Sleep disordersand dentistry’s role

e-supplement

© D

ream

stim

e.co

m

www.dentistryiq.com | July 2011

by Emilee McStay

very night, an estimated 18 million Americans stop breathing for 10 to 30 seconds, sometimes for a minute or longer, hundreds of times as they sleep. These men and women suffer from obstruc-

tive sleep apnea (OSA) and, if left untreated, are at a higher risk for excessive daytime sleepiness, high blood pressure, heart attack, stroke, diabetes, obesity, and driving accidents.

“The American Academy of Dental Sleep Medicine (AADSM) tries to make it as easy as possible for OSA pa-tients to receive safe and effective treatment,” said AADSM President, Jeffrey Pancer, DDS.

OSA patients can use the find-a-dentist feature on the AADSM’s Web site (www.aadsm.org) to search for dentists in their area who practice dental sleep medicine (DSM) and read more information about oral appliance therapy (OAT).

AADSM President-Elect Sheri Katz, DDS, said that when patients have OSA, they may feel like they are sleep-ing a proper number of hours, but the quality of their sleep is often poor.

For more on this topic, go to www.dentistryiq.com and search using the following key words: sleep disorders, obstructive sleep apnea, oral appliance therapy, sleep medicine.

July 2011 | www.dentistryiq.com

Dental sleep medicine

“Most people with OSA cannot achieve or maintain a deep, restorative sleep because every time they go into a deep sleep, their airway collapses and they wake up to re-sume breathing,” she said.

Dental sleep medicine (DSM) focuses on the management of sleep-disordered breathing (SDB), which includes snoring and OSA, with OAT and upper airway surgery.

Dr. Pancer explained that OAT involves the customized selection, fabrication, fitting, adjustments, and long-term follow-up care of specially designed oral devices, worn dur-ing sleep, which reposition the lower jaw and tongue base forward to maintain a more open upper airway. Oral appli-ances (OAs) look similar to mouth guards, but should be se-lected and fitted by a dentist trained in DSM to maintain unobstructed breathing while the patient sleeps.

Once a patient is diagnosed with OSA by a sleep physician at an accredited sleep center, he or she may be referred to a dentist or oral and maxillofacial surgeon for OAT or upper airway surgery.

“Approximately 25% to 50% of patients with OSA are unable to comply with Continuous Positive Airway Pressure (CPAP), the standard treatment therapy, or do not tolerate it, leaving a large population of untreated OSA patients for whom dentists can offer a much-needed service,” Dr. Pancer said.

The American Academy of Sleep Medicine has published practice parameters stating that OAT is indicated for treat-ment for those patients with mild to moderate apnea if they prefer it to CPAP, or if they cannot tolerate CPAP, or if they are unable to use positional therapy or weight loss to control their apnea. OAs are also recommended for severe patients if they are unable to tolerate CPAP.

According to Richard Drake, DDS, who has specialized in DSM for seven years and taught AADSM courses for four years, successfully treating OSA can reverse nearly all of the ill effects the disease may have on a patient.

“Patients better control their high blood pressure and diabetes, are less tired and sleepy, and therefore tend to lead

Dentists treat obstructive sleep apnea patients with oral appliance therapy, expanding their practices

e

“Deciding to learn about and practice dental sleep medi-cine is about becoming comfortable ‘switching hats’ and feel-ing excited about working in a different and new mindset,” she said.

Dr. Katz said that many dentists who enter dental sleep medicine are looking to try something challenging.

These dentists must learn about other disorders in the field, such as parasomnias, insomnia, and narcolepsy, in order to know what they cannot treat with oral appliance therapy, as well as work closely with sleep physicians and other medical professionals.

Educational institutions have also started recognizing the importance of training dentists in DSM. Tufts University in Boston, Mass., launched the first Dental Sleep Medicine Pro-gram of its kind through the Craniofacial Pain, Headache, and Sleep Center, which is part of the Department of General Dentistry.

Through the program, post-graduate dental students will receive both classroom and clinical instruction from experts in dental sleep medicine. Students will work with a multidis-ciplinary team of dentists, neurologists, chiropractors, physi-cal therapists, pain psychologists, occupational therapists, and behavioral management therapists to help treat sleep-related breathing disorders, such as OSA.

“Tufts’ pre-graduate dental students have learned DSM course content for several years,” said Leopoldo P. Correa, BDS, course director of the Dental Sleep Medicine Section at Tufts Dental School.

“Some of our students choose to incorporate DSM into their practices upon graduation, while other students leave Tufts with a better idea of how to identify patients who may have OSA and who should get tested at an accredited sleep center,” said Dr. Correa. “By offering a hands-on post-gradu-ate course, in addition to the course content in our pre-grad-uate and continuing-education programs, more students will gain the skills and in-depth experience they need to integrate DSM into their practices.”

Dr Correa said that post-graduate students and residents will participate in patient assessment, polysomnogram inter-pretation, and the use of ambulatory sleep study monitors when titrating oral appliances. The students will be trained in selecting, fitting, and adjusting the dental devices used to treat OSA and understand the potential limitations and com-plications of these devices.

“I think that in 10 years, DSM will be incorporated into every dental school and that learning OAT will be a require-ment for every dental student,” said Dr. Correa. “Dentists trained in DSM offer huge benefits to their patients and so-ciety.”

Emilee McStay is the public relations coordinator for the American Academy of Dental Sleep Medicine. Contact her at (708) 273-9366, emcstay@aadsm.org, or visit www.aadsm.org.

Dental sleep medicine

more active and fulfilled lives, take fewer pills, and are less likely to fall asleep while driving. Their minds function bet-ter and they think more clearly, they control their weight more easily, and have more energy to exercise and do the things they want to do,” Dr. Drake said.

He said the most rewarding part about dental sleep medi-cine is helping to turn someone’s life around. Dr. Drake said he was making an appliance for a gentleman who had his 25-year-old son along at the appointment and learned that the son had been in and out of school for years, was unable to hold down a job for more than a month due to sleepiness, was taking meds for depression, and was living at home with his parents.

“We tested him for sleep-disordered breathing, and when the test came back and showed that he suffered from severe sleep apnea, we made him an oral appliance,” Dr. Drake said. “He wore it religiously, and a follow-up study confirmed that it was treating his disease successfully. Two years later, he had moved out of his parents’ house, held a part-time job, had a girlfriend, was no longer taking anti-depression meds, and was about to finish school.”

Dr. Drake said that many dentists practice DSM because they enjoy helping people improve their lives and find it to be financially rewarding and physically less demanding.

“Dentists are recognizing the benefit of adding DSM to their practice,” Dr. Pancer added. “The AADSM has seen a 135% jump in our membership over the last five years.”

Dr. Pancer said that when he learned about the AADSM in 1996, it consisted of approximately 60 members, in contrast to more than 1,600 members today.

Despite the AADSM’s increase in membership, Dr. Drake said that there is still a growing need for dentists qualified in DSM because sleep physicians have difficulty finding a den-tist to whom they can refer their OSA patients.

Dr. Drake said that the number one reason dentists shy away from practicing DSM is that they don’t understand it and don’t take the time to educate themselves. He recom-mends that dentists take advantage of the mentorships, study groups, peer-reviewed journals, and introductory courses available through the AADSM to learn more about OAT.

Dr. Pancer added that dentists who have experience in DSM can take advanced courses in OAT or sit for the Amer-ican Board of Dental Sleep Medicine (ABDSM) exam. He said that the diplomates of the ABDSM represent the highest level of education and training in DSM.

Established in 1991, the AADSM hosts an annual meeting, offers educational courses for dental students and practicing dentists, distributes cutting-edge information through peer-reviewed publications, pamphlets and DVDs, and establishes and maintains appropriate treatment protocol.

Dr. Katz said that practicing DSM requires dentists to broaden their scope of knowledge to understand the field of sleep in general and the pathophysiology of OSA in addition to their skills as a dentist.

Sleep-disordered breathing: It’s not just a medical problem

tion that results in maximum patient comfort and efficacy. It passively allows the tongue to assume a forward posi-tion conducive to better airway patency.

Sleep dentistry is professionally gratifying and may be financially rewarding. However, one must always re-member that we are treating a potentially deadly medi-cal disorder, which happens to have a dental alternative therapy. You will be held to the usual medical standard, not the dental standard. Diagnosis is paramount. Always have a diagnosis prior to treatment and verify objectively your results. There is never any excuse for not obtaining a home sleep test that is read and interpreted by a qualified sleep specialist, or referring a patient for a polysomno-gram (PSG) overnight sleep study.

Many physicians feel that the dentist is the vanguard for diagnosis and treatment of this disorder. If you’re in-terested, get in the game but know the rules. Your team will also play a large part in the successful implementation of Dental Sleep Medicine into your practice. I encourage you to educate and involve your team as much as possible.

To learn more, I highly recommend attending the Den-tal Sleep Medicine Seminars by Dr. Allen Moses at Wil-lis Tower (formerly known as Sears Tower) in Chicago. Dates are August 26-28 and November 11-13. For more information about The Moses or Dr. Moses’ seminars visit www.themoses.com or contact Ashley Truitt, Direc-tor of Dental Sleep Medicine for The Moses at ashley@moderndentalusa.com and (940) 395-4555.

John T. Herald, D.D.S. lectures nationally and internationally about sleep-related pain and neuromuscular dysfunction. Dr. Herald has used oral appliances to treat sleep disturbances and related dental and medical problems since 1982. Dr. Herald is a found-ing member of the Academy of Clinical Sleep Disorders Disciplines and is also a Member of the American Academy of Dental Sleep Medicine. Dr. Herald graduated from Case Western Reserve University and is a member of the American Dental Association and Ohio Dental Association.

THE HOTTEST TOPIC IN DENTISTRY at the moment is Oral Appliance Therapy (OAT) for sleep apnea and primary snoring. The treatment of sleep apnea is para-mount to our nation’s health, especially due to its relation-ship to hypertension, hyperlipidemia elevated A1C (insulin resistance), and obesity. Hundreds of research articles year-ly detail the millions of dollars, if not billions, that could be saved by the successful treatment of this disorder.

There are many oral appliance designs FDA cleared for the treatment of snoring and obstructive sleep apnea. A key attribute to the design of a successful oral appliance is allowing maximum intraoral space for tongue posture and position, which includes a vertical and protrusive ele-ment.

In Phase 2 sleep, which makes up about 50 percent of the normal sleep cycle, the brain turns off the highest functioning recognition because the brain needs its rest. Only essential body functions, heart rate, oxygen satura-tion, CO2 monitoring and other functions generally as-sociated with the autonomic nervous system are vigilant. During a partial or full collapse of the airway, the body produces large amounts of adrenalin to facilitate muscle

contraction. Clenching of the muscles of mastication po-tentiates the pharyngeal dilator muscles to help open the non-patent airway. Tremendous forces are placed on the teeth to facilitate this open airway. These forces may be responsible for non-traumatic TMD, loosening of teeth, fracturing of cusps, abfractions, and abnormal wear. The body will enlist whatever mechanism available to survive. It has been my experience that many dental problems and restorative failures often occur due to Sleep Disordered Breathing (SDB).

Thousands of years ago, man developed the ability to speak. Residual components of our past still exist. For the first 18 to 24 months, babies can breathe and swallow simultaneously. Afterwards, the uvula migrates cervically and the epiglottis caudally. That short distance becomes a collapsible tube where most of our vowel sounds are formed. It also is non-cartilaginous and prone to collapse.

Our body also provides us with several “hard wired” neuromuscular reflexes, the most important being the jaw-tongue reflex. Opening the jaw several millimeters allows the tongue to reflexively reposition anteriorly. Tak-ing advantage of this reflex is the single-most important mechanism available to those who treat SDB with OAT.

The tongue is a hydrostat (mostly muscle and water) that can change form but not mass. If given the oppor-tunity, the tongue much prefers to be in the oral cavity and not in the throat. Successful OAT requires that there be maximum space for the tongue to move forward and upwards. The key is providing room for the tongue to reflexively move more forward than the mandible.

The newest and most unique appliance on the market that takes ad-vantage of these reflexes is The Moses™ device (right), which perhaps has the most tongue space of all. It is designed to be low-profile lingual-ly, providing adequate room intraorally, is ti-tratable (adjustable) and allows for full lip seal to facilitate nasal breathing.

Oral appliances provide an exoskeleton to support pro-trusion and vertical opening, thereby maximizing tongue posture and position. The innovative open anterior de-sign of The Moses accommodates a forward tongue posi-

Sleep-disordered breathing:It’s not just a medical problem

by Dr. John T. Herald

About the MediByte (above): Dentists can obtain top-down treatment control of sleep dentistry by combining The Moses with the MediByte

from BRAEBON. The MediByte is a convenient, accurate, and comfortable home sleep test device for patients suffering from snoring and/or sleep apnea. Patients are sent home with the MediByte, they then conduct an

overnight home sleep test. Home Sleep Delivered then has one of its board-certified sleep doctors interpret the results and

send it back to dentists in days.

®

DIQSam12h_Dntl_110331 1 3/31/11 2:47 PM

www.dentistryiq.com | July 2011July 2011 | www.dentistryiq.com

As a dentist who has worked with physicians for more than 12 years in the treatment of people who snore and suffer from sleep apnea, I recognize that the dentist’s role

in helping those patients has become increas-ingly important.

The medical problems associated with sleep disordered breathing have been well studied and documented. Hypertension, cardiovascular prob-lems, and impaired cognitive functioning are but a few of the possible health consequences. Untreat-ed patients with sleep apnea can put themselves at risk for increased morbidity and mortality. Public awareness has improved, but unfortunately many people still go undiagnosed.

Oral appliances, which are worn in the mouth like dental retainers, have proven to be a comfort-able and effective choice for patients who have the symptoms of sleep apnea, such as tiredness, snoring, and poor sleep. Many patients who are unwilling or unable to use CPAP machines have benefitted from using oral appliances, which have been recommended by the American Academy of Sleep Medicine in the treatment of OSA, ob-structive sleep apnea.

First, patients who have already been diag-nosed by their physicians with a sleep study called a polysomnogram are referred to the dentist for evaluation. Our examination includes a sleep his-tory and a complete exam of the upper airway and dentition. A discussion regarding the different types of oral appliances follows with an explana-tion of how they are designed to work. Patients who wear oral appliances often report improved comfort because they are able to sleep in any po-sition without using the cumbersome facial masks and hoses associated with CPAP. As the appli-ances are titrated and adjusted over a period of weeks, the dentist will often provide the patient with an overnight at-home sleep monitor that can

be returned to the office the next day. The results are downloaded into a computer program that provides feedback on apnea, hypoxia, and blood oxygen levels. With this information, further adjustment of the appliance can be made if needed. A follow-up study by the pa-tients’ sleep center is always recommended.

Dr. David Schwaber is a graduate of the University of Tennessee College of Dentistry. He has studied orthodontics at the Institute for Graduate Dentists and has a diplomate accreditation by the American Academy of Dental Sleep Medicine. As a consultant to the Hospital of Central Connecticut and other Greater Hartford sleep centers, he has presented numerous lectures to physicians and patient groups in the field of dental sleep medicine. His infor-mational Web site on dental sleep medicine is www.ctsleepdentist.com.

Special thanks to Irfan Ali, dental sleep technician/consultant at CT SleepDentist.com. Contact him at irfancda@gmail.com.

by David P. Schwaber, DDS, ABDSM

©dreamstime.com

Dentists play importantrole in treatment ofpatients’ sleep disorders

July 2011 | www.dentistryiq.com

I have had a personal experience with sleep apnea. My fa-ther was an undiagnosed sufferer. Growing up, I remem-ber him coming home from work and going straight to the couch to sleep instead of playing with my siblings and me. Not having quality time every day is hard on a family. I def-initely feel as though I missed out on having a stronger re-lationship with my father because of this condition. Tooth issues, such as decay, affect only one person, but snoring and sleep apnea affect entire families. Besides health conse-quences, these conditions can damage marriages, relation-ships, and work performance. My goal is to educate people about sleep apnea and the options available to get help.

There are four ways to solve a sleep apnea problem: lose weight, CPAP therapy, surgery, and oral appliance therapy (OAT). For those whose apnea is not weight-related, that leaves CPAP therapy, which many find to be intolerable, or surgery, which is painful and only 50% effective. Unfortu-nately, most ENT specialists and cardiologists are unfamiliar with the success of OAT in treating sleep apnea; therefore, they only recommend CPAP, leaving many patients without a choice. This is why both the general public and the medi-cal community need to know that oral appliance therapy is FDA-approved and has been proven to be highly effective in cases of mild to moderate and certain cases of severe ob-structive sleep apnea (OSA). OAT is the only therapy offered — other than surgery — when CPAP cannot be tolerated.

In the beginning, 1-800-Snoring was established with-in the 1-800-DENTIST company to inform people that OSA is a dangerous disease both physically and emotion-ally. The company has three distinct goals:

• To provide patients suffering from sleep apnea access to effective, compassionate, and noninvasive treatment from highly qualified dental sleep medicine providers

• To provide members with the marketing, education, and support they need to be quality doctors to whom we would want to send our friends and family for treatment

• To offer a cooperative marketing program so members can benefit from the full potential of our advertisements in their geographic areas

Sleep apnea is a big picture condition, so we search for doctors who are capable of seeing the whole issue and who are willing to work with the medical community to provide a total solution. We offer training and educational opportuni-ties for our members both in-person and over the Web. Our range of continuing-education topics help members of the dental and medical communities set up their practices to ac-commodate snoring and sleep apnea patients, recognize the signs of these conditions in existing patients, and even how to do medical billing. Every member of 1-800-Snoring pays a monthly fee. We use that money to run ads and send out

materials that promote sleep apnea treatment such as OAT.Regarding the educational opportunities he and his staff

have taken advantage of with 1-800-Snoring, Dr. Steven Greenman, in Westlake Village, Calif., says, “Once my team and I learned how to identify and talk to the people coming into the office with snoring and OSA problems, I have begun to see dramatic results in both the lives and marriages of the patients I am helping and the profitability of my practice.”

Dr. Eric Johnson, in Torrance, Calif., says, “1-800-Snoring is the best marketing investment we’ve made to date! We’ve used many other mediums such as newspaper, health expos, Internet, but nothing has worked as quickly and as effectively in bringing us new patients as 1-800-Snoring. No doubt about it ... the business model works ... the experts at 1-800-Snoring really know what they’re doing in terms of targeting our au-dience and bringing us qualified patients. And, the additional staff education and coaching is above and beyond!”

As of today, 77% of those suffering from OSA are un-diagnosed. To put that number into perspective, 18,000 of the people who attended this year’s Indy 500 have undiag-nosed OSA. That is a staggering number. This condition can lead to fatal health issues such as high blood pressure, heart failure, stroke, and diabetes.

Many patients don’t think their snoring or sleep apnea problem is their problem. Treating snoring and sleep apnea is markedly different than performing standard dental care. In “regular” dentistry, patients call because they are in pain or don’t like something about their teeth. With OSA, patients commonly call in because a spouse or significant other is bugging them ... because someone else is having a problem.

We have to talk to patients who suffer from sleep apnea in a way that makes them understand that the condition is not just annoying to the spouse, but it’s a potentially fatal condi-tion — all without scaring them off. My team and I resolved this issue by adding a more personal touch to how we take phone calls. Our operators ask questions about the patient, find out the nature of his or her condition, and then refer the patient to a provider who would be the best fit. By the end of these types of calls — without dispensing medical advice, yet educating them about their condition and assuring them regarding treatment options — patients will understand that snoring and sleep apnea are dangerous, and that they are do-ing the right thing by getting help.

I have always found that when you do things exception-ally and for the right reason, the rewards are the greatest and success comes in abundance. Today, it is about getting things exceptionally right.

Larry Twersky is the former president of 1-800-Dentist and the cur-rent CEO and founder of 1-800-SleepMed and 1-800-Snoring.

by Larry Twersky

Sleep apnea and the search for a solution through dental-medical collaboration

July 2011 | www.dentistryiq.com