1112017

1

Michigan Association of Osteopathic Family Physicians

(MAOFP)

January 19 2017

bull American Academy of Sleep Medicine guidelines for treatment of OSA include oral appliances for mild or moderate OSA to be provided by a dentist who is well versed in sleep and Temporomandibular Disorders I only treat these two diagnoses and

have been certified as Diplomat in Sleep from the American Sleep and Breathing Academy the American Academy of Craniofacial Pain and Sleep and in TMD from the American Academy of Craniofacial Pain the American Academy of Pain Management and Mastership in the International College of Craniomandibular Orthopaedics

bull I will concentrate on the AASM statement during the next 50 minutes as well as a perfunctory synopsis of OSA ramifications and treatments

Dr Richard Klein

A very brief overview of TMD and OA with contraindications for OSA

bullTMJ Internal DerangementsbullSigns and symptoms of TMDbullLack of Dental Support

1112017

2

bullInternal

derangements

Normal RDD NRD

D

DJD

Internal

Derangements

Dr Per-Lennart Westesson and Dr Lars Eriksson

Degenerative Joint

Disease

Westesson amp Eriksson

1112017

3

Symptoms of TMD TMD is not a disorder that only affects the jaws The muscles which

posture the correct occlusion are found in the face the head the neck and the upper back

When any of these muscles are in spasm a domino effect on adjacent areas initiates symptoms that are not often thought of in the context of TMD but which definitely may be causally related by it

Dr Janet Travell knew this when she was President Kennedys personal physician and was unfortunately denigrated by the medical community as spouting heresy

Common Ear symptoms of TMD

bull Otalgia

bull Ear congestion

bull Tinnitus which can be extremely ldquoear-attating

bull Buzzing of the ear

bull lightheadedness dizziness loss of balance

bull Hyperacusis

bull Subjective loss of hearing

bull Itchy ear

1112017

4

Eye Symptoms of TMD

bullRetro-orbital pain

bullBlurred vision

bullLacrimation

bullDouble vision

bullPhotophobia

1112017

5

RETRO-ORBITAL PAIN

bull Gary Hack etal at the University of Maryland observed a new muscle which they named the SPHENOMANDIBULARIS The muscle was consistently observed as originating from the maxillary surface of the sphenoid bone and inserting on the temporal crest (internal oblique line) of the mandible Controversy exists as to it actually being a new and separate muscle However when tense it will pull on the sphenoid bone which is painful

TBI

I am not ashamed to

admit that the first

time I heard TBI in

our clinical rounds

I thought the speech

pathologist was

referring to tooth brush instructions

1112017

6

Conversely she was

confused when I

spoke of a jaw registration as

articulation

TBI and OSA

Approximately 17 million people sustain a traumatic brain injury (TBI) every year in the United States with 14 million seeking treatment 250000 hospitalizations and 50000 deaths are documented

bull Why are these studies important

bull They are pertinent because they show a direct link between traumatic brain injury and obstructive sleep apnea

bull Not diagnosing obstructive sleep apnea in someone who has sustained a brain injury could impede recovery and rehabilitation

bull As more and more soldiers are coming back from a war that has turned young men and women into mere glimpses of their former selves ndash and as more and more professional athletes especially football players are suffering from the lingering effects of the sport this link is becoming increasingly more important

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

2

bullInternal

derangements

Normal RDD NRD

D

DJD

Internal

Derangements

Dr Per-Lennart Westesson and Dr Lars Eriksson

Degenerative Joint

Disease

Westesson amp Eriksson

1112017

3

Symptoms of TMD TMD is not a disorder that only affects the jaws The muscles which

posture the correct occlusion are found in the face the head the neck and the upper back

When any of these muscles are in spasm a domino effect on adjacent areas initiates symptoms that are not often thought of in the context of TMD but which definitely may be causally related by it

Dr Janet Travell knew this when she was President Kennedys personal physician and was unfortunately denigrated by the medical community as spouting heresy

Common Ear symptoms of TMD

bull Otalgia

bull Ear congestion

bull Tinnitus which can be extremely ldquoear-attating

bull Buzzing of the ear

bull lightheadedness dizziness loss of balance

bull Hyperacusis

bull Subjective loss of hearing

bull Itchy ear

1112017

4

Eye Symptoms of TMD

bullRetro-orbital pain

bullBlurred vision

bullLacrimation

bullDouble vision

bullPhotophobia

1112017

5

RETRO-ORBITAL PAIN

bull Gary Hack etal at the University of Maryland observed a new muscle which they named the SPHENOMANDIBULARIS The muscle was consistently observed as originating from the maxillary surface of the sphenoid bone and inserting on the temporal crest (internal oblique line) of the mandible Controversy exists as to it actually being a new and separate muscle However when tense it will pull on the sphenoid bone which is painful

TBI

I am not ashamed to

admit that the first

time I heard TBI in

our clinical rounds

I thought the speech

pathologist was

referring to tooth brush instructions

1112017

6

Conversely she was

confused when I

spoke of a jaw registration as

articulation

TBI and OSA

Approximately 17 million people sustain a traumatic brain injury (TBI) every year in the United States with 14 million seeking treatment 250000 hospitalizations and 50000 deaths are documented

bull Why are these studies important

bull They are pertinent because they show a direct link between traumatic brain injury and obstructive sleep apnea

bull Not diagnosing obstructive sleep apnea in someone who has sustained a brain injury could impede recovery and rehabilitation

bull As more and more soldiers are coming back from a war that has turned young men and women into mere glimpses of their former selves ndash and as more and more professional athletes especially football players are suffering from the lingering effects of the sport this link is becoming increasingly more important

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

3

Symptoms of TMD TMD is not a disorder that only affects the jaws The muscles which

posture the correct occlusion are found in the face the head the neck and the upper back

When any of these muscles are in spasm a domino effect on adjacent areas initiates symptoms that are not often thought of in the context of TMD but which definitely may be causally related by it

Dr Janet Travell knew this when she was President Kennedys personal physician and was unfortunately denigrated by the medical community as spouting heresy

Common Ear symptoms of TMD

bull Otalgia

bull Ear congestion

bull Tinnitus which can be extremely ldquoear-attating

bull Buzzing of the ear

bull lightheadedness dizziness loss of balance

bull Hyperacusis

bull Subjective loss of hearing

bull Itchy ear

1112017

4

Eye Symptoms of TMD

bullRetro-orbital pain

bullBlurred vision

bullLacrimation

bullDouble vision

bullPhotophobia

1112017

5

RETRO-ORBITAL PAIN

bull Gary Hack etal at the University of Maryland observed a new muscle which they named the SPHENOMANDIBULARIS The muscle was consistently observed as originating from the maxillary surface of the sphenoid bone and inserting on the temporal crest (internal oblique line) of the mandible Controversy exists as to it actually being a new and separate muscle However when tense it will pull on the sphenoid bone which is painful

TBI

I am not ashamed to

admit that the first

time I heard TBI in

our clinical rounds

I thought the speech

pathologist was

referring to tooth brush instructions

1112017

6

Conversely she was

confused when I

spoke of a jaw registration as

articulation

TBI and OSA

Approximately 17 million people sustain a traumatic brain injury (TBI) every year in the United States with 14 million seeking treatment 250000 hospitalizations and 50000 deaths are documented

bull Why are these studies important

bull They are pertinent because they show a direct link between traumatic brain injury and obstructive sleep apnea

bull Not diagnosing obstructive sleep apnea in someone who has sustained a brain injury could impede recovery and rehabilitation

bull As more and more soldiers are coming back from a war that has turned young men and women into mere glimpses of their former selves ndash and as more and more professional athletes especially football players are suffering from the lingering effects of the sport this link is becoming increasingly more important

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

4

Eye Symptoms of TMD

bullRetro-orbital pain

bullBlurred vision

bullLacrimation

bullDouble vision

bullPhotophobia

1112017

5

RETRO-ORBITAL PAIN

bull Gary Hack etal at the University of Maryland observed a new muscle which they named the SPHENOMANDIBULARIS The muscle was consistently observed as originating from the maxillary surface of the sphenoid bone and inserting on the temporal crest (internal oblique line) of the mandible Controversy exists as to it actually being a new and separate muscle However when tense it will pull on the sphenoid bone which is painful

TBI

I am not ashamed to

admit that the first

time I heard TBI in

our clinical rounds

I thought the speech

pathologist was

referring to tooth brush instructions

1112017

6

Conversely she was

confused when I

spoke of a jaw registration as

articulation

TBI and OSA

Approximately 17 million people sustain a traumatic brain injury (TBI) every year in the United States with 14 million seeking treatment 250000 hospitalizations and 50000 deaths are documented

bull Why are these studies important

bull They are pertinent because they show a direct link between traumatic brain injury and obstructive sleep apnea

bull Not diagnosing obstructive sleep apnea in someone who has sustained a brain injury could impede recovery and rehabilitation

bull As more and more soldiers are coming back from a war that has turned young men and women into mere glimpses of their former selves ndash and as more and more professional athletes especially football players are suffering from the lingering effects of the sport this link is becoming increasingly more important

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

5

RETRO-ORBITAL PAIN

bull Gary Hack etal at the University of Maryland observed a new muscle which they named the SPHENOMANDIBULARIS The muscle was consistently observed as originating from the maxillary surface of the sphenoid bone and inserting on the temporal crest (internal oblique line) of the mandible Controversy exists as to it actually being a new and separate muscle However when tense it will pull on the sphenoid bone which is painful

TBI

I am not ashamed to

admit that the first

time I heard TBI in

our clinical rounds

I thought the speech

pathologist was

referring to tooth brush instructions

1112017

6

Conversely she was

confused when I

spoke of a jaw registration as

articulation

TBI and OSA

Approximately 17 million people sustain a traumatic brain injury (TBI) every year in the United States with 14 million seeking treatment 250000 hospitalizations and 50000 deaths are documented

bull Why are these studies important

bull They are pertinent because they show a direct link between traumatic brain injury and obstructive sleep apnea

bull Not diagnosing obstructive sleep apnea in someone who has sustained a brain injury could impede recovery and rehabilitation

bull As more and more soldiers are coming back from a war that has turned young men and women into mere glimpses of their former selves ndash and as more and more professional athletes especially football players are suffering from the lingering effects of the sport this link is becoming increasingly more important

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

6

Conversely she was

confused when I

spoke of a jaw registration as

articulation

TBI and OSA

Approximately 17 million people sustain a traumatic brain injury (TBI) every year in the United States with 14 million seeking treatment 250000 hospitalizations and 50000 deaths are documented

bull Why are these studies important

bull They are pertinent because they show a direct link between traumatic brain injury and obstructive sleep apnea

bull Not diagnosing obstructive sleep apnea in someone who has sustained a brain injury could impede recovery and rehabilitation

bull As more and more soldiers are coming back from a war that has turned young men and women into mere glimpses of their former selves ndash and as more and more professional athletes especially football players are suffering from the lingering effects of the sport this link is becoming increasingly more important

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

7

Prevalence and Consequences of Sleep Disorders in Traumatic Brain Injury

bullThe authors reviewed evidence that cognitive dysfunction is a well known problem after TBI and is a major factor preventing return to independent living social readaptation and vocational pursuits Richard J Castriotta MD12 Mark C Wilde PsyD12 Jenny M Lai MD12 Strahil

Atanasov MD3 Brent E Masel MD4 and Samuel T Kuna MD56

Findings

bull 54 of that population had a normal polysomnography 46 had a sleep disorder (other studies have documented up to 23 had a SBD)

bull This is significantly higher that that of the general population

bull 23 had obstructive sleep apnea Again this finding is much higher than that of those who did or did not vote for our last President

ConclusionbullThe authors concluded that there was a high prevalence of sleep-disorders and excessive daytime sleepiness in individuals who had TBI and that consideration should be given to having all TBI patients evaluated for sleep disorders

1112017

8

Wersquoll discuss this later as it refers to pain

bullBut 1st letrsquos consider OSA since it is highly prevalent in your TBI patients

Sleep Apnea May Hasten Memory Loss and Alzheimers

bullPublished in the journal Neurology the study2 found that patients with sleep apnea andor snoring were diagnosed with mild cognitive impairment more than a decade earlier than those without sleep apnea

bull 2 Neurology April 15 2015

bullOn average those with untreated obstructed sleep apnea started experiencing cognitive impairment at the age of 77 compared to 90 among those without breathing problems

bullThose who used a CPAP machine to address their sleep apnea started declining mentally at the same age as those who did not have sleep apnea

1112017

9

Scary video by WatchPAT

Obstructive SleepApnea

Definition of Sleep apnea

bullSleep Apnea occurs when the soft tissue in your mouth (the tongue tonsils pharynx uvula etc) relax too much and collapse at the back of your throat and cut off the airway making it difficult or impossible to breath

AHI Three levels of severity

Mild 5 to 15 times per hour

Moderate 15 to 30 times per hour

Severe gt30 times per hour

Copyright 2011 Braebon

1112017

10

SLEEP APNEA SYMPTOMS

bull Short term memory problems

bull Weight gain

bull Tiredness

bull Dry mouth

bull Sore throat

bull Slow metabolism

bull Bed partner frustration

bull AND A PLETHORA OF SERIOUS MEDICAL DISEASES DISORDERS AND MALADIES

High blood pressure

Heart failure

Heart rhythm disturbances

Atherosclerotic heart disease

Pulmonary hypertension

Insulin resistance

Sudden death

Erectile dysfunction

Memory problems

Depression

Anxiety

Gastroesophageal reflux

Sleep Apnea Increases Risk of

bull It has been estimated that 80 of depressed patients complain of disturbed sleep and sleeplessness is a risk factor for impaired mood

bull helliphelliphelliphelliphelliphelliphelliphellip The most common complaint of helliphelliphelliphelliphelliphelliphelliphellip PTSD is sleeplessness and 50 -helliphelliphelliphelliphelliphelliphelliphellip 70 of chronic pain patients helliphelliphelliphelliphelliphelliphelliphelliphellip report disturbed sleep

Consequences

1112017

11

Headachesbull Headaches are the most commonly reported pain complaint in the

population (textbook of pain)

bull Sleep disorders such as sleep apnea are found among headache patients at rates greater than what is found in the general population TX of sleep disorders decreases headache complaints Cephalgia is the most common complaint of TMD

bull (Archives of Internal Medicine)

Risk Factors

ObesityLarge neckSnoringNon-restorative sleepDaytime sleepinessfatigueHigh arched palateRetrognathiaCrowded airwaySmokingdrinking

(and remember sleep apnea occurs in women children and skinny guys toohellipthese are just risk factors)

Life Cycle of a LEAF

1112017

12

The cells in our body deteriorate as we age but they do so much quicker without oxygen

The Beatles were only partially correct when they sang

ldquoAll you need is loverdquo

The Hollies had a better understanding of life when they sangrdquo

ldquoAll I need is the air that I breath and to love yourdquo

1112017

13

NORMAL SLEEP

bull CHARACTERIZED BY A DECREASE IN

bull BODY TEMPERATURE

bull BLOOD PRESSURE

bull BREATHING RATE

bull MOST OTHER BODY FUNCTIONS

bull INCREASED NASAL RESISTANCE

bull CHARACTERIZED BY AN bull ACTIVE BRAIN

1112017

10

SLEEP APNEA SYMPTOMS

bull Short term memory problems

bull Weight gain

bull Tiredness

bull Dry mouth

bull Sore throat

bull Slow metabolism

bull Bed partner frustration

bull AND A PLETHORA OF SERIOUS MEDICAL DISEASES DISORDERS AND MALADIES

High blood pressure

Heart failure

Heart rhythm disturbances

Atherosclerotic heart disease

Pulmonary hypertension

Insulin resistance

Sudden death

Erectile dysfunction

Memory problems

Depression

Anxiety

Gastroesophageal reflux

Sleep Apnea Increases Risk of

bull It has been estimated that 80 of depressed patients complain of disturbed sleep and sleeplessness is a risk factor for impaired mood

bull helliphelliphelliphelliphelliphelliphelliphellip The most common complaint of helliphelliphelliphelliphelliphelliphelliphellip PTSD is sleeplessness and 50 -helliphelliphelliphelliphelliphelliphelliphellip 70 of chronic pain patients helliphelliphelliphelliphelliphelliphelliphelliphellip report disturbed sleep

Consequences

1112017

11

Headachesbull Headaches are the most commonly reported pain complaint in the

population (textbook of pain)

bull Sleep disorders such as sleep apnea are found among headache patients at rates greater than what is found in the general population TX of sleep disorders decreases headache complaints Cephalgia is the most common complaint of TMD

bull (Archives of Internal Medicine)

Risk Factors

ObesityLarge neckSnoringNon-restorative sleepDaytime sleepinessfatigueHigh arched palateRetrognathiaCrowded airwaySmokingdrinking

(and remember sleep apnea occurs in women children and skinny guys toohellipthese are just risk factors)

Life Cycle of a LEAF

1112017

12

The cells in our body deteriorate as we age but they do so much quicker without oxygen

The Beatles were only partially correct when they sang

ldquoAll you need is loverdquo

The Hollies had a better understanding of life when they sangrdquo

ldquoAll I need is the air that I breath and to love yourdquo

1112017

13

NORMAL SLEEP

bull CHARACTERIZED BY A DECREASE IN

bull BODY TEMPERATURE

bull BLOOD PRESSURE

bull BREATHING RATE

bull MOST OTHER BODY FUNCTIONS

bull INCREASED NASAL RESISTANCE

bull CHARACTERIZED BY AN bull ACTIVE BRAIN

1112017

11

Headachesbull Headaches are the most commonly reported pain complaint in the

population (textbook of pain)

bull Sleep disorders such as sleep apnea are found among headache patients at rates greater than what is found in the general population TX of sleep disorders decreases headache complaints Cephalgia is the most common complaint of TMD

bull (Archives of Internal Medicine)

Risk Factors

ObesityLarge neckSnoringNon-restorative sleepDaytime sleepinessfatigueHigh arched palateRetrognathiaCrowded airwaySmokingdrinking

(and remember sleep apnea occurs in women children and skinny guys toohellipthese are just risk factors)

Life Cycle of a LEAF

1112017

12

The cells in our body deteriorate as we age but they do so much quicker without oxygen

The Beatles were only partially correct when they sang

ldquoAll you need is loverdquo

The Hollies had a better understanding of life when they sangrdquo

ldquoAll I need is the air that I breath and to love yourdquo

1112017

13

NORMAL SLEEP

bull CHARACTERIZED BY A DECREASE IN

bull BODY TEMPERATURE

bull BLOOD PRESSURE

bull BREATHING RATE

bull MOST OTHER BODY FUNCTIONS

bull INCREASED NASAL RESISTANCE

bull CHARACTERIZED BY AN bull ACTIVE BRAIN

1112017

12

The cells in our body deteriorate as we age but they do so much quicker without oxygen

The Beatles were only partially correct when they sang

ldquoAll you need is loverdquo

The Hollies had a better understanding of life when they sangrdquo

ldquoAll I need is the air that I breath and to love yourdquo

1112017

13

NORMAL SLEEP

bull CHARACTERIZED BY A DECREASE IN

bull BODY TEMPERATURE

bull BLOOD PRESSURE

bull BREATHING RATE

bull MOST OTHER BODY FUNCTIONS

bull INCREASED NASAL RESISTANCE

bull CHARACTERIZED BY AN bull ACTIVE BRAIN

1112017

13

NORMAL SLEEP

bull CHARACTERIZED BY A DECREASE IN

bull BODY TEMPERATURE

bull BLOOD PRESSURE

bull BREATHING RATE

bull MOST OTHER BODY FUNCTIONS

bull INCREASED NASAL RESISTANCE

bull CHARACTERIZED BY AN bull ACTIVE BRAIN

1112017

14

Copyright 2011 BRAEBON

Normal healthy breathing during sleep

Wake-up-gasping-choking-and-die-in-your-sleep-diseaserdquo ndash No sound during event

Who gets sent for a sleep study

1112017

15

Who usually doesnrsquot

Sleep apnoea is a common occurrence in femalesKarl A Franklin et al European Respiratory Journal August 2012

bull We investigated 400 females from a population-based random sample of 10000 females aged 20ndash70 years with a questionnaire and anovernight polysomnography

bull Obstructive sleep apnoea was found in 50 of females aged 20ndash70 years

bull Sleep apnoea was related to age obesity and hypertension but not to daytime sleepiness

bull Severe sleep apnoea was scored in 14 of females aged 55ndash70 years and in 31 of obese females with a body-mass index of gt30 kgmiddotmminus2 aged 50ndash70 years

1112017

16

EPWORTH SLEEPINESS SCALEINTERPRETATIONbull 0-7 IT IS UNLIKELY THAT YOU ARE ABNORMALLY SLEEPY

bull 8-9 YOU HAVE AN AVERAGE AMOUNT OF DAYTIME SLEEPINESS

bull 10-15 YOU MAY BE EXCESSIVELY SLEEPY DEPENDING ON THE SITUATION YOU MAY WANT TO CONSIDER SEEKING MEDICAL ATTENTION

bull 16-24 YOU ARE EXCESSIVELY SLEEPY AND SHOULD CONSIDER SEEKING MEDICAL ATTENTION

This person most likely is simply tired or had a bad nightrsquos sleep OSA is not

indicated

I referred this patient to a sleep physician

1112017

17

MALLAMPATI

1112017

18

Lavigne GJ Kato T Kolta A Sessle BJ Neurobiological mechanisms involved in sleep bruxism Crit Rev Oral Biol Med 20031430-46

bullSleep-related bruxism (SB) is characterized by the grinding or clenching of the teeth during sleep usually associated with sleep arousals although the incidence of sleep arousals in SB subjects is within the normal range (up to 14 arousalshour of sleep is considered normal)

IT HAS BEEN SHOWN THAT CPAP ELIMINATION OF OSA alsoELIMINATES SNORING

IT HAS NOT BEEN DEMONSTRATED THAT CPAP TREATMENT OF OSA

ELIMINATES OR REDUCES S-B

Neurobiological mechanisms involved in sleep bruxismLavigne GJ1 Kato T Kolta A Sessle BJ

bull Sleep bruxism (SB) is mainly associated with rhythmic masticatory muscle activity (RMMA) characterized by repetitive jaw muscle contractions (3 bursts or more at a frequency of 1 Hz)

bull The consequences of SB may include tooth destruction jaw pain headaches or the limitation of mandibular movement as well as tooth-grinding sounds that disrupt the sleep of bed partners RMMA is observed in 60 of normal sleepers

1112017

15

Who usually doesnrsquot

Sleep apnoea is a common occurrence in femalesKarl A Franklin et al European Respiratory Journal August 2012

bull We investigated 400 females from a population-based random sample of 10000 females aged 20ndash70 years with a questionnaire and anovernight polysomnography

bull Obstructive sleep apnoea was found in 50 of females aged 20ndash70 years

bull Sleep apnoea was related to age obesity and hypertension but not to daytime sleepiness

bull Severe sleep apnoea was scored in 14 of females aged 55ndash70 years and in 31 of obese females with a body-mass index of gt30 kgmiddotmminus2 aged 50ndash70 years

1112017

16

EPWORTH SLEEPINESS SCALEINTERPRETATIONbull 0-7 IT IS UNLIKELY THAT YOU ARE ABNORMALLY SLEEPY

bull 8-9 YOU HAVE AN AVERAGE AMOUNT OF DAYTIME SLEEPINESS

bull 10-15 YOU MAY BE EXCESSIVELY SLEEPY DEPENDING ON THE SITUATION YOU MAY WANT TO CONSIDER SEEKING MEDICAL ATTENTION

bull 16-24 YOU ARE EXCESSIVELY SLEEPY AND SHOULD CONSIDER SEEKING MEDICAL ATTENTION

This person most likely is simply tired or had a bad nightrsquos sleep OSA is not

indicated

I referred this patient to a sleep physician

1112017

17

MALLAMPATI

1112017

18

Lavigne GJ Kato T Kolta A Sessle BJ Neurobiological mechanisms involved in sleep bruxism Crit Rev Oral Biol Med 20031430-46

bullSleep-related bruxism (SB) is characterized by the grinding or clenching of the teeth during sleep usually associated with sleep arousals although the incidence of sleep arousals in SB subjects is within the normal range (up to 14 arousalshour of sleep is considered normal)

IT HAS BEEN SHOWN THAT CPAP ELIMINATION OF OSA alsoELIMINATES SNORING

IT HAS NOT BEEN DEMONSTRATED THAT CPAP TREATMENT OF OSA

ELIMINATES OR REDUCES S-B

Neurobiological mechanisms involved in sleep bruxismLavigne GJ1 Kato T Kolta A Sessle BJ

bull Sleep bruxism (SB) is mainly associated with rhythmic masticatory muscle activity (RMMA) characterized by repetitive jaw muscle contractions (3 bursts or more at a frequency of 1 Hz)

bull The consequences of SB may include tooth destruction jaw pain headaches or the limitation of mandibular movement as well as tooth-grinding sounds that disrupt the sleep of bed partners RMMA is observed in 60 of normal sleepers

1112017

16

EPWORTH SLEEPINESS SCALEINTERPRETATIONbull 0-7 IT IS UNLIKELY THAT YOU ARE ABNORMALLY SLEEPY

bull 8-9 YOU HAVE AN AVERAGE AMOUNT OF DAYTIME SLEEPINESS

bull 10-15 YOU MAY BE EXCESSIVELY SLEEPY DEPENDING ON THE SITUATION YOU MAY WANT TO CONSIDER SEEKING MEDICAL ATTENTION

bull 16-24 YOU ARE EXCESSIVELY SLEEPY AND SHOULD CONSIDER SEEKING MEDICAL ATTENTION

This person most likely is simply tired or had a bad nightrsquos sleep OSA is not

indicated

I referred this patient to a sleep physician

1112017

17

MALLAMPATI

1112017

18

Lavigne GJ Kato T Kolta A Sessle BJ Neurobiological mechanisms involved in sleep bruxism Crit Rev Oral Biol Med 20031430-46

bullSleep-related bruxism (SB) is characterized by the grinding or clenching of the teeth during sleep usually associated with sleep arousals although the incidence of sleep arousals in SB subjects is within the normal range (up to 14 arousalshour of sleep is considered normal)

IT HAS BEEN SHOWN THAT CPAP ELIMINATION OF OSA alsoELIMINATES SNORING

IT HAS NOT BEEN DEMONSTRATED THAT CPAP TREATMENT OF OSA

ELIMINATES OR REDUCES S-B

Neurobiological mechanisms involved in sleep bruxismLavigne GJ1 Kato T Kolta A Sessle BJ

bull Sleep bruxism (SB) is mainly associated with rhythmic masticatory muscle activity (RMMA) characterized by repetitive jaw muscle contractions (3 bursts or more at a frequency of 1 Hz)

bull The consequences of SB may include tooth destruction jaw pain headaches or the limitation of mandibular movement as well as tooth-grinding sounds that disrupt the sleep of bed partners RMMA is observed in 60 of normal sleepers

1112017

17

MALLAMPATI

1112017

18

Lavigne GJ Kato T Kolta A Sessle BJ Neurobiological mechanisms involved in sleep bruxism Crit Rev Oral Biol Med 20031430-46

bullSleep-related bruxism (SB) is characterized by the grinding or clenching of the teeth during sleep usually associated with sleep arousals although the incidence of sleep arousals in SB subjects is within the normal range (up to 14 arousalshour of sleep is considered normal)

IT HAS BEEN SHOWN THAT CPAP ELIMINATION OF OSA alsoELIMINATES SNORING

IT HAS NOT BEEN DEMONSTRATED THAT CPAP TREATMENT OF OSA

ELIMINATES OR REDUCES S-B

Neurobiological mechanisms involved in sleep bruxismLavigne GJ1 Kato T Kolta A Sessle BJ

bull Sleep bruxism (SB) is mainly associated with rhythmic masticatory muscle activity (RMMA) characterized by repetitive jaw muscle contractions (3 bursts or more at a frequency of 1 Hz)

bull The consequences of SB may include tooth destruction jaw pain headaches or the limitation of mandibular movement as well as tooth-grinding sounds that disrupt the sleep of bed partners RMMA is observed in 60 of normal sleepers

1112017

18

Lavigne GJ Kato T Kolta A Sessle BJ Neurobiological mechanisms involved in sleep bruxism Crit Rev Oral Biol Med 20031430-46

bullSleep-related bruxism (SB) is characterized by the grinding or clenching of the teeth during sleep usually associated with sleep arousals although the incidence of sleep arousals in SB subjects is within the normal range (up to 14 arousalshour of sleep is considered normal)

IT HAS BEEN SHOWN THAT CPAP ELIMINATION OF OSA alsoELIMINATES SNORING

IT HAS NOT BEEN DEMONSTRATED THAT CPAP TREATMENT OF OSA

ELIMINATES OR REDUCES S-B

Neurobiological mechanisms involved in sleep bruxismLavigne GJ1 Kato T Kolta A Sessle BJ

bull Sleep bruxism (SB) is mainly associated with rhythmic masticatory muscle activity (RMMA) characterized by repetitive jaw muscle contractions (3 bursts or more at a frequency of 1 Hz)

bull The consequences of SB may include tooth destruction jaw pain headaches or the limitation of mandibular movement as well as tooth-grinding sounds that disrupt the sleep of bed partners RMMA is observed in 60 of normal sleepers

1112017

19

bull The pathophysiology of SB is becoming clearer

bull There is an abundance of evidence outlining the neurophysiology and neurochemistry of rhythmic jaw movements (RJM) in relation to chewing swallowing and breathing Several brainstem structures (eg reticular pontis oralis pontis caudalis) and neurochemicals (eg serotonin dopamine gamma aminobutyric acid [GABA] noradrenaline) are involved in both the genesis of RJM and the modulation of muscle tone during sleep

bull It creates a co-activation of both jaw-opening and jaw-closing muscles instead of the alternating jaw-opening and jaw-closing muscle activity pattern typical of chewing

Journal of Pain amp Symptom Management

bullPain duration and intensitywere correlated with decreased sleep impaired sleep quality and delayed sleep onset

Multiple Medical Studies

bullHave published that the majority (59 67 74) of OSA patients will not appropriately wear the CPAP

1112017

20

bull IN 1995 Johnny Cochran said ldquoIf the glove doesnrsquot fithellipyou must acquitrdquo As DR Dement intimated in the 1970s ldquoWe didnt know what to measurehellipso we measured everything we could think ofhellip and it stuckrdquo

bull Almost forty years later some of what ldquostuckrdquo is being revised reinterpreted and common sense is beginning to prevail Seven to eight hours of sleep per night is recommended

The Other 72 of Sleep

bull Sticking with the antiquated definition of a ldquocompliant userrdquo of a

CPAP (4 hrsnight and 5 nightsweek) one must use it roughly 28 of the time

bull WHAT ABOUT THE OTHER 72 OF SLEEP

bull Is it acceptable to not get the O2 we need simply because an antiquated standard ldquostuckrdquo

bull In 1995 CPAP became the gold standard Now in the 21st century I

say ldquoif the mask doesnrsquot fit hellipdonrsquot quitrdquo because an oral appliance may save your health and your life

Treatment of Sleep Apnea

Tracheotomy Oral

Surgery CPAPBiPAP

OA

Behavioral Modification

1112017

21

Orofacial Findings

bullThe most common orofacial characteristics include a retrognathic mandible narrow palate large neck circumference long soft palate tonsillar hypertrophy nasal septal deviation and relative macroglossia

Oral Appliances for Sleep Apnea amp Snoring

Tongue Retaining Devices Mandibular Repositioning Appliances

Oral Appliances (OA)

bull Properly fabricated an oral appliance will protrude the tongue and reposition the mandible anteriorly and inferiorly to the most beneficial neuromuscular position to prevent posterior airway collapse

bull This position is titratable and individualized to exact patient requirements and may need periodic adjustments just as does CPAP

1112017

22

BEFORE

APPLIANCE

7c

WITH

APPLIANCE

9 cc

1112017

23

Copyright 2011 BRAEBON

More Directly Related to hellipDental Sleep Medicine

bull EACH PATIENT IS AN INDIVIDUAL AND JUST AS CPAP PRESSURE IS INDIVIDUALLY TITRATEDhellipSO TOO ARE ORAL APPLIANCES

bull IF I DELIVER AN OA TO A PATIENT WHO WILL NOT UTILIZE THE CPAPhellipI WILL PROVIDE ONE OR SEVERAL HOME SLEEP STUDIES TO ASCERTAIN THE EFFICACY OF THE OAhellip AND THEN I REQUIRE THAT THEY RETURN TO THEIR SLEEP

bull DOCTOR FOR A SUBSEQUENT STUDY WHILE helliphelliphelliphelliphelliphelliphellipUTILIZINGTHE OA

Positional Apnea in a 73-Year Old Male with Atrial Fibrillation

bull This case study illustrates the cost-effective approach to successful outcomes associated with positional therapy that are not surprising and are consistent with a recent study which concluded ldquopositional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA with similar effects on sleep quality and nocturnal oxygenationrdquo

bull Journal Sleep Diagnosis and Therapy

1112017

24

HOW THE ORAL APPLIANCE TREATS OSA

bull Prevent collapse of airwaybull Forward advancement of jawbull Support forward tongue positionbull Change shape of pharyngeal airwaybull Increase vertical dimension of occlusionbull Correct dysphagia bull Increase volume of space for tonguebull Trains protrusive tongue reflexesbull Alter position of hyoid bone relative to

mandible

THE VARYING ROLES OF THE NOSE AND MOUTH IN BREATHING

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

20

bull IN 1995 Johnny Cochran said ldquoIf the glove doesnrsquot fithellipyou must acquitrdquo As DR Dement intimated in the 1970s ldquoWe didnt know what to measurehellipso we measured everything we could think ofhellip and it stuckrdquo

bull Almost forty years later some of what ldquostuckrdquo is being revised reinterpreted and common sense is beginning to prevail Seven to eight hours of sleep per night is recommended

The Other 72 of Sleep

bull Sticking with the antiquated definition of a ldquocompliant userrdquo of a

CPAP (4 hrsnight and 5 nightsweek) one must use it roughly 28 of the time

bull WHAT ABOUT THE OTHER 72 OF SLEEP

bull Is it acceptable to not get the O2 we need simply because an antiquated standard ldquostuckrdquo

bull In 1995 CPAP became the gold standard Now in the 21st century I

say ldquoif the mask doesnrsquot fit hellipdonrsquot quitrdquo because an oral appliance may save your health and your life

Treatment of Sleep Apnea

Tracheotomy Oral

Surgery CPAPBiPAP

OA

Behavioral Modification

1112017

21

Orofacial Findings

bullThe most common orofacial characteristics include a retrognathic mandible narrow palate large neck circumference long soft palate tonsillar hypertrophy nasal septal deviation and relative macroglossia

Oral Appliances for Sleep Apnea amp Snoring

Tongue Retaining Devices Mandibular Repositioning Appliances

Oral Appliances (OA)

bull Properly fabricated an oral appliance will protrude the tongue and reposition the mandible anteriorly and inferiorly to the most beneficial neuromuscular position to prevent posterior airway collapse

bull This position is titratable and individualized to exact patient requirements and may need periodic adjustments just as does CPAP

1112017

22

BEFORE

APPLIANCE

7c

WITH

APPLIANCE

9 cc

1112017

23

Copyright 2011 BRAEBON

More Directly Related to hellipDental Sleep Medicine

bull EACH PATIENT IS AN INDIVIDUAL AND JUST AS CPAP PRESSURE IS INDIVIDUALLY TITRATEDhellipSO TOO ARE ORAL APPLIANCES

bull IF I DELIVER AN OA TO A PATIENT WHO WILL NOT UTILIZE THE CPAPhellipI WILL PROVIDE ONE OR SEVERAL HOME SLEEP STUDIES TO ASCERTAIN THE EFFICACY OF THE OAhellip AND THEN I REQUIRE THAT THEY RETURN TO THEIR SLEEP

bull DOCTOR FOR A SUBSEQUENT STUDY WHILE helliphelliphelliphelliphelliphelliphellipUTILIZINGTHE OA

Positional Apnea in a 73-Year Old Male with Atrial Fibrillation

bull This case study illustrates the cost-effective approach to successful outcomes associated with positional therapy that are not surprising and are consistent with a recent study which concluded ldquopositional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA with similar effects on sleep quality and nocturnal oxygenationrdquo

bull Journal Sleep Diagnosis and Therapy

1112017

24

HOW THE ORAL APPLIANCE TREATS OSA

bull Prevent collapse of airwaybull Forward advancement of jawbull Support forward tongue positionbull Change shape of pharyngeal airwaybull Increase vertical dimension of occlusionbull Correct dysphagia bull Increase volume of space for tonguebull Trains protrusive tongue reflexesbull Alter position of hyoid bone relative to

mandible

THE VARYING ROLES OF THE NOSE AND MOUTH IN BREATHING

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

21

Orofacial Findings

bullThe most common orofacial characteristics include a retrognathic mandible narrow palate large neck circumference long soft palate tonsillar hypertrophy nasal septal deviation and relative macroglossia

Oral Appliances for Sleep Apnea amp Snoring

Tongue Retaining Devices Mandibular Repositioning Appliances

Oral Appliances (OA)

bull Properly fabricated an oral appliance will protrude the tongue and reposition the mandible anteriorly and inferiorly to the most beneficial neuromuscular position to prevent posterior airway collapse

bull This position is titratable and individualized to exact patient requirements and may need periodic adjustments just as does CPAP

1112017

22

BEFORE

APPLIANCE

7c

WITH

APPLIANCE

9 cc

1112017

23

Copyright 2011 BRAEBON

More Directly Related to hellipDental Sleep Medicine

bull EACH PATIENT IS AN INDIVIDUAL AND JUST AS CPAP PRESSURE IS INDIVIDUALLY TITRATEDhellipSO TOO ARE ORAL APPLIANCES

bull IF I DELIVER AN OA TO A PATIENT WHO WILL NOT UTILIZE THE CPAPhellipI WILL PROVIDE ONE OR SEVERAL HOME SLEEP STUDIES TO ASCERTAIN THE EFFICACY OF THE OAhellip AND THEN I REQUIRE THAT THEY RETURN TO THEIR SLEEP

bull DOCTOR FOR A SUBSEQUENT STUDY WHILE helliphelliphelliphelliphelliphelliphellipUTILIZINGTHE OA

Positional Apnea in a 73-Year Old Male with Atrial Fibrillation

bull This case study illustrates the cost-effective approach to successful outcomes associated with positional therapy that are not surprising and are consistent with a recent study which concluded ldquopositional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA with similar effects on sleep quality and nocturnal oxygenationrdquo

bull Journal Sleep Diagnosis and Therapy

1112017

24

HOW THE ORAL APPLIANCE TREATS OSA

bull Prevent collapse of airwaybull Forward advancement of jawbull Support forward tongue positionbull Change shape of pharyngeal airwaybull Increase vertical dimension of occlusionbull Correct dysphagia bull Increase volume of space for tonguebull Trains protrusive tongue reflexesbull Alter position of hyoid bone relative to

mandible

THE VARYING ROLES OF THE NOSE AND MOUTH IN BREATHING

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

22

BEFORE

APPLIANCE

7c

WITH

APPLIANCE

9 cc

1112017

23

Copyright 2011 BRAEBON

More Directly Related to hellipDental Sleep Medicine

bull EACH PATIENT IS AN INDIVIDUAL AND JUST AS CPAP PRESSURE IS INDIVIDUALLY TITRATEDhellipSO TOO ARE ORAL APPLIANCES

bull IF I DELIVER AN OA TO A PATIENT WHO WILL NOT UTILIZE THE CPAPhellipI WILL PROVIDE ONE OR SEVERAL HOME SLEEP STUDIES TO ASCERTAIN THE EFFICACY OF THE OAhellip AND THEN I REQUIRE THAT THEY RETURN TO THEIR SLEEP

bull DOCTOR FOR A SUBSEQUENT STUDY WHILE helliphelliphelliphelliphelliphelliphellipUTILIZINGTHE OA

Positional Apnea in a 73-Year Old Male with Atrial Fibrillation

bull This case study illustrates the cost-effective approach to successful outcomes associated with positional therapy that are not surprising and are consistent with a recent study which concluded ldquopositional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA with similar effects on sleep quality and nocturnal oxygenationrdquo

bull Journal Sleep Diagnosis and Therapy

1112017

24

HOW THE ORAL APPLIANCE TREATS OSA

bull Prevent collapse of airwaybull Forward advancement of jawbull Support forward tongue positionbull Change shape of pharyngeal airwaybull Increase vertical dimension of occlusionbull Correct dysphagia bull Increase volume of space for tonguebull Trains protrusive tongue reflexesbull Alter position of hyoid bone relative to

mandible

THE VARYING ROLES OF THE NOSE AND MOUTH IN BREATHING

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

23

Copyright 2011 BRAEBON

More Directly Related to hellipDental Sleep Medicine

bull EACH PATIENT IS AN INDIVIDUAL AND JUST AS CPAP PRESSURE IS INDIVIDUALLY TITRATEDhellipSO TOO ARE ORAL APPLIANCES

bull IF I DELIVER AN OA TO A PATIENT WHO WILL NOT UTILIZE THE CPAPhellipI WILL PROVIDE ONE OR SEVERAL HOME SLEEP STUDIES TO ASCERTAIN THE EFFICACY OF THE OAhellip AND THEN I REQUIRE THAT THEY RETURN TO THEIR SLEEP

bull DOCTOR FOR A SUBSEQUENT STUDY WHILE helliphelliphelliphelliphelliphelliphellipUTILIZINGTHE OA

Positional Apnea in a 73-Year Old Male with Atrial Fibrillation

bull This case study illustrates the cost-effective approach to successful outcomes associated with positional therapy that are not surprising and are consistent with a recent study which concluded ldquopositional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA with similar effects on sleep quality and nocturnal oxygenationrdquo

bull Journal Sleep Diagnosis and Therapy

1112017

24

HOW THE ORAL APPLIANCE TREATS OSA

bull Prevent collapse of airwaybull Forward advancement of jawbull Support forward tongue positionbull Change shape of pharyngeal airwaybull Increase vertical dimension of occlusionbull Correct dysphagia bull Increase volume of space for tonguebull Trains protrusive tongue reflexesbull Alter position of hyoid bone relative to

mandible

THE VARYING ROLES OF THE NOSE AND MOUTH IN BREATHING

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

24

HOW THE ORAL APPLIANCE TREATS OSA

bull Prevent collapse of airwaybull Forward advancement of jawbull Support forward tongue positionbull Change shape of pharyngeal airwaybull Increase vertical dimension of occlusionbull Correct dysphagia bull Increase volume of space for tonguebull Trains protrusive tongue reflexesbull Alter position of hyoid bone relative to

mandible

THE VARYING ROLES OF THE NOSE AND MOUTH IN BREATHING

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

25

THE NOSE

bull A recent pediatric study reveals why addressing the tongue is so important for resolving sleep apnea As explained in this study having an abnormally short lingual frenulum can result in impaired orofacial growth in early childhood reducing the width of the upper airway

bull The upper airway is very pliable so this increases the risk of it collapsing during sleep They found that children with an untreated short frenulum developed abnormal tongue function early in life which also impacted their orofacial growth and led to disordered breathing during sleep

WHAT IS THE ROLE OF THE NOSE

ITS FUNCTIONS ARE VITAL

bull WARMING

bull HUMIDIFICATION

bull FILTERING

bull CLEANING

OF AMBIENT AIR INHALED INTO THE LUNGS

INFUSION OF NITRIC OXIDE

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

26

Humidification and

Dehumidification

bull During intake air is humidified to increase lung oxygen facilitation

bull Upon exhalation air is dehumidified to keep water in our cells

bull If this were not the case we would dehydrate unless we continually drank water

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

27

Cosmetic Surgery

bullHe couldnrsquot breath through his small nose became hypercapnic and helliphelliphellipdied

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea

bull HA McLean AM Urton HS Driver AKW Tan AG Day+ PW Munt and MF Fitzpatrick

bullThis study demonstrates that relief of severe nasal obstruction in patients with a normal retroglossal airway is associated with a significant reduction in mouth breathing during sleep improved sleep architecture and a modest improvement in OSA severity

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

28

bullThere are several novel aspects to these findings First the study documents a clearly increased upper airway resistance in association with oral breathing during stable sleep as compared with nasal breathing irrespective of central or OSA

bullSecondly this methodology included simultaneous documentation of oral and nasal ventilation during sleep to confirm the absence of any nasal airflow in the oral breathing condition and vice versa

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

29

bullThe substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the nasal route during sleep in subjects with normal nasal resistance

bull Many studies have shown that nasal obstruction can induce or increase apnea frequency in OSA patients When nasal resistance is high a greater pressure drop is required to achieve the same flow and hence collapse of the pharynx is facilitated and this could mitigate the effect of mandibular advancement

bull Moreover high nasal resistance is associated with mouth breathing which could potentially limit the beneficial effect of mandibular advancement

bull Dental Appliance Treatment for Obstructive

bull Andrew S L Chan Richard W W Lee and Peter A Cistulli

bull httpchestjournalchestpubsorgcontent1322693fullhtml

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

30

bullCurrent evidence suggests that despite the superior efficacy of CPAP both treatments produce similar subjective and objective health benefits

bullThe superior self-reported tolerance and compliance associated with MAD treatment is a likely explanation

bullThe practice parameters of the AASM recommend the use of oral appliances for mild-to-moderate OSA or for patients with severe OSA who are unable to tolerate CPAP or refuse treatment with CPAP with a required written prescription by a sleep physician

The following are Medicare rules

1) A diagnosis of OSA is not within the dental scope of practice A dentist providing an OA

must do so under the and with the team effort of a licensed Physician with a written

prescription

2) A physician is not skilled in the intricacies of fabricating fitting monitoring adjusting

and choosing an appropriate Oral Appliance individualized per patient

3) A dentist may not provide an oral appliance if the patient has an active

Temporomandibular Disorder

4) The OA must be fabricated within 90 days of the patientrsquos appointment with the sleep

physician

Since the rules are clear and they involve both of our professions it would behoove

both DOMD and DDS to communicate for the benefit of OSA patients

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

31

Subsequent to my 3 hour 2013 Meeting with the US Department of Transportation regarding Truckers

bull During the State Board of Dental Examiners meeting Board members put sleep Dentistry in squarely back into the spotlight The Board has addressed sleep Dentistry issues in a public hearing and all four Board meetings in 2013

bull There was discussion that there can be a shared relationship between the Dental and medical scopes of practice

bull Under the proposed rule a Dentist may treat benign snoring with an oral appliance after referral to a licensed physician where appropriate within the standard of care By contrast a Dentist may not diagnose treat or monitor OSA without collaboration with a licensed physician Additionally an oral appliance shall only be fabricated by a licensed Dentist or by a Dental lab under a prescription or work order prepared by a Dentist

American Dental Association

bull Treatment using an oral appliance designed specifically to treat OSA should be fabricated by a dentist familiar with device design maintenance and therapeutic efficacy and who has an association with and a referral from a sleep team

bull JADA Vol 136 p 1123

Donrsquot be afraid of OSA Get a grip on the facts and save patientrsquos lives

1112017

32

bullA SYMBIOTIC RELATION BETWEEN PHYSICIANS SLEEP PROFESSIONALS AND DENTISTS CAN SIGNIFICANTLY IMPROVE THE SLEEP HEALTH OF MILLIONS OF PEOPLE EACH AND EVERY YEAR

bull THAT RELATIONSHIP IS NOT A ONE WAY STREET AND THE

American Sleep amp Breathing Academy of over 8000 members UNDERSTANDS THAThellip JUST LOOK AT THE MULTITUDE OF SLEEP PROFESSIONAL CATAGORIES ON THEIR BOARD OF DIRECTORS

THE END

Thank you for your interest I hope this presentation was helpful

Dr Richard Klein