dialog is an ideal reference for the front office staff to guide them through initial sleep patient calls until they develop their own comfort level. The administrative staff should all have a good understanding of the content of the consultation, examination and treatment protocol provided by the “sleep” dentist and clinical assistant. The front office and hygiene staff should be encouraged to listen in and observe these visits to understand those areas of the process while broadening their knowledge of DSM …So that the right hand knows what the left hand is doing. The hygienist’s role in the DSM practice is to identify potential patients with sleep-related breathing concerns when they have the first contact with existing recall patients or new patients in the general practice. They should be able to recognize through screening forms (such as ESS, STOP, BANG, BED Partner) that a patient’s responses on the form are concerning and then “plant the seed” to the patient in mentioning that a discussion with the dentist during the exam will be in order The clinical assistant’s role begins with the collection and recording of patient information during the initial sleep examination including vitals, dental, perio and TMJ status and nasal and oropharyngeal airway data. The assistant completes a panoramic radiograph, a TMJ series if warranted and acoustic imaging of the airways using the rhinometer and pharyngometer without and then with airway metrics. An explanation is provided to the patient on how this data is used to qualify them as a candidate for an oral appliance. The tone of this presentation by the clinical assistant

should notably elevate the interest and ownership level of the patient with their airway problem and anxiously transition them into the dentist’s consultation that confirms oral appliance therapy (OAT) as a treatment option. OAT begins once written informed consent is obtained and reviewed with the patient. Thereafter, the assistant’s work includes taking accurate impressions, appliance insertion and instructions, pharyngometry with the appliance, patient preparation for the home sleep test and downloading the data while working in collaboration with the sleep dentist in finding the best airway. At each step of the clinical protocol, the administrative staff is involved with preparing and forwarding documentation to the patient’s monitoring physician including requests for the LMN and oral appliance Rx, treatment initiation and completion. Medical insurance coverage verification, authorization and claims processing are handled concurrent with the appropriate clinical step whether directly or in using a billing service. One final consideration is to extend the staff role beyond the office setting, involving them at public awareness talks, health fairs, media events, etc. Dental Sleep Medicine is a staffdriven, turnkey system that should be enjoyable, productive and very rewarding. When the entire staff is on board, the DSM practice is will organized and runs efficiently. Educate your staff, get them all involved and your sleep patients and practice will truly benefit.

Michael P. Hnat, DMD

Dr Michael Hnat received his dental degree from the University of Pittsburgh School of Dental Medicine in 1979 and has been in private general practice since then. He completed undergraduate studies summa cum laude at West Virginia University majoring in Biology with a minor in Physiology. In 2007 Dr Hnat relocated his practice to McMurray, PA focusing on dental sleep medicine as an integral part of his care to patients. His dental sleep medicine facilityProgressive Dental Solutions- was one of the first in the country to be granted full accreditation by the American Academy of Dental Sleep Medicine demonstrating proficiency, practice and professionalism in providing optimal care to patients with sleep disordered breathing. He passionately works with a broad network of medical specialists and sleep labs throughout Southwestern PA and neighboring areas of Ohio and West Virginia in helping these individuals improve their quality of life.

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Dental Continuing Education

New to Treating OSA? What is Success?

By!Barry!Freydberg,!DDS

So what’s it like? Each successful case is still a thrill; each not so successful case is a disappointment, right? But what is success? How is it defined? Dr.!Barry!Freydberg,!a!1968!graduate!of!the!University!Of!Illinois!College!Of!Dentistry!is!a!fullBtime!practicing! dentist.!He!was!named!“One!of!the!Alumni!of!the!Year”!in!2004.He!is!a!Fellow!of!the!Academy!of!General! Dentistry,!a!Fellow!of!the!International!College!of!Dentists,!a!Fellow!of!the!American!College!of!Dentists!and! a!Fellow!of!the!International!Academy!for!DentalBFacial!Esthetics.!He!is!a!leading!speaker!on!conservative! “Prepless”!esthetic!dentistry!and!is!considered!a!pioneer!in!raising!dentists’!awareness!of!the!everBgrowing!link! Barry!Freydberg!DDS between!high!technology!and!practice!and!clinical!management.!And,!as!digital!technology!has!matured,!he!also!! focuses!on!“Techsthetics”,!the!link!between!technology!and!diagnosing,!marketing!and!providing!better!esthetic!dentistry.

According to the AADSM, success for Mild and Moderate OSA is achieving an AHI of under 10 or cutting the AHI in ½. For severe OSA, cutting the AHI in half. And, ‘success’ may not be 100%. And there may be frustrations too. Let’s take the following into consideration for success: 1.#

Even successes and failures in research studies can be misleading. Especially when measuring the relative effectiveness of oral appliances vs. CPAP. Dentists are often taught that a patient who is CPAP compliant should be ‘hands-off’ to us. However, while the studies do agree the CPAP is better, when worn, there are many flaws in some of the studies that cloud this success rate, further clouding the answer to “What is success?” It is important to go beyond the “results and summary” when reading a study. What can affect OAT success rates in the studies we read? Let’s take the following into consideration. 1.# 1.# 1.#

2.#

1.# 1.#

You must be confident in your knowledge and education, and have your own professional standards and proven protocols. Most physicians have not had the training you have had, and for that reason, might not understand Sleep the same way you do. There is no other practitioner in the airway more than the dentist. It is only natural that our industry would be geared to identify sleep disordered breathing problems, and obstructions of the airway. We see it everyday, there is no hiding from it! PAGE

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1.# 1.#

You get the idea, right? Success varies objectively and subjectively. Only your knowledge and communication with the MD’s and patients you work with can put you on the same page. As I mentioned before, success is something that is clearly defined by you and your patient. If you meet those goals, then that is success to me. Come to one of my courses, we’ll talk more.


The Acoustic Rhinometer is: Fast and Easy to Use Office-Based Systems Cost Effective Accurate Non-Invasive

WWW.SLEEPGS.COM++++PAGE 13


By Gregory Carnevale, MD, FAAOA

OSA Education and Advocacy

When a diagnosis of obstructive sleep apnea (OSA) is given, discussion in my office concerns not only the health consequences of OSA, but also the levels of patient perceived daytime impairment— in other words, excessive daytime sleepiness (EDS). Excessive daytime sleepiness is the subjective feeling of having the ability to fall asleep and lack of daytime energy despite an adequate night’s sleep. Despite many successful treatments for OSA, what my patients most want to be associated with treatment success is feeling less sleepy during the day.

How do we measure abnormal daytime sleepiness? Subjectively, it is measured most frequently by the Epworth Sleepiness Scale (ESS). The ESS was developed by Dr. Murray Johns, who was the Founding Director of the Sleep Disorders Unit at Epworth Hospital, Melbourne, Australia. He published the first ESS in 1991, describing a new questionnaire to measure daytime sleepiness which can now be considered the most frequently used questionnaire to assess daytime sleepiness. The ESS asks patients to judge, on a 4-point scale (03), their usual chance of dozing off or falling asleep in 8 different situations or activities that most people engage in as part of their daily lives, although not necessarily every day. The questions do not ask people how many times they would doze off in each situation which would depend on the frequency of being in those situations. The questions refer, rather, to the chances of dozing off whenever in those situations. The scoring for each question is then added up, with a range between 0 and 24. The greater the severity of the person’s levels of daytime sleepiness, the higher the score. The ESS takes only a few minutes to complete. PAGE

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An estimation of the average level of sleepiness in daily life is assessed by the total ESS. It should not be considered a diagnostic tool, but is a method to assess a patient’s perspective on how sleepy they are during the day. The advantages include its speed to administer and its comparability with other measurements of “sleepiness” such as the multiple sleep latency test (MSLT) and the maintenance of wakefulness test (MWT). Total ESS scores are reliable in a test-retest sense longitudinally (over a period of months) and should not be used to measure rapid changes of sleep propensity over a short period of time (hours). Currently, there is no objective gold standard for measuring a patient’s average sleep propensity. The ESS has been translated into many different languages including French, Finnish, German, Greek, Italian, Japanese, Mandarin, Portuguese, Spanish, Swedish, and Turkish! A modification of the original ESS was published in 1997 to clarify what patients should do if they did not have much experience in some of the situations described n the ESS items. This improved completion of the questionnaire (note: incomplete questionnaires are invalid). The extra


sentence “It is important that you answer each question as best you can” was added which made nearly everyone able to give an estimate of their dozing behavior. Unfortunately, despite the best treatments (CPAP, oral appliances, upper airway surgery, etc.), nearly everyone has days when they feel sleepy. Poor sleep habits are often the cause of daytime sleepiness. Here are things you can do to improve nighttime sleep and avoid daytime sleepiness.

1. Get adequate nighttime sleep. Most adults require 7-9 hours of sleep/night 2. No “multi-tasking” in bed. It is tempting to work on the laptop, watch television, eat, talk on the phone, or talk to your significant other. Keep the bed for “sleep and sex.” It is important to create a relaxing “bubble” around bedtime. 3. Have a consistent wake-up time. It is always better to regulate your sleepwake cycle first by getting out of bed at a regular time. Once you have mastered waking up at the same time daily, if you

are still sleepy, move to an earlier bedtime gradually (15 minute earlier). Don’t however, go to bed unless tired. 4. Eat regularly timed meals which are healthy, this helps to regulate the sleep-wake cycle and to prevent energy deficits. 5. Exercising several times a week helps to regulate circadian rhythms and makes it easier to fall asleep and sleep more soundly. Exercise also improves your daytime energy. Exercise should be preferentially done outside for exposure to sunlight which helps

Dr. Carnevale is board certified in both the specialty of Otolaryngology-Head and Neck Surgery and Sleep Medicine, and completed a Fellowship in Otolaryngic Allergy. He received his medical education at Upstate Medical University in Syracuse, New York, where he received his Doctor of Medicine Degree, completed a year of General Surgery and four years of Otolaryngology - Head and Neck Surgery. He holds a Bachelor of Science Degree, Cum Laude, from the University of Notre Dame in Indiana. Dr. Carnevale is licensed to practice medicine and surgery in New York, California, Pennsylvania, Florida, Virginia, Washington, Georgia, Texas, Michigan, and Ohio.

further regulate the sleep-wake cycle. Avoid exercising within three hours of bedtime. 6. Avoid napping late in the day which can make daytime sleepiness worse and interfere with nighttime sleep. 7. Avoid medications and alcohol which affect sleep. Alcohol, for example, can diminish “deep” sleep and other medication, such as over-the-counter sleep aids, can have lasting effects throughout the next day.

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I advise patients to continue with further workup, when despite adequate sleep and following the above guidelines, excessive sleepiness persists. Excessive sleepiness can be measured as stated by the ESS. There are additional objective tests (MSLT, MWT) as stated briefly, which can be used to assess for sleepiness, but this is beyond the scope of this article. In other words, sleepiness is not always caused by OSA. Many other factors should be considered and the workup depends on the presentation and overall patient history and examination. Some common examples of other causes of sleepiness include: narcolepsy, depression, PTSD, anxiety, insomnia, hypothyroidism, anemia, among others. When in doubt or with lack of benefit from what appears to be adequate treatment, a referral to a sleep specialist can help.

OSA Education and Advocacy

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Image is key. Your practice has to standout from the rest.

contact: Holly@Sleepgs.com

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

0 - Would never doze 1 - Slight chance of dozing

2 - Moderate chance of dozing 3 - High chance of dozing

Situation Chance of Dozing Sitting and reading ____ Watching TV ____ 1-6 Obstructive Sleep Apnea Sitting inactive in a public place ____ is Less Likely. Being a passenger in a car for an hour or more ____ 7-8 Lying down in the afternoon ____ Your Score is Average. Sitting and talking to someone ____ 9 or Higher ____ Obstructive Sleep Apnea Sitting quietly after lunch (no alcohol) is More Likely and You Should Seek the Advice of a Sleep Specialist.

Total score (add the scores up) (This is your EST score)

____

The other side of your practice

Dental Sleep Medicine Seminars 16 CEU PACE/AGD Approved! www.sleepseminars.com

See Page 34-35

16 CE’s

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OSA Education and Advocacy

HOW SNORING

Share this article with your patients!

Dr Horowitz is a 1991 graduate of The Medical University of South Carolina, College of Dental Medicine and completed a General practice residency at the Mountainside Hospital in Montclair, N.J. He is a Fellow of the Academy of General Dentistry, a member of the American Academy of Dental Sleep Medicine, an instructor for Sleep Group Solutions, a mentor at the prestigious Kois Center for Advanced Dental Studies, a member of the American Academy of Cosmetic Dentistry, the American Orthodontic Society, and The American Dental Association. He is the founder of, and a practicing dentist at the Carolina Center for Cosmetic and Restorative Dentistry at 1515 9th Ave., Conway, S.C. He can be contacted at (843) 2483843 or via the practice website. www. carolinacosmeticdental.com

AFFECTS YOUR PARTNER By Jeffrey W. Horowitz, DMD, FAGD

As you know I have been discussing snoring and obstructive sleep apnea as a major health concern for some time now. What I have failed to address is the incredible toll that these conditions can take on a spouse or bed-partner. This is an article to share, and I hope that it creates awareness that snoring is not just an individual’s problem.

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Let me start by saying I am not a marriage counselor, therapist or a psychiatrist. I’m just a dentist with a strong background in sleep disordered breathing. I know the signs and symptoms of sleep disordered breathing and I often hear the primary complaint directly from the bed-partner. According to a poll in USA Today, 45% of spouses reported that their bed-partner snores loudly, yet only 5% of their counterparts even admit that they snore. This is alarming, because whether it stems from denial or ignorance, the end result is anything but bliss. While 70% of the time loud snoring is indicative of Obstructive Sleep Apnea, a deadly condition in and of itself, our purpose here is to learn what is happening to the spouse. Let’s start with just the sound of snoring which is often louder than 60 decibels. For reference, a pneumatic drill is the equivalent of 70 decibels. Imagine sleeping next to a pneumatic drill! One concern would obviously be hearing loss with continued exposure. This is a valid concern and studies have shown that hearing loss with prolonged exposure can occur. But the immediate response to snoring is what concerns me the most. When faced with a partner who is snoring loudly, bed-partners will respond in one of two ways. They will either “tough it out” resulting in significant sleep deprivation with physiological consequences, or move to another bed which can have serious long-term emotional consequences on a relationship. When discussing sleep disordered breathing, many of the presenting

symptoms revolve around sleep deprivation. The lack of oxygen in the apnea patient is the primary concern; however this also leads to arousals, and disruption of the normal sleep cycle. When sleep cycles are disrupted, so too is critical hormone regulation, which ultimately can affect mood, hunger, insulin dynamics, and many other body systems.

Daytime fatigue ensues, which can mimic legal alcohol intoxication with 4 hours or less of quality sleep. According to Matthew Walker, a professor of psychology at Berkley University, brain function of an individual whose sleep time is significantly reduced can be quite similar to that of a patient with a psychiatric disorder. The result can be irritability, depression or feeling romantically despondent. The issue here is that snoring causes arousals for the bed-partner as well, which comes with the same consequences that affect the snorer. In a preliminary study at the Sleep Disorders Center at Rush University Medical Center, married couples were tested together for sleep efficiency where one had sleep apnea, and the other did not. Initial results showed that the spouse of the apnea patient had increased arousals, as many as eight per hour, disrupting the normal sleep cycle. A decrease in sleep efficiency (the percentage of time one is sleeping during the night) was also noted. Normal sleep efficiency is 90%, where results in this study showed sleep efficiency ratings in the low

70’s. This same study by survey, evaluated marital satisfaction, daytime sleepiness and quality of life. As one would suspect, when the spouse with apnea was treated for 2 weeks, all of the subjective survey scores, as well as the sleep efficiency score improved. Unfortunately for many couples, a choice is made to not sleep in the same bed. While this may immediately improve sleep for the spouse, the long term emotional consequences may not be healthy for the relationship, not to mention that a serious health condition for the snorer is being ignored. In the book “Two in a Bed: The Social System of Couple Bed Sharing”, author Paul Rosenblatt interviewed 42 couples to examine how sharing a bed affects a couple’s relationship and intimacy. From his interviews, it was concluded that sharing a bed can be crucial to a relationship, as time in bed is often used for reconciliation, “catching up” planning and solving problems. This time is difficult to replace in otherwise busy lives, and improved communication can lead to improved intimacy. So for the snorers, please take your bed-partner’s concerns seriously. Treating sleep disordered breathing is not difficult. Doing so can not only add 12-15 years to your life, but improve the quality of your relationship as you live. For the bed partners out there, understand that the snorer can sometimes feel embarrassed. Let them know that you are trying to improve their health, and how important it is to you to share life from the same bed. Here’s to peaceful and restful nights. WWW.SLEEPGS.COM++++PAGE 19


OSA Education and Advocacy

OSA is NOT Here to Stay! Share this article with your patients!

The Importance of Sleep Wellness.

The importance of sleep to physical health has been a fundamental tenet of common medical knowledge for centuries. Sleep allows our bodies to relax, rejuvenate, and dream, permitting the mind to work on a subconscious level, solving problems and preparing for the coming day. While we sleep our bodies burn calories, create vital nutrients and hormones, and perform complex chemical processes that keep our bodies internally balanced, or in homeostasis.

However, as a result of what has become the norm in American society—a much busier life—the healthy sleep of many adults and children is often compromised. This lack of healthy sleep in large percentages of the population is causing widespread concern within medical and dental communities all over the United States-and it’s about time.

Early bird gets the worm

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We see that sleep is of concern, it frequently appears in our conversations with health care professionals. We even read articles on sleep in popular magazines such as US News and World Report, Time, and Newsweek. A recent special report on sleep was presented on the cable news station CNN, narrated by resident medical expert Dr. Sanjay Gupta. We know it’s important. Even the physical and mental manifestations of lack of sleep, such as weight gain, hormonal imbalances, headaches, inability to concentrate, and even depression, are becoming more and more commonplace.


Research shows, some sleep deprivation can be psychological (mental stress at work, in relationships, or in family life). However, there is a serious physiological cause of lack of sleep that exists as well, it’s called an airway obstruction. An airway obstruction at night results in what health care practitioners call Sleep Disordered Breathing. Everyone is at risk, and snoring is an alert call which can signal a much greater problem. A severe airway condition, called Obstructive Sleep Apnea (OSA), is a commonly undiagnosed disorder, and in many cases fatal when not treated.

Around the world, Dentists are quickly becoming the first line of defense in raising awareness of Sleep Apnea. Offering treatment options, such as Oral Appliance Therapy (OAT) many Dentists have become experts in the treatment of snoring and sleep apnea, and are saving lives! Dentists are educating patients on the importance of sleep, and are attending dental continuing education courses on Dental Sleep Medicine. Dental professionals are learning to identify everyday signs and symptoms of Sleep Apnea. They are using evidence based and proven protocols, to put the symptomatic patient through a diagnostic process. If you are one of the many Americans who desperately need better sleep wellness, or believe you may have a Sleep Disordered Breathing issue, ask your Dentist if they screen and treat Sleep Apnea. It may be one of the most important questions you ever ask your Dentist.

By!Holly!Jordano Sleep!Apnea!Awareness!Advocate!

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OSA Education and Advocacy

By!Michael!Hnat,!DDS

Each time breathing stops, the brain alerts the breathing muscles to work harder. Low oxygen levels in the blood cause repeated increases in the heart rate..

this e r a Sh cle arti our y with ts! en pati

Low oxygen levels in the blood cause repeated increases in the heart rate each time the brain alerts the breathing muscles to work harder when breathing stops. Eventually the continuous changes in heart rate throughout the night cause damage to the heart tissue. Arrythmia – when the heart beats too fast or too slow – is one effect of heart damage. Similarly, fibrillation is an erratic heart beat that occurs in the upper chambers of the heart. Ultimately, the effects on heart rate from sleep apnea have the potential to cause inadequate blood flow from the damaged heart to the entire body. This in turn increases the workload on the heart and may cause it to fail. Researchers at the prestigious Mayo Clinic found that patients with obstructive sleep apnea have an increased risk of having a heart attack between typical sleeping hours 12am-6am. In fact, in their study of the individuals who had a heart attack during these nighttime hours, 91% had OSA. This is rather convincing support of the effect of nighttime oxygen shortages on heart function. Proven treatments for sleep apnea include a pressurized breathing mask (CPAP), oral appliances worn over the teeth to keep the airway open or airway surgeries that remove excessive tissue blocking the airway. Untreated sleep apnea carries significant medical risks and is documented to reduce life expectancy between eight to ten years.

The real Heart of the matter is seeking treatment before sleep apnea can do its damage.

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Millions of Americans suffer from sleep disorders.

Fastest growing specialty in the industry – Dental Sleep Medicine Together with our dental Distribution partner, Sleep Group Solutions, Embla offers you the opportunity to incorporate sleep analysis into your dental practice. The Embetta has been used in millions of sleep studies and has been designated by the American Academy of Sleep Medicine for their landmark study on Portable Monitoring in the Diagnosis and Management of Obstuctive Sleep Apnea. The Embletta is cost effective. at only $5-$7 per use. To learn more, please visit: www.sleepgs.com or call: 1-855-4SLEEPGS RENTAL & LEASING AVAILABLE

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OSA Education and Advocacy

Putting the Passion Back into your Practice!

By!Holly!Jordano,! Sleep!Apnea!Awareness!Advocate!

As an advocate for raising awareness of Sleep Apnea, my sense of urgency to spread information on the deadly disease, is crucial. Time is of the essence, as Sleep Apnea increases health issues such as obesity, type 2 diabetes, high blood pressure, depression, constant fatigue, links to cancer, and even death. When I speak to dental professionals about implementing a sleep protocol into their practice, I genuinely feel I am providing a community service, and indirectly saving lives, and that feels good.

Share this article with your patients!

Obviously and undeniably, the real lifesavers in this particular equation are the dental professionals who have attended continuing education courses on Dental Sleep Medicine. These industry heroes have learned to identify, screen, and offer treatment options to patients’ in desperate need of this service. In my opinion, Dentists are a crucial catalyst in raising the awareness of Sleep Apnea. If you speak to a Dentist who treats Sleep Apnea patients, you’ll tend to notice one common similarity among the handful of Dental Sleep Medicine professionals. Passion. They are all extremely passionate about offering this life-saving service, and they aren’t afraid to talk about it!

I often ask Dentists what inspired this passion to treat sleep disordered breathing patients, and why are you passionate about raising awareness of Sleep Apnea? Here is what a handful of them told me… PAGE

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Dr. Daniel Tache (Appleton, WI):

I am passionate about raising awareness of Sleep Apnea, because of A.N! It began about 7 years ago and it concerns my very first adolescent sleep patient (‘A.N’) who was referred to me by his Pediatric Neurologist, and described as having a “failure to thrive.” When I first met ‘A.N’, he was still 14, about to turn 15, however, he appeared far younger than his years; more like a boy about to start middle school rather than a young man about to enter high school. Up until a year or so ago, he had been a near straight-A student but was now struggling with merely holding a passing grade. A.N’s affect was very flat; he smiled little if at all when he first visited our office and rarely would make any eye contact with the staff or myself. A.N was, without question, one of the most unhappy, lethargic, void-ofpersonality adolescents I had ever met. I knew I had to help him.... and we did. We treated A.N with an oral appliance, and he is a very different young man today, a far reach from the boy who originally walked into my office, months before. He is one of the many people we help through Oral Appliance Therapy, and for that, I am passionate about raising awareness. *Read Dr. Taches full experience with A.N, including the step-by-step treatment process, and a full update on A.N’s health! Page number 26.

Dr. Charles Kravitz (Ft. Lauderdale, FL):

I became an avid advocate of Sleep Apnea education as I watched a very close friend suffer the ravages of undiagnosed Sleep Apnea. Over a period of 7 years I witnessed my friend’s memory and cognitive ability diminishing. It is very disturbing to listen to him speak. His medical team, which includes two Neurologists, have diagnosed dementia,

and have concurred, based upon his tests and symptoms that his undiagnosed S A is the main contributor to his loses. My friend is the ‘picture’ of excellent physical health- externally and internally. When you look at him you would think he is half his actual age- until you notice that he stares vacantly into space. On top of that I lost a cousin a few years ago who was grossly overweight and diagnosed with sleep apnea too late. It’s been my mission ever since to educate on the dangers of Sleep Apnea.

Dr. George Jones (Sunset Beach, NC):

I got involved in Sleep Disorder Dentistry by accident. My good friend and mentor, Larry, asked me to attend a SGS seminar with him, and I tried to get out of it. “I’m not interested”, I told him. But he informed me that he had been diagnosed with Severe Obstructive Sleep Apnea, and was unable to wear a CPAP, and was looking for a dental alternative. I reluctantly attended a SGS seminar in Myrtle Beach SC. In the first hour I was amazed by what I was hearing. I had no idea how deadly this disease was. By the end of the first day, I knew this was a chance for my office to have a positive impact on my patients’ wellbeing in a way we had never been able to achieve before. After successfully treating Larry with an appliance, and being witness to how that was an impact in the quality of his life, my whole office was hooked. We love the feeling of adding quality and longevity to our patients’ lives. Whenever we can raise awareness of Sleep Apnea, and save a life, we do it…and we love it!

Dr. Marty Lipsey

(Modesto, CA):

I am an advocate for sleep apnea awareness because we see many patients in our practice that so

desperately need this treatment. Many patients, both young and older, complain about being tired all day. These patients literally fall asleep during treatment, and most of them have family members that snore, or also complain about being tired. I began to notice many of our patients had undiagnosed sleepbreathing disorders. Now, we are in a great position to help with screening and to help these patients uncover what can be life threatening and life shortening problems. Learning to look ‘beyond the teeth’ to screen for these sleep health conditions is a great service we can offer, and a great way to expand our practices. Throw in a little learning to help our patients maximize their medical insurance benefits for treatment, and it’s a win for all!

Dr. Vesna Sutter

(Geneva, IL):

Treating Sleep Apnea Patients in my practice has brought a new energy to me and my entire team. We love the way we are helping improve and prolong patients’ lives. I am extremely excited to share my knowledge with other dentists about treating patients for snoring and sleep apnea, so they too can experience this energy. Our whole team is passionate about spreading the word, as we are proud of the work we have done thus far, and want to inspire more offices to offer this treatment!

Whatever your reason may be for treating Sleep Disordered Breathing patients, I applaud you! Congratulations on putting the passion, back into your practice! Please feel free to share your experiences in Dental Sleep Medicine, in an effort to raise awareness and inspire more Dentists to get on board and offer this life saving treatment. You can email your personal, or encouraging Sleep Apnea experiences to Holly@Sleepgs.com. WWW.SLEEPGS.COM++++PAGE 25


OSA Education and Advocacy

By!Daniel!Tache,!DDS

This is Why I Do It!

Yes, I am passionate about treating Sleep Disordered Breathing Patients. Here’s why... One of my most memorable experiences in treating patients for snoring and Sleep Apnea began about 7 years ago, and it concerns my very first adolescent sleep patient with the initials of A.N., a 14 year old, male, 8th grader, was referred for treatment by Dr. Kotagal, Pediatric Neurologist at the Mayo Clinic, so I was very excited to get involved with this case. A.N had been diagnosed with both Upper Airway Resistance Syndrome (UARS) and Restless Legs Syndrome (RLS). Dr. Kotagal was emphatic that BOTH the breathing AND the movement disorder (RLS) be addressed if we were to improve A.N’s condition which he described as “failure to thrive”.

When I first met A.N, he was still 14, about to turn 15, however, he appeared far younger than his years; more like a boy about to start middle school rather than a young man about to enter high school. He was short, a little chubby, and he had a cherubic face. Up until a year or so ago he had been a near straight-A student but was now struggling with merely holding a passing grade. A.N’s affect was very flat; he smiled little if at all when he first visited our office and rarely would make any eye contact with the staff or me, even during one-onone conversations. Despite the cherubic face, A.N was, without question, one of the most unhappy, lethargic, void-of-personality adolescents I had ever met. I knew I had to help him.

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Treatment: MANAGING THE RLS With the guidance of Dr. Kotagal, we had been managing A.N’s RLS reasonably well with oral iron supplements, so we then turned our attention to his breathing problem.

MANAGING THE UARS We went about treating him as we did with all patients: we performed a dental examination and found that A.N had a full complement of teeth (minus 3rd molars) but his dentition was very crowded and he had an Angle Class II, div. 1 malocclusion. Acoustic airway analysis (Eccovision Technology), showed that mandibular advancement alone would not likely stabilize his airway, so we increased the vertical until we saw the stability we were looking for and then went about to fabricate a Respire Mandibular Advancement Device.

For the most part, treatment progressed reasonably well, without much drama…not what we were expecting when we first met A.N. because he is not the happiest fellow and seemed so detached from what was transpiring around him and seemed to have a very antagonistic relationship with his mother who attended all of his appointments. I would imagine that she was tired of dealing with this very difficult child? As the weeks passed, one thing that we noticed was that when A.N would come to his appointments, he would often have a smile now, and we could actually see his eyes because he was not looking down all of the time, and he ALWAYS HAD HIS ORAL AIRWAY APPLIANCE IN HIS MOUTH! His mother said that he would put it in his mouth immediately after school, from the moment that she would pick him up from school and would continue wear it until he went to school the next day!


After we completed the titration of his oral airway appliance and followed-up with a home sleep test which showed no evidence of UARS, he was dismissed for three months while he consulted with an orthodontist for Phase II treatment; I also wanted time for him to simply heal. It was closer to 5 months before A.N returned for his follow-up appointment and man-o-man, were we about to have a surprise. When he was seated, we were no longer looking at a short, chubby, grumpy child but a young man! He had

grown perhaps 4 inches or more, his voice was deeper and he had “peach fuzz” on his face…he was growing a beard! Breathtaking is the only word that would describe the physical transformation that we were observing before our very own eyes... but the best was yet to come. At that visit, A.N was not only accompanied, as always, by his mother, but by his father too! He asked to speak with me in private, and with tears in his eyes, he wanted to tell me that during these past few months, his “son had returned” to the boy he had always known; happy, thriving and

enjoying school again and that his grades had improved from C’s and D’s to straight A’s! After that visit, A.N entered into Phase II functional orthodontics which he has now completed. He is now about 6’2” and actually a little on the skinny side, and doing very well in school. What a wonderful experience for any clinician, and I encourage you to explore the exciting and rewarding benefits of Dental Sleep Medicine!

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WWW.SLEEPGS.COM++++PAGE 27


Technology and Oral Appliances

Implementing a Complete Sleep Solution

By George Jones, DDS

I think if you talked to most dentists who treat Sleep Disordered Breathing and sleep apnea, they would tell you of the great sense of satisfaction and achievement in having made a real difference in patients’ lives. When you treat that patient that has a real understanding of their disease process and a commitment to utilize every method at our disposal to achieve the maximum medical benefit, those feelings can be coupled with the knowledge that we really couldn’t have done anything more to achieve a better outcome.

This past year I had the pleasure of treating Richard, a 70 y/o Caucasian male. He is relatively healthy with no OSA risk factors such as hypertension, diabetes, or heart disease. During his 6 month hygiene appointment he was screened for Sleep Disordered Breathing. While he only scored a 5 on his Epworth questionnaire, his casual comment to the hygienist that, “his wife has woke him up several times in the past couple of months claiming he had stopped breathing”, was enough for us to recommend an advanced screening. Total$AHI

Supine$AHI

The administering physician recommended CPAP therapy, and Richard was reappointed for a Titration Sleep study on 7/27/12. The titration study was unsuccessful, as patient was Total$AHI Supine$AHI unable to tolerate CPAP, and left in the middle of the titration study. Richard contacted our office for the fabrication of an Oral Appliance, having received a prescription and letter of medical necessity from the Sleep Physician. We used our Eccovision Pharyngometer along with our Airway Metrics Mandibular Positioning System to determine the mandible position which had the greatest effect on Richard’s airway. It was found that a 4mm vertical with a 4mm advancement gave us a 128 % improvement. A bite registration was Total$AHI

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Supine$AHI

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Time$spent$ in$supine$ position

taken at this position, as well as upper and lower impressions. We sent our models and bite to Respire Medical, and a Respire Blue series Time$spent$ Mandibular Advancementin$supine$ Device was fabricated at the bite indicated. position Upon receiving the Respire Blue, it was delivered, and adjusted. The patient was then retested with the Eccovision Pharyngometer to confirm that the anticipated airway improvement was delivered. Patient was instructed to contact us for any further adjustments and the patient was reappointed for 1 month to have a home sleep study to confirm the efficacy of the appliance. The home sleep study was done with an Embletta monitor, and the results were as follows. Time$spent$ in$supine$ position


While we were both pleased with the results, I mentioned to Richard, he could do even better if we were able to keep him off his back while he sleeps. We discussed several options that might help him with this: Rem-a-tee belt, prop pillows, golf balls stitched into a pocket on the back of a tee shirt. Richard elected to try several home remedies to start. But he returned within about a month, stating that his efforts were only moderately effective, and he was ready to try a Rem-a-tee belt. The Rem-a-tee belt is an adjustable nylon/neoprene Belt with 3 inflatable bumpers on the back, designed to comfortably keep patients out of the supine position. Available at thesleepmall.com.

Rem-a-tee belt

Once the belt was received, patient was instructed on its care and use, again scheduled for a home sleep test. This time we opted to use the Watermark Ares home sleep monitor, as it has no effort belts like the Embletta, which we felt might be compromised by the Rem-a-tee belt’s shoulder straps. The results were as follows Total$AHI Total$AHI

Supine$AHI

Time$spent$

Supine$AHI

Time$spent$ in$supine$ in$supine$ positionposition

So to compare where Richard started with his original diagnosis

Total$AHI

Baseline$PG SG$from$ Sleep$Lab Oral$ Appliance$ only Oral$ Appliance$ and$ positional$ therapy

Supine$AHI

Time$spent$ in$supine$ position minutes

minutes

minutes

minutes

Summary needed.

Dr. George Jones is a native of Wheeling, WV and earned his BS in Chemistry from Wheeling Jesuit University. He received his Dental Degree from the University Of Florida College Of Dentistry, and relocated to coastal North Carolina in 2003. Over the years, Dr. Jones has served as a consultant and evaluator for several dental manufacturers and maintains a private practice in Sunset Beach, NC.

*!Log!onto!www.TheSleepMagazine.com!for!the!full!summary. WWW.SLEEPGS.COM++++PAGE 29


Technology and Oral Appliances

By!David!Walton

Bite Registration for a Functional Appliance Important Points to Look Out For: The bite registration and the position of the jaw are the no.1 determining factors in the success or failure of an oral device. Below I discuss some of the important points to look out for in order for the patient’s appliance to be successful.

How the bite registration will affect the airway: Doctors often ask if we can position the models in a way for the appliance to work. There is no accurate way for us to guess a position to open up the airway. Accuracy at this stage will save a lot of time and energy as the patient goes through their treatment. We recommend using The Airway Metrics (airwaymetrics.com) jigs to set the jaw at different vertical and protrusive positions and then test using the pharyngometer (sleepgs.com) to see how each position opens the airway. This gives a great indication of how measurements you have taken will affect the patient’s airway. Many devices on the market have a range of advancement of around 4-6mm. We often see that bite registrations which are too conservative reach their maximum expansion of the device and have to be sent back for a reset so it can be advanced a farther 4-6mm. Again, accuracy at this initial stage will save a lot of time later on.

Side Shifts: Many times in our lab we have received bite registrations when the patient has bitten off to one side when the registration material has set. Once the oral device is fabricated and placed in the patient’s mouth the jaw may want to glide back to the natural position. This can lead to TMJ discomfort along with placing stress onto the patient’s device.

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A technique to avoid this is to have the patient press their tongue forward as the bite registration is setting. This will help line the patient’s jaw in a comfortably centered position as it is difficult for the patient to unnaturally bite to one side while doing this. Another technique is that once the material has set and the excess trimmed, place the bite registration back into the patient’s mouth and have them sit for 2-3 minutes. This will give you time to assess the jaw position and the patient time to feel if the position is comfortable. There are often natural side shifts and this should also be taken into consideration.

Anterior/Posterior Indentations: Detailed indentations are vital for the lab to determine exactly where the models fit into the bite. A bite registration only covering the anterior or only the posterior leaves some guess work for the lab. Below are images that show a bite with only anterior material with little detail, and how that can affect the outcome of the device. The quality of detailed indentions will help any lab locate the bite. Here is a registration that has great coverage of all occlusal surfaces which will help in the manufacturing of the device.

As mentioned previously the technique of having the patient press their tongue forward will help line the jaw up, but also in this case it will press the registration material against the lingual cusps giving the required detail.

Vertical position: The vertical position of the bite registration is often overlooked. With our Respire devices we ask for a minimum of 4mm on the bite registration. With bite registrations that are 1-2mm we won’t have enough space to add the soft material/ball clasps etc, so we will have to open the bite slightly. The problem we often see is that on an articulator it does not open in a straight up and down manner, they curve in the arch of the jaw. So as the articulator is opened up, the jaw does not stay in the same protrusion, it falls back very slightly. This is a very small amount but as I’m sure you are aware we are trying to be as accurate as possible, and again we don’t want to guess a bite by hand articulating the models into a new protrusion. The great point of the Airway Metrics is the range of options you have with vertical position. Contact me at 718-643-7326 or david@respiremedical.com for information on our webinar series where we discuss these topics among other oral appliance issues.

David Walton Co-Founder Respire Medical

David$Walton$is$the$co>founder$of$ Respire$Medical.$$The$Brooklyn$ based$oral$appliance$company$ the$needs$of$doctors$and$patients$ in$the$treatment$of$obstructive$ sleep$apnea$(OSA)$and$snoring.$ The$Respire$Team$has$a$wealth$ of$knowledge$and$experience$ to$drive$the$company$forward$ and$push$the$boundaries$of$oral$ appliance$treatment.$Both$David$ Walton$and$Walid$Raad$have$had$ extensive$experience$working$ in$both$Australia$and$the$UK.$$ Respire$Medical$offers$TMJ$ splints$as$well$as$the$Respire$ Pink$Series$(Herbst),$The$Respire$ Respire$Green$Series$.$$Log$on$ to$RespireMedical.com$for$more$

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Technology and Oral Appliances

By John Nadeau

The dental sleep medicine landscape is rapidly evolving, the old protocols no longer apply and barricades to entry and success in this market are disappearing. While not one of the “old timers” of dental sleep medicine, I’ve been actively involved in this field for many years and I’ve been privilege to an incredible transformation in awareness, standard protocols and technology integration. One need only visit one of our Dental Sleep Medicine CE courses to see the first big change. Years ago options for even learning about dental sleep were few and far between – now we are hosting over 80 training seminars and hundreds of in-office trainings in 2013 alone. Now instead of taking the course because it sounded like an interesting topic dentists are learning more because patients are coming in and requesting treatment for sleep apnea. The awareness continues to grow every day. Historical roadblocks are also coming down. It was not long ago that the only protocol to follow involved a dentist sending their patient away to a sleep lab or hospital for diagnosis. Right away this posed a problem for many “sleep dentists” as patients frequently refused to follow through with this referral. Additionally, those who did go to the lab frequently ended up being put on CPAP leaving few, if any, patients for the dentist to treat with oral appliances. Today the flow of each case is not completely in the hands of a sleep lab. Many dentists

are taking advantage of home sleep testing technology and vast networks of board certified sleep physicians who are able to provide interpretation and diagnosis. Patients with mild or moderate sleep apnea end up with effective oral appliance therapy very quickly while those with severe OSA are sent to local specialists for more detailed evaluation. This results in more optimal treatment being delivered faster and at a lower cost to the patient than the historical model. For the dentist this means no more losing control of a case or having a patient who would have otherwise been a great candidate for oral appliance therapy be offered CPAP instead. The dental sleep evolution continues inside dental practices to the clinical parts of dental sleep medicine as well. Where there were once only 2-3 devices FDA cleared to treat apnea there are now dozens, each with its own pro’s and con’s. Bite registration techniques and technology have evolved as well. Gone are the days of using a George Gauge™ and having the patient advance an arbitrary 5070% protrusive and just guessing at appliance position. Now dentists have the ability to measure the effect of both protrusive and vertical change on the airway using Eccovision™ airway acoustics to determine optimal therapeutic

position. Being able to see patients who will and will not respond well to treatment ahead of time has drastically increased case acceptance and clinical success rates with oral appliance therapy while cutting down on appliance titration time. These changes have helped position the dentist as an integral part of a complete medical protocol for the diagnosis and management of sleep related breathing disorders. I’m happy dentists are no longer practicing a “blind leading the blind” protocol of guessing bite position and then delivering an appliance that may or may not help without any objective way to measure. One thing that is guaranteed to change is the number of people with sleep apnea. Current research points to increasing obesity rates in the United States continuing their climb until they reach a peak in 2030 at a nationwide average of over 44%. The number of people with OSA will continue to increase right along with it. When teaching about dental sleep medicine every single weekend we say “the time has never been better to get involved” and unfortunately that statement will also continue to be true as more and more people suffer the debilitating consequences of untreated OSA. WWW.SLEEPGS.COM++++PAGE 33


Dental Sleep Medicine SEMINARS 16 CEU PACE/AGD Approved!

Our Seminars Include: The Fastest Growing Dental Treatment SGS is pleased to be offering the most comprehensive selection of dental sleep medicine seminars in the industry. Treatment of sleep disorders medicine and recent developments have put dentists on the front line. With Obstructive Sleep Apnea reaching epidemic levels in our society you have a unique opportunity to save the lives of those suffering while adding a valuable service in your practice. Many dentists are looking to branch out from traditional dentistry because they are either ready to try something new or because the economy has forced them to look for additional revenue streams – Dental Sleep Medicine is the perfect solution.


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2014 dates available online at www.sleepgs.com Meet the Instructors

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Dr. Dan Tache Dr. George Jones Dr. Vesna Sutter Dr. Jeffrey Horowitz Dr. Jerome Gildner Dr. Damian Blum Dr. Stacey Layman

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Technology and Oral Appliances

Future Health of Our Patients Depends on Dentists Treating Snoring And Sleep Apnea With Oral Appliances

By!Brock!Rondeau,!DDS!IBO

Home!Sleep!Study The sleep study measures the number of apneic and hypopneic events that occur every hour while the patient is asleep.

Dentists who fabricate oral appliances to treat snoring must send the patient for either a home sleep study or a hospital sleep study to diagnose the presence or absence of obstructive sleep apnea. Prior to any treatment for either snoring or sleep apnea the diagnosis must be made by a sleep specialist in either a private sleep clinic or hospital. Obstructive sleep apnea is a serious medical problem that can predispose patients to cardiovascular disease including high blood pressure, heart attacks, strokes, congestive heart failure, and atrial fibrillations. Other medical complications include type 2 diabetes, acid reflux, impotence, kidney problems, fibromyalgia.1,2 Obstructive sleep apnea affects children and adults and can seriously affect the growth and general health of young children if not diagnosed and treated. Sleep apnea is characterized by periods of cessation of breathing (apnea) and reduced breathing (hypopnea). Both types of events have similar pathophysiology and are equally detrimental to the health of the patient. The most common form of sleep apnea is obstructive sleep apnea which is caused by a partial or complete collapse of the upper airway. The diagnosis is made by a sleep specialist upon analyzing the sleep study which evaluates the AHI (Apnea-Hypopnea Index). Apnea: Cessation of breath for more than 10 seconds Hypopnea: More than 50% reduction in airflow. Oxygen desaturation more than 4%

Brock!Rondeau,!D.D.S.,!I.B.O.,!D.A.B.C.P. ! Dr.!Brock!Rondeau!is!one!of!North!America’s!most! sought!after!clinicians!whos!practice!is!limited! to!the!treatment!of!patients!with!orthodontic,! orthopedic,!TMJ!and!snoring!and!sleep!apnea! problems!for!the!past!25!years. Diplomate!International!Board!for!Orthodontics Diplomate!American!Board!of!Craniofacial!Pain Fellowship!International!Association!for! Orthodontics Association!for!Orthodontics Fellow!of!the!Academy!of!Craniofacial!Pain One!of!North!America’s!most!sought!after! clinicians! Over!16,000!dentists!have!attended!his!courses! and!study!clubs!Actively!teaching!orthodontics! for!over!23!years!He!has!lectured!to!over!16,000! dentists!worldwide!and!currently!lectures!over! 100!days!a!year!in!the!US,!Canada,!Australia,! England,!Poland!and!China.

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In 1995 the Apnea-Hypopnea Index (AHI) American Academy of Sleep Normal less than 5 events per hour Medicine (sleep Mild OSA 5-15 events per hour specialists) made Moderate OSA 16-30 events per hour the statement that Severe OSA over 30 events per hour was extremely favorable in 1. Oral appliances are recommended as the first treatment terms of treating option for patients with mild to moderate sleep apnea. patients with snoring and 2. CPAP (Continuous Positive Air Pressure) is recommended as the first treatment option for severe apnea. sleep apnea problems with oral 3. Oral appliances and surgery are possible options for patients who cannot tolerate CPAP. appliances.3

Respire! Appliance


Most of the research that has been completed in the past shows that the CPAP device is slightly more effective in reducing AHI and oxygen desaturation than oral appliances. However, oral appliances are effective in treating mild, moderate and severe sleep apnea.4 The acceptance rate for CPAP for severe sleep apnea patients is much higher than for mild-moderate cases. Unfortunately, there are still a number of sleep specialists that prefer to recommend CPAP for the majority of these patients with sleep apnea regardless of severity. Most patients in a general dental practice will be snorers with either mild or moderate sleep apnea and are therefore ideal candidates for oral appliances.

Three Basic Treatments For Sleep Apnea 1. 2. 3.

Oral appliances CPAP Nasal or oral surgery

CPAP is a device that consists of either a nasal or full face mask with an air compressor that blows air CPAP!Device up the nose. Many patients try this treatment based on the recommendation of the sleep specialist but are unable to tolerate it. The reasons given include claustrophobia, headaches from the straps, air in the stomach, noise from the device, dry nose, and dry throat. Failure to comply with CPAP treatment was 83% in mild sleep apnea.5

Many patients are not informed about oral appliances either by the sleep specialists or medical doctors who prefer to prescribe CPAP. The majority of medical doctors do not have a clear understanding of sleep apnea or other sleep related disorders and rely on the sleep specialists to help these patients. Also due to the fact that this subject is not taught in dental school, many dentists do not screen patients for sleep disorders.6 This is unfortunate because the dental profession sees patients on a more regular basis than the medical profession and are therefore in an excellent position to screen patients. I recommend that dentists screen their patients using the Epworth Sleepiness Scale.

Epworth Sleepiness Scale The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, selfadministered questionnaire and widely used by sleep professionals in quantifying the level of daytime sleepiness. (Johns, M.W. “A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale.” Sleep 14 (1991): 540-545.) How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you. The two main signs of obstructive sleep apnea are snoring and daytime sleepiness. I recommend that patients should be asked

if they snore and has their bed partner ever noticed periods where they stop breathing at night. If they answer yes to either question I recommend they be encouraged to complete the Epworth Sleepiness Scale. This scale used worldwide by dentists to determine how sleepy the patient is during the daytime as a result of not having efficient sleep at night due to the apneic and hypopneic events (arousals). If the Epworth Sleepiness Scale score is above 7 then I recommend the patient be referred for an overnight sleep study and the diagnosis made by a certified sleep specialist. If the diagnosis is mild to moderate sleep apnea the dentist is encouraged to fabricate an oral appliance. It is critically important for the growth and well being of children that obstructive sleep apnea and ADHD (Attention Deficit Hyperactivity Disorder) are diagnosed and treated as early as possible. These children are unable to sleep properly usually due to a constricted maxillary arch or airway obstructions due to enlarged tonsils or adenoids. When children have frequent arousals all night they never get to Stage 3 sleep where growth hormones are secreted. When no growth hormones are secreted the children are often shorter and weigh less than other children should at that age.7 These children have trouble focusing in school, reduced grades, also snore, and often have a reduced interest in

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Technology and Oral Appliances sports due to daytime fatigue. This lack of interest in exercise also predisposes them to obesity. A recent statistic in Canada stated that 30% of our population is obese. This is an alarming trend which we all must try and avoid by diagnosing and treating these problems at an early age. To correct these airway obstruction problems most children need the following: 1. Removal of airway obstructions- usually the tonsils and adenoids. 2. Arch development of their maxillary and mandibular arches with functional appliances while they are actively growing. 3. Functional appliances to treat Class II skeletal problems with retrognathic mandibles with Rick-A-Nator or Twin Block appliances to move the lower jaw and tongue forward to open the airway.

Before!Treatment !After!Treatment Retruded!Lower!Jaw!!! Twin!Block!8!Months Lower!Jaw!–!Tongue! Forward

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Children with ADHD are often extremely hyperactive and aggressive and are difficult to handle in school. The medical profession often treats children with ADHD with medication such as Ritalin. These are central nervous system stimulants that often have serious side effects. The dental profession is in an excellent position to eliminate the cause of the problem which is the obstructed airway rather than just treat the symptoms with drugs. Following the treatment as outlined above, we then give the children a “new drug called oxygen” as a result of using a functional jaw repositioning appliance to reposition the tongue forward which increases the size of the airway. Parents are so appreciative when these problems are solved and the children can resume a normal life. The literature is clear that while oral appliances are slightly less effective than CPAP they are preferred by the majority of patients.8,9 Dentists need to become involved in helping improve not only patient’s quality of life but also length of their lives. Some research has stated that patients’ with severe obstructive sleep apnea may live 10-15 years less than patients without this sleep disorder.10 All patients are concerned with being healthy which is the key to improved quality of life. Patients with sleep apnea do not have a good quality of life. With this disorder comes an increased risk of depression, headaches due to lack of oxygen at night, impotence, loss of memory, reduced cognitive ability, and fibromyalgia. Sleep apnea has also been linked to dementia and Alzheimer’s which is something no one is looking forward to later in life. The problem is that when patients have what can amount to hundreds of disruptions in their breathing at night this causes oxygen desaturation in the


blood. The heart then tries to work harder to get oxygen to the rest of the body which can often lead to high blood pressure with increased risk of cardiovascular problems. In the future I think you will see obstructive sleep apnea linked to many more medical conditions. Dentists who get involved in treating patients with snoring and sleep apnea gain a great deal of satisfaction knowing that they have improved the quality of life of their patients. 1. By eliminating snoring they have dramatically improved the relationship between the bed partner and the snorer. Many couples are in separate bedrooms due to loud snoring. This is obviously not good for relationships. This is evidenced by the fact that the divorce rate is higher for couples that have snoring problems. 2. New research has shown that the quality of the bed partner’s sleep is seriously affected by the snorer. If the bed partner loses 1 hour or more of sleep per night and never gets to Stage 3 (deep sleep) this can have a negative effect on their overall health. Restoration of memory and

the immune system become more active in Stage 3 deep sleep. Many bed partners do not get enough Stage 3 sleep due to loud snoring. 3. Improving quality of lives by reducing the chances of traffic and industrial accidents due to excessive daytime sleepiness.11 In the U.S. and Canada more motor vehicle accidents are now caused by drivers falling asleep at the wheel due to untreated obstructive sleep apnea and daytime fatigue than are caused by excessive use of alcohol. At the present time, there is no mandatory testing for commercial drivers or pilots. This is an extremely volatile situation since it has been found in one study in Green Bay Wisconsin that 80% of the drivers of the Sneider Trucking Company were diagnosed with obstructive sleep apnea. If you were able to screen your patients, and motivate them to have a sleep study, and be successfully treated for their snoring and sleep apnea this would be ideal for the patient and their family. 4. Oral appliances have been shown to increase oxygen saturation which helps reduce blood pressure. Diastolic blood pressure

is the first to rise in association with subliminal obstructive sleep apnea.12,13 Reduction in blood pressure will help reduce the chances of cardiovascular problems as discussed earlier. 5. Improved quality of life by reducing the tendency for depression, headaches, acid reflux, Type 2 Diabetes, impotence, memory loss, dementia and Alzheimer’s.

Sleep apnea is a condition that affects 20% of the adult population as well as children with major health consequences for all. Sleep apnea has recently gained recognition as one of the world’s most prevalent undiagnosed disorders. Some estimate that 85% of patients with sleep apnea are undiagnosed.14 Our patients trust us with helping them achieve optimum oral health. The time has come for the dental profession to help improve our patients’ overall health as well as their quality of life.

REFERENCES 1.! 2.! 3.! 4.! 5.! 6.! 7.! 8.! 9.! 10.! 11.! 12.! 13.! 14.!

Babu!AR,!Herdegen!J.!Fogelfeld!L,!et!al.,!“Type!2!diabetes,!glycemic!control!and!continuous!positive!airway!pressure!in!obstructive!sleep!apnea”,!!Arch!Intern!Med,!165,!447B452,!2005 JeanBLouis,!G,!Zizi,!F.!Clark!LT,!Brown,!CD,!McFarlane,!SI,!“Obstructive!Sleep!Apnea!and!Cardiovascular!Disease:!!Role!of!the!Metabolic!Syndrome!and!Its!Components”,!J.!Clin!Sleep!Med!2008:!4(3):261B272. Kushida!CA.!Morgenthaler!TI.!Littner!MR.!et!al.!Practice!parameters!for!the!treatment!of!snoring!and!obstructive!sleep!apnea!with!oral!appliances:!!an!update!for!2005.!!Sleep!!2006e29:240B243. Cistulli!PA,!Gotsopoulos!H,!Marklund!M,!Lowe!AA.!Treatment!of!snoring!and!obstructive!sleep!apnea!with!mandibular!repositioning!appliances.!!Sleep!Med!Rev!!2004e!8:443B457. Waldhom!RE,!Herrick!TW,!Nguyen!MC,!O’Donnell!AE,!Sodero!J,!Potolicchio!SJ.!!LongBterm!compliance!with!nasal!continuous!positive!airway!pressure!therapy!of!obstructive!sleep!apnea.!!Chest!!1990e97:33B38. Bian!H.!Knowledge,!opinions,!and!clinical!experience!of!general!practice!dentists!toward!obstructive!sleep!apnea!and!oral!appliances.!!Sleep!Breath!2004e8:85B90. Ali!NJ.!Pitson!DJ.!Stradling!JR.!!Snoring,!sleep!disturbance,!and!behavior!in!4B5!year!olds.!!Arch!Dis!Child.!!1993e68:360B366. Ferguson!KA.!Cartwright!R.!Rogers!R.!SchmidtBNowara!W.!Oral!appliances!for!snoring!and!obstructive!sleep!apnea:!!a!review.!!Sleep!2006e29:244B62. Lowe!AA.!!Sjoholm!TT.!!Ryan!CF.!Fleetham!JA.!!Ferguson!KA.!!Remmers!!JE.!!Treatment,!airway!and!compliance!effects!of!a!titratable!oral!appliance!Sleep!2000e23:(Suppl!4):S172BS178. Lacasse!Y,!Godbout!C,!Series!F.!HealthBrelated!quality!of!life!in!obstructive!sleep!apnea.!Eur!Respir!J.!2002e19:499B503. Young!T.!Blustein!J.!Finn!L.!Palta!M.!Sleep!disordered!breathing!and!motor!vehicle!accidents!in!a!populationBbased!sample!of!employed!adults.!!Sleep!!1997e20:608B13. American!Journal!hypertension!!2003e15:236B239. Peppard!PE,!Young!T,!Palta!M,!Skatrud!J.!Prospective!study!of!the!association!between!sleepBdisordered!breathing!and!hypertension.!!N!Engl!J!Med.2000e342:1378B1384 Young!T.!Evans!L.!Finn!L.!Palta!M.!!Estimation!of!the!clinically!diagnosed!proportion!of!sleep!apnea!syndrome!in!middleBaged!men!and!women.!!Sleep!!

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Case Studies

Improving Efficacy of Non-Responders to Mandibular

Advancement in the Management of Obstructive Sleep Apnea

By Daniel Tache, DMD

In 2006, the American Academy of Sleep Medicine published updated practice A!native!of!Salem,!MA,!Dr.!Tache’!has!been! practicing!dentistry!since!1975.!He!received!his! undergraduate!degree!from!St.!Anselm’s!College! in!Manchester,!NH,!and!his!Doctor!of!Dental! Medicine!degree!from!Tufts!University!School! of!Dental!Medicine!in!1974.!Dr.!Tache!began! lecturing!for!SGS!in!2006!and!is!currently! serving!as!President!of!the!Wisconsin!Sleep! Society. For!16!years,!Dr.!Tache’!was!in!private!practice! in!Houston,!TX!and!served!as!a!guest!lecturer! and!assistant!clinical!professor!at!the!University! of!Texas!Dental!Branch.!During!that!time,!he! temperomandibular! dysfunction!and!orofacial!pain. In!1999,!he!moved!to!Wisconsin!and!has!placed! the!emphasis!of!his!practice!on!the!diagnosis! and!treatment!of!orofacial!pain!and!TMD!in! Appleton,!Green!Bay!and!Manitowoc.!Dr!Tache’! continues!to!lecture!locally!and!nationally!on! the!subjects!of!orofacial!pain!&!sleep!apnea! dentist!in!the!management!of!these!serious! modalities. PAGE

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parameters on the use of oral appliance therapy in the treatment of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS).1, 2 These guidelines stated that oral appliances are indicated as therapy in patients with simple snoring and mild to moderate OSAH in patients who prefer oral appliances, or those who refuse or have failed to continue to use PAP.


Case Studies

Since that time, the application of oral airway appliances has become an accepted treatment option for snoring and mild-moderate obstructive sleep apnea (OSA) and Upper Airway Resistance Syndrome (UARS).3-5 Most patients with OSA, experience obstruction primarily at the levels of the velopharynx and/ or oropharynx. Oral Airway Appliance Therapy (OAT) has been shown to favorably impact the airway in some patients helping to maintain sufficient patency during sleep.

OAT: Mandibular Advancement Oral Airway Appliance Therapy (OAT) can improve upper airway patency during sleep by: a) increasing airway dimensions, b) decreasing upper airway compliance through improved airway muscle tone or c) a combination of both mechanisms. These appliances are most often referred to in the literature as MADs or mandibular advancement devices because they are principally designed to be advancement-only. Despite the considerable variation in mandibular advancement device design, the clinical effects from advancement of the mandible to near-maximum protrusive rangeof-motion, appear remarkably consistent and OSA improves in most subjects.11, 12 Although the preponderance of individuals with mild-moderate OSA treated with MADs demonstrate airway improvement in both the retropalatal and retroglossal regions with advancement alone, a small number of the subjects fail to respond to advancement or show a decline in airway dimensions.4, 13

OAT: Increased Vertical Indeed, numerous prospective controlled clinical trials have consistently proved the benefit to airway stability from advancement of the mandible. However, a smaller subset of individuals who may not benefit from advancement or in fact, who may experience a negative effect upon airway caliper and stability from advancement, may actually benefit from OAT that has increased vertical support. Improved genioglossus muscle tone has been shown with downward rotation of the mandible.14 Some have observed improvement in airway patency with bite-opening attributable to increased tone of palatoglossus and superior pharyngeal constrictor muscles.15 It has also been proposed that this mechanism is also explained by a decreased gravitational effect of the tongue on upper airway patency and preservation of the velopharyngeal airway by maintaining increased stretch of the palatoglossal and palatopharyngeal arches which in turn, prevents relapse of the tongue during sleep.16-18

Continued!next!page.

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Case Studies

Continued!from!previous!page Improving Efficacy Of Non-Responders To Mandibular Advancement In The Management Of Obstructive Sleep Apnea

The phenomenon of increased airway obstruction when the mandible is maximally advanced, has been demonstrated 21 Although a worsening of airway stability with advancement is the exception with the mild-moderate OSA patient, it nonetheless represents a formidable challenge in the management of some of our dental sleep medicine patients.

Alternative application of oral airway devices These facts are a reality which dental sleep clinicians will have to confront. One option for consideration is using the oral airway appliances not as an alternative to the Continuous Positive Airway Pressure (CPAP) device but as an adjuvant to PAP therapy.

Combination Therapy and Hybrid Therapy Combination Therapy and Hybrid Therapy are terms currently used to describe the adjuvant application oral airway devices in concert with CPAP. Combining therapies can reduce excessive CPAP pressure when a sufficiently titrated MAD is worn, as the term implies, concurrently with CPAP. By having the mandible repositioned by the device, the airway is rendered partially stabilized thereby reducing the pressure required of the CPAP to maintain a patent airway. High upper airway resistance (HUAR) has been shown to be reduced as well when oral airway devices and CPAP are combined, further reducing the higher pressures required of the CPAP. 24 Hybrid therapy may improve acceptance of CPAP because the oral airway device from contact allergy/irritation from the interface straps or mask leakage from excessive movement of the mask. It seems quite logical to consider Combination Therapy or Hybrid Therapy as a front-line approach to rescuing a developing intolerance to PAP therapy, however there is little more than anecdotal evidence to support this combined use with CPAP.25 PAGE

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Case Studies A preponderance of patients referred to the dentist for fitting with an oral airway appliance, have previously failed to be CPAPtolerant so it may be a bit na誰ve to expect many to become more tolerant simply because they have not responded to the appliance which was offered to them. Being mindful of the considerable health risks consequent from failure to effectively control the OSA, the qualified dentist who serves this population of patients, is compelled to explore all avenues for improved responsiveness to the oral airway appliance.

Predicting treatment outcomes Determination of patient suitability for OAT. There are numerous variables which have been shown to correlate with the effectiveness of a mandibular repositioning device such as a lower AHI, lower BMI, smaller neck circumference, negative family history of OSA, younger age, female gender who has not begun menopause, pronounced retrognathia, and protrusive range of motion >10mm to name a few.

The MATRx Device The MATRx is a Remotely Controlled Mandibular Positioner (RCMP) device that provides prospective means for predicting treatment outcomes during a polysomnographic study26.27 Although predictability appears to be much improved with the use of the RCMP, a major limitation resides in that it assesses responsiveness to advancement only and as was previously stated, some individuals being treated for OSA experience degradation of airway stability when the mandible is advanced. Although, these are the exceptions, the potential health consequence can be ominous. The focus of the remainder of this article will focus on the patient who is not an advancement-responder.

Managing Patients NOT Responding to Advancement: Assessing Vertical Dimension The acoustic reflection (AR) technique has proved to be a useful tool in characterizing upper airway properties in patients with OSA.28 AR technology is simple, quick, and non-invasive and provides useful objective measurement of the nasal (rhinometry) and pharyngeal (Pharyngometry) cavity caliper and most importantly, in real time. There are abundant studies pointing to its accuracy and reproducibility. because its a real-time dynamic and simple procedure to determine cross-sectional area of a body cavity, its application to assessing airway compliance should be obvious.

More recently, predictability of responsiveness to a MAD has been greatly improved by development of the MATRx Device, developed by Remmers, Hajduk, Lowe, & Platt.

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Case Studies

Continued!from!page!43 Improving Efficacy Of Non-Responders To Mandibular Advancement In The Management Of Obstructive Sleep Apnea

Post-treatment Assessment

Long-Term Follow-up

Follow-up is necessary to evaluate treatment response to mandibular repositioning and to assess for recurrence of OSAH. Because mandibular repositioning devices are dose-dependent, the use of portable sleep monitors is appropriate while attempting to optimize patient response. The AASM recommends an attended Polysomnogram (PSG) be performed to objectively verify that the oral appliance is improving apnea, oxygenation,

AR is based on the generation of sound waves by calibrated wave tubes; the generated energy is reflected in the airway and then recorded by microphones in the wave tubes, then processed by the CPU as seen in Figure 4. Previous page

Standard operating procedure for most all dental practices is the annual and semi-annual recall visit. It is part of the fabric of how the dental practice operates. Since most dentists practicing Dental Sleep Medicine emerge from this paradigm, the dental office is uniquely prepared for caring for the sleepdisturbed breathing patient. Close follow-up is essential and recommended for as long as the patient is using oral appliance therapy, and the frequency and timing depends on the severity of OSAH; there are a number of dependent variables which can affect treatment response such as increase in BMI, degree of mandibular repositioning, use of sedating medications, loss of muscle tone with ageing, to name a few. It is not enough that non-snoring and feeling more refreshed are the only metrics that are followed because nonsnoring and feeling better have been shown NOT to correlate with sufficient efficacy of a Mandibular Repositioning Device (MRD)29. Other clinical features, viz. side effects, degradation of the integrity of the device that could lead to fracture, and medical co-morbidities to which the attending primary care physician may need to be alerted, require the dental sleep clinician’s vigilance. Generally, a yearly review is recommended. It should always and repeatedly be emphasized to the patient utilizing a MDR that he/she should NOT make any substantial, permanent changes in the treatment position of the mandible without first consulting you, the treating clinician.

and sleep fragmentation.2

Comments & Reflections Having technology such as AR (www.sleepgroupsolutions) is not essential for treatment of many of the patients who present with mild or moderate, positional-dependent OSAH Syndrome. The case presented herein would not likely have been a success without the help of current AR technology. If this were an isolated case, it would not be of any value to extol the benefits of having this technology available. You could just advance and hope that it will work. Happily, in most cases, you will be very successful, but this case study with annotations was written with someone else in mind, i.e., for the benefi t of the patient who is being treated for mild-moderate OSAH Syndrome whose airway will not sufficiently respond to mandibular ADVANCEMENT; It is well established that some patients do not respond. Obese males, and women, young and old with polycystic ovarian syndrome to name just two subgroups of those unlikely to be so lucky. In the likely event that one of these patients does NOT respond under your care, or becomes worse with MAD therapy, this author finds such technology as AR essential. PAGE

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Case Study: Management of the Sleep-Disturbed Breathing Patient Utilizing a Mandibular Repositioning Device (MRD) - A Proposed Approach to Augmentation of an Ineffective MRD When Advancement is Not Sufficiently Stabilizing the Airway“Regular follow-up visits are continued as long as the patient is using oral appliance therapy ‌ generally, a yearly review is recommended.â€? Kushida CA, 20062 Modifing Your Patient’s Mandibular Repositioning Device When dvancement Is Not Sufficiently Stabilizing The irway.

Meet J. L.

Intraoral View

CBCT Tomograms

Baseline Analysis Mean Area = 2.65 cm2 (Avg. = 2.80 cm2)

RV = 0.90 cm2

s 4HE !MERICAN !CADEMY OF 3LEEP -EDICINE IN THE 0RACTICE Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005 requires that:

s 4HIS CASE WILL DEMONSTRATE

1. The importance of monitoring respiratory indices on our OSA patients, regardless of level of severity 2. An approach of improving efficacy of a mandibular advancement device (MAD) when sufficient advancement is not sufficiently reducing the respiratory indices sufficiently

s *, IS A  YO RETIRED TEACHER WHO WAS DIAGNOSED WITH MILD /3!3 IN  s *, WAS INITIALLY OFFERED NASAL #0!0 FOR MANAGEMENT OF HER /3!3 s *, GREW INTOLERANT DESPITE HER BEST EFFORT AND WAS REFERRED TO US BY HER SLEEP specialist for treatment with a mandibular repositioning device (MRD) s *, HAS HAD A PAST HISTORY OF 4-* PROBLEMS s 3HE REPORTED THAT SHE HAS CONTINUED TO hGRINDv AT NIGHT EVEN THOUGH SHE FEELS THAT it is improved since receiving her oral airway appliance s (ER MANDIBULAR RANGE OF MOTION WAS SOMEWHAT REDUCED WITH SOME DEVIATION OF THE mandible upon maximum opening s (ER ACTIVE RANGE OF MOTION !2/- IS APPROXIMATELY MM WITH SLIGHT DEVIATION to the right s #"#4 TOMOGRAMS WERE TAKEN TO ASSESS 4- JOINT FUNCTION

Clinical Assessment: CBCT of Temporomandibular Joints

s 4HE #ONE "EAM #4 IMAGES APPEARED TO BE NORMAL WITH RESPECT TO ANATOMY AND FUNCTION s 4HE CONDYLES DO NOT SHOW DEGENERATIVE CHANGES AND ALSO APPEAR TO BE TRANSLATING WELL s Negative CBCT findings would suggest that any dysfunction would likely be muscular in nature s 4HE BASELINE ACOUSTIC ASSESSMENT SHOWS A SUBOPTIMAL SIZE AIRWAY MEAN AVERAGE AIRWAY is >2.80 cm2 for women s 7E WILL NEXT ASSESS THE COMPLIANCE OR STABILITY OF THE AIRWAY BY HAVING *, EXPRESS AS MUCH air as possible while the wavetube is in place; analogous to a Mueller Maneuver s 4HIS NEGATIVE LOAD WILL REVEAL AT WHICH LEVEL AND HOW MUCH THE AIRWAY COLLAPSES s 4HE CALIPER OF THE AIRWAY AFTER APPLYING THIS NEGATIVE LOAD IS TERMED 2ESIDUAL 6OLUME 26 s 4HE AIRWAY IS CONSIDERED TOO COMPLIANT OR COLLAPSIBLE IF THE MINIMUM IS   CM s !T RESIDUAL VOLUME 26 AREA OF AIRWAY AFTER ALL AIR EXPRESSED THE MINIMAL CROSS SECTIONAL diameter if only 0.90 cm2 s 4HIS IS A RELATIVELY UNSTABLE AIRWAY s 4HE SMALLER SIZE OF THE AIRWAY COUPLED WITH THIS DEGREE OF COMPLIANCE WOULD EXPLAIN WHY JL has OSA. s .EXT WE WILL HAVE *, REPOSITION THE MANDIBLE AND THEN CHECK AIRWAY STABILITY WHEN advanced and/or depressed (additional vertical height) Comparing Effects of Advanced Vs. Opening s 4HE !IRWAY APPEARS TO STABILIZE WITH INCREASED VERTICAL s !DDING VERTICAL MAY BE AN OPTION IF ADVANCEMENT DOES NOT SUFlCE s 'IVEN THAT HER LEVEL OF 3$" IS QUITE MILD ADVANCEMENT ALONE SHOULD BE SUFlCIENT s ! 'EORGE 'AUGE '' WAS USED INITIALLY FOR THE AIRWAY CONSTRUCTION BITE A PROTRUSIVE position of 60% of maximum protrusive was used as a starting point.

Comparative RV of Airway with Repositioning Mandible Advanced (only) = 0.88 cm2 Mandible w/ Add’l vertical = 1.54 cm2

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Case Studies

Case Study: JL: OSA Recall Visit (overdue) Sufficiently Stabilizing the Airways 4HIS IS HOW THE APPLIANCE LOOKED AT THE TIME THAT *, RETURNED FOR HER lRST FOLLOW UP after a prolonged period of time s 3HE WAS INSISTENT THAT SHE DID FEEL BETTER AND WAS NO LONGER SNORING FOR WHICH SHE was grateful s !T THIS POSITION SHE WAS ABLE TO CONTROL JAW DISCOMFORT s 3HE HAD ATTEMPTED TO ADVANCE THE MANDIBLE BEYOND THIS TITRATION POSITION BUT HER jaw discomfort increased significantly s &ROM THIS VANTAGE POINT ONE CAN SEE THAT *, HAS ADVANCED THE MANDIBLE A significant amount s 3HE CANNOT ADVANCE MUCH MORE BEYOND THIS POINT WITHOUT SIGNIlCANT DISCOMFORT s ! HOME SLEEP TEST TO ASSESS HOW EFFECTIVE THE -!$ IS IN REDUCING /3! IS NOW appropriate

Assessing Efficacy of the MAD: The Home Sleep Test (HST) Comments on Home Sleep Test (HST) report: The Devil is in the Details The HST report says that she is entirely “normalâ€? but the patient would disagree that she feels as “normalâ€? as she would like. It is critical to consider all of the data from a sleep study, not just the AHI this writer only considers to be a gross estimate of sleep wellness. This is particularly relevant for patients who report a Past Medical History of TMD or fibromyalgia, or any of the Functional Somatic Syndromes (FSS). There is a substantial body of (emerging) knowledge suggesting that many of these FSS patients have a non-apneic, sleep-disturbances in common due to frequent nocturnal microarousals leading to increased sympathetic.8 When reviewing a HST or PSG, this author considers the presence or absence of snoring and the AHI as a gross estimates of sleep wellness even when the patient subjectively reports improvement; the details can often reflect otherwise.10 The silent, non-apneic sleep-disturbed breathing patient may have a constellation of symptoms, heretofore described as one of the Functional Somatic Syndromes (FSS).8, 13 Being mindful of this may permit one to offer or refer for more effective management of these patients beyond management, which is often all that is offered patients identified as being afflicted with a FSS. In this particular case, JL, has a level of SDB, which, under most circumstances, would be overlooked by many if all that is monitored were the AHI. Her respiratory-related symptoms significantly degrade the quality of her life.9 In the view of this writer, it is as important to consider the %age of inspiratory flow limitation or other indicators such as the flattening index, particularly in women, who are more adversely affected19 Powers found hypersomnia in UARS patients however, these patients showed altered results on the MSLT that were not correlated with the Epworth scale (ESS) 20 Excessive daytime sleepiness and fear of automobile accidents was the chief concern of JL and what prompted her to go for her initial sleep study. It is important to converse with the patient when it comes to sleepiness because it is so subjective and some of the frequently used metrics, such as the ESS, should be personally reviewed with the patient by the doctor and not accepted, prima facie as a true reflection of patient vigilance.22; 23. What this writer does is review each of the ESS questions with the patient and I pose each question with the admonition to, “Imagine or pretend that you had no other responsibilities, no job, no children to drive around for that day, what is the possibility that you would feel drowsy? Most women when hurriedly completing these questionnaires, unless coached, could likely not imagine having a minute to 1. Lie down to rest in the afternoon, or 2. Sit quietly after a lunch, and/or 3. (Imagine being) ‌ a passenger in a car for an hour without a break. Often, after taking the time to review with the patient, the ESS score will increase significantly. So, we will attempt to modify the current MAD in an effort to reduce the (Inspiratory) Flow-Limitation Index, which we hope will also help to reduce her persistent daytime sleepiness. PAGE

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s *, WAS GIVEN A PORTABLE SLEEP MONITOR TO ASSESS THE EFlCACY OF HER -2$ AS IT currently is performing s !T lRST LOOK THE !() IS SUFlCIENTLY REDUCED TO HR HOWEVER A CLOSER LOOK MAY explain why she continues to have residual symptoms: 1. %age Flow-limited breathing is 75 (normal < 60) 2. Saturations <90% is 7% (normal is < 1%) 3. Risk Indicator (RI) is 7 (normal is < 5); the RI is roughly equivalent to the RDI s *, CONTINUES TO HAVE AIRWAY INSTABILITY THAT ALTHOUGH NOT REmECTED AS AN ELEVATED AHI, could explain most of her symptoms because of the impact on the sympathetic nervous system s ! DIAGNOSIS OF RESIDUAL 5PPER !IRWAY 2ESISTANCE 3YNDROME WOULD BE appropriate7 and it must be addressed s 0ATIENTS SUFFERING FROM 5!23 SHOW A HIGH PERCENTAGE OF mOW LIMITED BREATHING patterns9 s &LOW LIMITED BREATHING IS OFTEN ASSOCIATED WITH %%' CHANGES ASSOCIATED WITH microarousals

Continues!on!Page!48


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Case Studies Improving Efficacy Of Non-Responders To Mandibular Advancement In The Management Of Obstructive Sleep Apnea

s 3O HERE IS WHAT THE APPLIANCE LOOKED LIKE INTRAORALLY IN *, BEFORE OUR ATTEMPT TO modify it with the hope that it will improve efficacy s *, IS HAS ADVANCED IT NEARLY TO A PROTRUSIVE END POINT SO FURTHER ADVANCEMENT WILL not be possible s 7E WILL ASSESS VERTICAL DIMENSION USING 0HARYNGOMETRY THIS IS A REAL TIME STUDY and will show us if we have a possible pathway with the addition of vertical to stabilize the airway Appearance of MAD When JL First

s 2ECALL FROM THE INITIAL ACOUSTIC ANALYSIS OF *,S AIRWAY WHICH SHOWED that increasingvertical (red line) seemed to reduce airway compliance more than advancement (blue line) s 3O WE WILL REEXAMINE HER AIRWAY VERTICALLY 7)4( /2!, $%6)#% INPLACE while we incrementally add vertical utilizing the Airway Metrics Vertical Titration KeysÂŽ

Modifying a MAD to Improve Efficacy -Acoustic Pharyngometry & Airway Metrics ACOUSTIC ANALYSIS OF THE IMPACT OF ADDING VERTICAL TO A MAD 1. Vertical Titration Key (VTK) is placed between the separated maxillary and mandibular components of most any MAD; start with the lowest (3mm) VTK ; most popular MRDs can be so modified (Respire, TAP, MAD, EMA etc.) 2. The acoustic mouthpiece is placed over the mouth and the acoustic assessment is performed by introducing sound waves from the wave tube into the oro-, velo- and hypopharynx (see figure 4) 3. We are looking for a minimum cross-sectional diameter of 1.5-2.0 cm2 at Residual Volume (RV) i.e. when all air is expressed (mod. Mueller Maneuver) 4. Continue to add higher VTKs until maximum benefit is obtained 5. We can see from the print of the screen obtained from analysis of JL, that the addition of 6mm of vertical did seem to help greatly stabilize the airway; minimum diameter was stable at 2.22 cm2

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Modifying a MAD to Improve Efficacy -Acoustic Pharyngometry & Airway Metrics (cont.) s )F THE AIRWAY DOES SHOW A FAVORABLE RESPONSE THE BEST VERTICAL IS recorded with a bite registration medium of preference s (ERE IS THE -!$ -!3 WITH A MM 64+ IN PLACE s "ELOW WE SHOW A 4!0 %LITE ALSO WITH A MM 64+ s 7HEN WE ARE ADJUSTING A 4!0 APPLIANCE WE WILL HAVE THE PATIENT protrude to at least end-to-end or comfort and then test

MAD with 6mm VTK

TAP Elite with 6mm VTK

Splint Modified

MAD with Airway Bite / 6mm VTK

MAD mounted with airway bite completed / in place

MAD mounted with airway bite completed / side view

MAD Mounted on plasterless articulator with airway bite

MAD mounted with airway bite removed

Acrylic added to posterior platforms of MAD

Modifying a MAD to Improve Efficacy -Acoustic Pharyngometry & Airway Metrics (cont.)

s (ERE IS THE MODIlED APPLIANCE AS IT appeared at the time of re-delivery s 4HE APPLIANCE WAS COMFORTABLE s 4HE MODIlCATION IN LAB WAS accomplished in less than an hour s 4HE 'ALETTI !RTICULATOR (http://www.galetti-articulator.com) is a very useful tool for making such modifications to an MRD

Acrylic added to posterior of MAD â&#x20AC;&#x201C; articulator closed

Acrylic addition completed; now polish, adjust and deliver

Acrylic highlighted and adjusted; ready for delivery

s 4HE LAST STEP IN THIS PROCESS IS TO TEST the efficacy; initially, a HST was performed but JL was referred back for an attended PSG s (ER SLEEP SPECIALIST DID NOT FEEL THAT another titration PSG was needed

Vertical platforms added

Acrylic added to posterior platforms of MAD

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Sleep Insights

Sleep apnea myths

1 FREE

Sleep Apnea Myth Quiz

for commercial drivers to be aware of the differences between sleep apnea myths and facts. The FMCSA has had sleep guidelines in place for more than 23 years, and there are more than 30 million Americans with undiagnosed sleep problems, so it’s not a new problem. However, the issue is getting more attention recently because dozens of clinical studies clearly show

disease? Any two suggest a high likelihood

people with untreated sleep apnea have a seven-fold risk for accidents and signifi-

fully treated their sleep apnea with CPAP

control it, so I don’t have sleep apnea. Sleep is not voluntary, especially with sleep apnea. If you’re drowsy, you can fall asleep and never even know it. When you’re driving, being asleep for even a few seconds can kill you or someone else. Myth: I get plenty of sleep, so I do not have sleep apnea. The average person needs seven or eight hours of sleep a night. If you go to bed late and wake up early to an alarm clock you probably are building up a sleep debt. If you spend eight hours in bed but still feel tired, you may have a disorder like sleep apnea, preventing you from getting enough quality sleep. Myth: I must be obese to have sleep apnea. Several common screening factors are predictive of sleep apnea, and obesity is No. 1 on the list. Do you snore, gasp or make choking sounds during sleep? Body mass 30higher? or higher? Necksize size 17 17 max index index(BMI) 30 or Neck inches or more (15.5 for women)? High blood pressure, type 2 diabetes or heart PAGE

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sleepgs.com

Earn!1!CE,!Take!the!Quiz!on!page!57

Because sleep apnea screening and testing is on the rise, it has become important

cantly more health risks. Myth: I can tell when I am sleepy and

CE

of sleep apnea. Myth: Even if wear CPAP, I won’t feel any different. Drivers who have successtypically say that they feel years younger, are finally able to lose weight and have increased energy and stamina. Myth: If I test positive for sleep apnea, my employer will use it against me. When a driver tests positive for sleep apnea, he/she only needs to show that they are being treated with CPAP and are wearing the device for four hours, five days per week. Your CPAP will track the usage hours that occur, and no other information is looked at by your DOT examiner or employer. Your health information always belongs to you. If you answered “yes” to the questions listed above, you may have obstructive sleep apnea, but you are not alone. Sleep apnea affects more than 18 million American adults and about 28 percent of commercial truckers. Consider discussing this issue with your physician or DOT examiner. It’s time to be driving toward sleep wellness. Jill Glenn, RPSGT, is vice president of clinical operations and Dana Voien is president and CEO of Sleepsafe Drivers (sleepsafedrivers.com).


The Sleep Mall Welcome to The Sleep Mall One Stop Sleep Solutions! TheSleepMall.com is your source for supplies and disposable items relating to the screening and treatment of snoring and sleep apnea. Our inventory includes Dental Sleep Medicine supplies, oral appliances, CPAP supplies, Home Sleep Testing devices and disposables, and in-lab PSG equipment. You’ree just a click away!

www.TheSleepMall.com Mall.com The Sleep Mall Carries: Pharyngometer Supplies Rhinometer Supplies Oral Appliances Watermark ARES Patient Kits Embletta Supplies

For years, Henry’s wife and children joked about his loud snoring. Henry’s wife finally took it seriously when she noticed long pauses in his breathing while he slept. Henry began to notice a lack of energy through out the day. He often felt tired during his commute to work, and his headaches, frequent daytime sleepiness and irritability made it almost impossible to do the activities he once enjoyed. Henry knew he needed to sleep better in order to enjoy his life again. His doctor explained the connection between his diabetes, and OSA.

Your Dentist offers the complete solution for sleep apnea, including testing and well-fitting custom oral appliances.

Patient Brochures & Flyers SLEEP APNEA AND AIRWAY MANAGEMENT One Stop - More Solutions.

And MORE!

If you have noticed two or more of these symptoms,you may suffer from Obstructive Sleep Apnea (OSA).

The information within this brochure is for educational purposes only, and should not be taken as definitive or binding medical advice. Because each person is medically different, individuals should see their personal physician for specific information and/or treatment. Diabetes and Sleep Apnea © Copyright 2013 Sleep Group Solutions, Inc. All Rights Reserved.

DiabetesSleepApneaBro2.indd 1

3/15/13 1:46 PM

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Home Sleep Testing 1, 2, 3!

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Case Studies

PSG versus Home Sleep Study-A patient case study By!George!Jones,!DDS

I think itâ&#x20AC;&#x2122;s safe to say that any Dentist involved in treating OSA recognizes that a PSG from an accredited Sleep Lab is the gold standard for obtaining a diagnosis.

Dr. George Jones is a native of Wheeling, WV and earned his BS in Chemistry from Wheeling Jesuit University. He received his Dental Degree from the University Of Florida College Of Dentistry, and relocated to coastal North Carolina in 2003. Over the years, Dr. Jones has served as a consultant and evaluator for several dental manufacturers and maintains a private practice in Sunset Beach, NC. . Figure 1

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That isn’t meant to demean the home sleep study, which certainly has its place, and is rapidly gaining acceptance amongst both sleep physicians and insurance companies. In fact, United Healthcare, as of November 1, 2012 has mandated that Home sleep studies be used first, and that they will only pay for a PSG at a sleep lab if the patient is not an eligible candidate for a home sleep study. It is anticipated that other major insurance companies will soon follow suit. When patients ask which is better, we simply explain that both modalities are valid, and that PSG is a very detailed study of an atypical night’s sleep (because you are in a strange environment, without your bed partner, and being monitored electronically and visually) and that the home sleep study is a less detailed study of a typical night’s sleep. What follows is an interesting contrast of results from a patient who has been through both. We recently saw a new patient for a Comprehensive Dental Exam, X-rays, and Prophy. Kristen, not her real name, is a 46 year old Caucasian female, 5’4” in height,

184 lbs, BMI 31.2. Her medical history is notable for a history of smoking (10 cigarettes a day for 30 years), social drinking, and psychological issues. Her dental history is unremarkable. As we were presenting our OSA questionnaire &initial screening, Kristen became visibly upset. It turns out that she had recently been diagnosed with Moderate OSA, and due to her psychological issues and experience at the sleep lab, actually refused to even consider CPAP. (Incidentally, she scored 13 on the Epworth Sleepiness Scale, 8 on the Subjective Self Assessment, and was noted as a Malampatti Class III.) We requested a copy of the sleep study, and brought Kristen back for a consult. The highlights of her PSG were a supine RDI of 23.3 and non supine RDI of 0, she spent 98.6% of her time in the supine position, and her Oxygen Saturation Nadir was 88%. (See Figure 1) As I was discussing these results with Kristin, she became very animated, “Dr. Jones, it was just awful, being in a strange place, knowing someone was watching your every move!” We began discussing treatment options, which were to either proceed with CPAP titration, or a combination

of positional therapy along with a Mandibular Advancement Device. “But Dr. Jones,” she exclaimed, “I NEVER SLEEP ON MY BACK AT HOME!” I remarked that according to this study, she spent nearly all night in the supine position. “I was terrified, and I hardly slept at all, I just lay there on my back hoping morning would come.” I asked Kristin if she would be willing to try a home sleep study, so that we could see her results would look like with a typical night’s sleep, in the comfort of her own home. She agreed and was set up with an Embletta home sleep monitor. The results confirmed exactly what she had expressed: She spent only 46 minutes or 7.7% of her time in the supine position at home, her AHI was only a 1.7 for the test, and a supine AHI of 19.5. Her SPO2 nadir was 89. I think it is interesting to note that the events in the supine position for both studies is fairly consistent (AHI of 19.5 vs. RDI of 23.3) but it is interesting to note the difference in the total number of events for the studies 17 hypopneas for the home study vs. 109 events (17 apneas + 92 hypopneas) for the PSG.

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for Dental Sleep Medicine

Want to implement or have implemented Dental Sleep Medicine in your practice but both you and your staff are pulling your hair out dealing with medical insurance? Do you have everything in place, but just can’t seem to help your patients say “yes” because you are asking them to pay in full up front? Whether you are asking one of these questions or any question related to the medical insurance and financial protocol of moving your dental sleep medicine practice forward, we have an answer for you. Dental Sleep Med Systems has been fine tuning systems for dental sleep medicine for approximately 8 years. We not only use these financial and insurance systems in our two “sleep only” practices, but also teach these systems to dental teams around the country. We are now offering Medical Billing Plus to our existing and new clients. With Medical Billing Plus, we take care of EVERYTHING from verifying medical benefits to billing the claim. The “Plus” is that we also take care of training your staff on how to successfully present oral appliance therapy to your patients in the most patient and physician friendly manner. Our systems are tried and true and will not only help you to help your patients get to “yes,” but they will also help you to minimize patient out of pocket expense and maximize reimbursement from medical insurance. We’ll be the team mentor and extra employee you need to do this successfully and we won’t add to your payroll or payroll taxes! Here is a better picture of the system. On a case-by-case basis, we will supply you everything you need to put your best foot forward and present the treatment plan for

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oral appliance therapy to your patient. You will have a customized presentation form for each patient, ready for your case presentation appointment. We’ll do all the paperwork that is necessary behind the scenes and make you the star by presenting to the patient how you can maximize their medical insurance benefits and minimize out of pocket responsibility. Most importantly, we’ll give you all the knowledge necessary to present the treatment in a patient and physician friendly manner. We provide and train on financial arrangement forms specific for dental sleep medicine. The forms and accompanying education will help you and your patient move forward with treatment. We will teach your staff the tried and true presentation techniques that help us to get greatest patient acceptance. Give us a call today to schedule a complimentary webinar. We’ll show you some pearls, which we know will help you take a big step forward in your dental sleep medicine treatment presentations. You can reach us at 866-602-6550.


1 FREE

CE

Sleep Apnea Myth Quiz Answers!from!article!on!page!50

sleepgs.com

!NSWER THE FOLLOWING QUESTIONS CORRECTLY FOR  &2%% #% &AX QUIZ TO   

1.

7.

8. 2.

9. 3.

4. 10.

5.

6.

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About Us

Sleep Group Solutions Company Profile Sleep Group Solutions is a privately held sleep medicine company based in Hollywood Florida. Established in 2005, SGS focuses primarily on airway diagnostics and the rapidly growing dental sleep medicine markets in which SGS has become the industry leader. Rapid growth within SGS and the industry has been spurred by the fact that over $4 Billion is spent annually to treat sleep apnea with therapies that are largely unsuccessful and have managed to cumulatively treat less than 1% of the affected patients over the past 20 years. Physicians and dentists have increasingly sought out SGS as Medicare and private insurances have pushed the sleep medicine market in this direction.Today, Sleep Group Solutions stands alone as the only provider of a complete suite of solutions starting with continuing education courses and in-office training through screening, diagnostic and treatment instrumentation. With over 50 Million people in North America suffering with sleep apnea and less than .5% of the dentists currently trained and equipped to offer assistance we can expect to see continued rapid growth of this field over the next decade. By offering every piece of the education, screening, diagnosis and treatment puzzle SGS is in a unique position to capitalize on this tremendous growth. PAGE

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Sleep Group Solutions Company Divisions Education Success in any field of medicine starts with proper education. It creates awareness and puts clinicians in a position to offer assistance with a problem. SGS realizes the importance of educating physicians and dentists on not only the scope of the sleep apnea epidemic but the precise step-by-step protocols they can implement in their practices to help manage this problem. SGS is the world’s largest provider of dental sleep medicine continuing education with weekly 2-day seminars across North America. SGS instructors are all highly credentialed with unmatched experience and expertise in sleep dentistry. Customized in-office training programs are offered as a second tier of training as well as special events, study club lectures and mini residency programs across the country.

Instrumentation UÊEccovision Acoustic Pharyngometer SGS Manufactures and distributes the Eccovision Acoustic Pharyngometer system. The Pharyngometer device has become a “gold standard” tool used by thousands of practitioners, hospitals and universities worldwide. The Eccovision is valued for its accuracy, non-invasive testing, low cost per use and has been used in hundreds of clinical research articles. The Pharyngometer is used in sleep disorders dentistry because of its ability to identify narrow, obstructed and collapsible airways as well as its ability to determine proper position of the mandible for oral appliance therapy. This test is reimbursed by private insurance and Medicare.

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Instrumentation (cont’d) UÊEccovision Acoustic Rhinometer The Acoustic Rhinometer is a tool used frequently by dentists and otolaryngologists to measure nasal airway size and identify obstructions in the nose that could be contributing to the sleep disordered breathing problem. This is a quick non-invasive test that can be done in seconds providing the doctor with valuable information. The Rhinometer test is reimbursed by private insurance and Medicare.

UÊSGS 3D Airway Software SGS engineers have developed airway imaging software to complement the use of the Eccovision Acoustic Diagnostic Imaging System. This 3D airway software takes readings from the Pharyngometer and Rhinometer and renders a three dimensional airway complete with volumetric and point-by-point measurements of cross-sectional area.

UÊHome Sleep Testing The in-home sleep apnea testing market has experienced explosive growth over the past two years. SGS is positioned as a leader in this market. We have partnered with the world’s largest sleep diagnostics company. SGS clients are using the latest technology and the most powerful, cost effective device available while being part of the largest network of dentists and physicians using the same hardware and software. Our home sleep testing program has opened the door for increased diagnoses resulting in more patients receiving the care they need.

Sleep Study Interpretation/Diagnosis A home sleep study is only good when accompanied by proper diagnosis by a board certified sleep physician. SGS works directly with hundreds of sleep physicians across North America to provide this service through SGS’ web service www.interpstudies.com . This site connects dentists and sleep physicians making it possible for legal diagnosis of sleep apnea to come from most Home Sleep Testing devices dispensed by the dentist. This very affordable service enables patients to enter treatment earlier than if they had to wait for a sleep study in a sleep lab and provides dentists using home sleep testing with a valuable diagnostic option for patients who refused or could not go for a full in-lab study.

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Dental Sleep Med Systems Dental Sleep Med Systems is an insurance and practice management software solution available exclusively through SGS. Dental Sleep Med Systems was designed from the ground up to provide dentists with all necessary forms, letters and patient records needed for dental sleep medicine. It also boasts powerful insurance billing features – claim forms are automatically generated and submitted electronically for the fastest possible payment on claims.

Sleep Study Interpretation/Diagnosis UÊOral Appliances – Respire To complement the screening and diagnostic services being offered SGS has unique oral appliance solutions to treat snoring and sleep apnea. Respire Medical provides 3 options of oral appliances for the treatment of snoring and sleep apnea. The Respire Blue Series is our signature device, at $249 it is less than half of the leading competitors in this area. The Respire Pink is a Herbst design at $299, which is suitable for sleep bruxing patients with its strong construction. The Respire Green Series is an appliance that offers increased lateral movements while holding the patient in the desired position, also very competitively priced at $249. The Respire Medical appliance is a mandibular repositioning splint that is custom fabricated by Respire Medical in New York. The Respire appliance offers many advantages over other designs allowing for comfortable range of motion and micro adjustments to the position of the mandible. Perhaps the greatest advantage is the price; the Respire appliance is available for a $249 lab fee which is 4-5 times less than competitive devices.

– NORAD The NORAD appliance fills the need of dentists and physicians looking for an immediate delivery solution to treat snoring and sleep apnea. The NORAD’s boil and bite design allows for chair side fitting and it can be re-fit as dental work is done prior to making a more permanent Respire appliance.

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1-800-SleepLab SGS launched 1-800-SleepLab in early 2010 and it has already grown to be the largest public directory of sleep medicine practitioners in the country. Patients are going online and seeking answers to healthcare problems more than ever before, with the 1-800-SleepLab program patients can find sleep labs, sleep physicians and sleep dentists in their area. By calling the 1800 number patients will be directed to a nearby facility for consultation.

1-800-SleepTest / www.sleeptest.com In 2011 SGS partnered with online giant SleepTest.com and 1-800-SleepTest to provide yet another lead generation source for dentists offering oral appliances to treat sleep apnea. SleepTest.com is an online resource dedicated to educating the public on sleep apnea and related sleep disorders. The goal is to offer free preliminary screening that can help identify any potential sleep problems. This Sleep Test is quick and easy, and can be completed in about 5minutes.

mSleepTest iPhone/iPod/iPad Application SGS continues the direct-to-consumer marketing achieved with 1800SleepLab and expands it with this innovative application for iPhones. Consumers can download this application for free and follow instructions to run a simple sleep screening on themselves. The results are submitted to SGS and forwarded to a nearby medical or dental sleep specialist for evaluation.

Marketing Assistance As part of the SGS training program for implementing sleep medicine in a dental office clients are offered marketing assistance. SGS will share marketing letters to other medical professionals and sample newspaper and radio ad campaigns. Clients are also offered a series of patient information brochures discussing the link between sleep apnea and snoring, quality of life, children, women, cardiovascular disease and diabetes. PAGE

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â&#x20AC;&#x153;The Sleep Magazineâ&#x20AC;? Sleep Group Solutions publishes a quarterly journal called The Sleep Magazine. This publication goes out to tens of thousands of dentists and physicians and helps raise awareness and bridge the gap between the medical and dental sleep communities. The Sleep Magazine features editorials, clinical articles and case presentations from SGS client dentists, physicians and some of the biggest names in the industry. SGS launched this publication in 2009 and has received overwhelming praise; many doctors began using it as patient education literature for the waiting room. Future issues will bring more excellent articles and detailed information on protocols and technology for both dentists and physicians involved in the treatment of snoring and sleep apnea.


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3LEEP !PNEA 4HE 3ILENT +ILLER %STIMATED  -ILLION !MERICANS 5NDIAGNOSED WITH /3!

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Are You a Drowsy Driver? Share this Quiz with your patients!

Take The Are you at risk for falling asleep behind the wheel? Take this simple quiz and find out. Just circle “True” or “False” for each of the following statements, and check your answers below... 1. There is no relationship between one’s sleep and work schedule and risk of being involved in a drowsy-driving crash. (True or False) 2. Working the night shift does not affect one’s chances of being involved in a sleep-related crash.

(True or False)

3. The largest at-risk group for sleep-related crashes is commercial drivers.

(True or False)

4. Overall, sleep-related crashes have certain characteristics that set them apart from other types of crashes.

(True or False)

5. People with a sleep and breathing disorder called obstructive sleep apnea have about the same risk as the rest of the general population of being involved in a drowsy-driving crash. (True or False) 6. Eating a big lunch tends to make everyone sleep.

(True or False)

7. People can usually tell when they are going to fall asleep.

(True or False)

8. Drivers in drowsy-driving crashes are more likely to report sleep problems.

(True or False)

9. Rolling down a window or singing along with the radio while driving will help keep someone awake.

(True or False)

10. Wandering, disconnected thoughts are a warning sign of driver fatigue.

(True or False)

11. You can stockpile sleep on the weekends to avoid being sleepy during the week.

(True or False)

12. I’m a safe driver so it doesn’t matter if I’m sleepy.

(True or False)

Answers to Quiz PAGE

64

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1. FALSE, 2. FALSE, 3. FALSE, 4. TRUE, 5. FALSE, 6. FALSE, 7. FALSE, 8. TRUE, 9. FALSE, 10. TRUE, 11. FALSE, 12. FALSE.


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Our!Brochures!explain!the!effects!of!snoring!/!sleep!apnea.!Our!new! patient!education!program!is!designed!to!provide!insight!for!your! patients,!enabling!them!to!make!a!selfBevaluation,!realizing!the!impact! sleep!disruption!may!be!having!on!them!and!their!families. A!common!sense!approach!and!a!little!guidance!helps!in!the!treatment! for!snoring!and!sleep!apnea.!Help!your!patients!make!an!informed! decision,!place!your!Sleep!Medicine!Patient!Education!brochures!in! your!waiting!room!today!

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SLEEP APNEA AND AIRWAY MANAGEMENT One Stop - More Solutions.


2013 Dental Sleep Medicine Seminars Calendar 16 CEU PACE/AGD Approved!

These two day information packed seminars will help you jump start your dental sleep medicine practice!

May 2013

July 2013

17th-18th: Detroit, MI 17th-18th: NYC, NY

12th-13th: New Orleans, LA 12th-13th: Baltimore, MD 19th-20th: Chicago, IL 19th-20th: San Francisco, CA 26th-27th: Philadelphia, PA

June 2013 7th-8th: San Antonio, TX 14th-15th: Milwaukee, WI 14th-15th: Irvine, CA 21st-22nd: Boston, MA 22nd-23rd: Houston, TX 28th-29th: New York, NY

August 2013 2nd-3rd: Buffalo, NY 2nd-3rd: Portland, OR 9th-10th: Newark, NJ 16th-17th: San Diego, CA 16th-17th: Charleston, SC 23rd-24th: Rochester, NY

September 2013 6th-7th: Cleveland, OH 6th-7th: Salt Lake City, UT 13th-14th: Orlando, FL 20th-21st: Irvine, CA 27th-28th: Washington, DC

October 2013 4th-5th: Nashville, TN 11th-12th: Hartford, CT 18th-19th: Denver, CO 25th-26th: Ft. Lauderdale, FL 26th-27th: Eau Claire, WI

Register Today!

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SLEEP APNEA AND AIRWAY MANAGEMENT One Stop - More Solutions.

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November 2013 8th-9th: Seattle, WA 15th-16th: Kansas City, KS 15th-16th: Los Angeles, CA 22nd-23rd: Dallas, TX 22nd-23rd: Philadelphia, PA

December 2013 6th-7th: Irvine, CA 13th-14th: Chicago, IL 13th-14th: Tampa, FL

16 CEâ&#x20AC;&#x2122;s


SLEEP DISORDERS DENTISTRY Seminar Registration Form

Registration Information: Desired Course Date: __________________ City/State: ____________________________________ There will be a total of _____________________ Doctors and _________________ Staff attending Attendee Names: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Practice Address: _______________________________________________________________ City:_________________________ State: __________ Zip:________________ ___________________________ Fax: _______________________________ email:_______________________________________________________________

Payment Information: Cost is $995 per doctor, $395 per staff member Billing address same as above?

(check one)

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No

If billing address is different, please provide address below

_______________________________________________________________ _______________________________________________________________

a

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Exp. _____ / ______ / _________ Cv2# ___________

Credit Card # __________________________________________________________________ Cardholder Signature: ___________________________________________________________

Please FAX completed form to: 305.405.4008 For more information, visit: sleepgs.com


Identifying and Treating

SLEEP DISORDERS CPAP Eccovision

Home Sleep Testing

SGS, develops, produces and distributes medical equipment Sleep Seminars and services dealing with airway management, sleep disorders, and the diagnosis and treatment of sleep apnea. It is our goal to help facilitate widespread diagnosis of Sleep Apnea by providing our practitioners with dental sleep medicine supplies, oral appliances, CPAP supplies, home sleep study devices and in-lab PSG equipment. For more information, please contact us at the number below.

www.sleepgs.com

Oral Appliances


The Sleep Magazine- 6th Issue