7th Issue 2015- The Sleep Magazine

Sleep Magazine the

Understanding sleep disorders

Usd $14.75

www.thesleepmagazine.com

7th edition

“the Biggest Merge in the last 10 years”

MitsUi, sgs, Whole yoU and

respire See page 9

This Is The Time For Dental Sleep Medicine Page 6

A Report on a Creative OAT Solution for an Edentulous Patient. 6

The Mylo-hyoid Ridges: Trouble Makers for M.A.D.s Page 40

The Most Leveraged Procedure

In Dentistry: The Treatment of

Sleep Apnea Page 32

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SLEEP APNEA AND AIRWAY MANAGEMENTOne Stop - More Solutions.

Sleep Apnea- The Hottest Niche in Today’s Dentistry

$995 $395

$995 Doctor$395 Staff Member

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16 CE’s

Meet the Instructors

Dr. Barry Freydberg Dr. Michael Hnat Dr. Dawne Slabach Mr. John Nadeau Dr. Marty Lipsey Dr. Dan Tache Dr. George Jones Dr. Jeffrey Horowitz Dr. Damian Blum

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

Dental Sleep Medicine Seminars

WE ARE COMING TO A CITY NEAR YOU!see our Seminar Calendar at:

www.sleepgs.com

WWW.SLEEPGS.COM PAGE 3

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Contents:Sleep Magazine the

U President’s Letter . . . . . . . . . . . . . . . . . Page 4

U This Is the Time For Dental Sleep Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . Page 6

U Mitsui Chemicals Enters The Playing Field By Partnering with Sleep Group Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 9

U Let Them Know What You’ve Got! A marketing program to build your Dental Sleep Medicine practice. . . . . . . . . . . . . . . . . .Page 11

U Is it ADHD, or does your child have Sleep Apnea? . . . . . . . . . . . . . . . . . . . . . . . . . .Page 12

U The Call That Can Save Your Life SGS Out In Front With a Call Center . . . . . . . . . . . . Page 18

U A Report on a Creative OAT Solution for an Edentulous Patient. . . . . . . . . . . . .Page 20

U A Unique Application of A Mandibular Reposi-tioning Device to Manage Both Temporomandibu-lar Joint Dysfunction and Sleep-Related Breathing Disorders When Co-existing in the Same Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Page 22

U Recognizing the Role of Vertical Dimension in Successful Appliance Therapy for O.S.A. . . . . . . . . . . . . . . . . . . . . . . . . .Page 24

U Obstructive Sleep Apnea- Impactful Consequences for Children and Adults . .Page 27

U My dental sleep medicine story—15 years of dental sleep education . . . . . . . . . . . . . .0

U The Most Leveraged Procedure In Dentistry: The Treatment of Sleep Apnea . . . . . . .Page 32

U Oral Appliance Therapy for the CPAP Intolerant Patient . . . . . . . . . . . . . . . . . .Page 34

U The Mylo-hyoid Ridges: Troublemakers for Mandibular Advancement Devices . . . . .Page 40

U Dental Continuing Education . . . . . . .Page 44

U The Power of Medical Billing . . . . . . . .Page 47

U Diagnosing OSA in Women: The differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Page 49

U About SGS . . . . . . . . . . . . . . . . . . . . . . .Page 50

www.sleepseminars.com

This is a very rewarding and fun time.Rewarding because I see how Sleep Apnea awareness is spreading exponentially in the public. Public awareness is being sparked by media attention and in our social media groups which in turn stimulates more public interest.

Rewarding because I know that you and I are making an impact in training dentists to become warriors in our battle against Obstructive Sleep Apnea. Our two day seminars, presented every week across the nation, produce 50 to 100 dental teams educated and ready to serve their OSA effected patients. Rewarding also because I know that more victims of OSA are having a better quality of living and many lives are saved. In this edition of The Sleep Magazine you will read some heroic case presentations by Sleep Group Solutions’ lecturers and our affiliates. We are very gratified by the relationship we are developing with the chapters of the Academy of General Dentistry (AGD). In this issue we are showcasing an article by Dr. Robert Garfield, Executive Director of the Southern California AGD (SCAGD). Since last November State and local Dental Societies have been hosting SGS speakers at their monthly and annual meetings. The accolades and endorsements, that we continue to receive, are available to you to share with your own dental organization or Study Club. Contact me to provide a speaker for your meeting. All this is rewarding and also a lot of fun. Rani Ben-DavidPresident- Sleep Group Solutions

“We understand that education is the key to success in this field. Knowing

this, SGS has put together the most comprehensive series of CE seminars in

the industry. We utilize over a dozen instructors who share a common goal

of teaching attendees how to duplicate the success they’ve each personally

achieved.” - Rani Ben-David

The magazine has no medical responsibility and the articles and medical opinions are the writers of the articles and can not hold the

owner of the magazine responsible for any error.

Sleep Group Solutions7th Edition

PresidentRani Ben-David

[email protected]

CEOTamir Cohen

[email protected]

Director of Marketing & PRHolly Jordano

[email protected]

Creative DirectorMiguel Valcarcel

[email protected]

EditorsHolly Jordano, John Nadeau,

Dr. Dan Tache, Dr. Charles KravitzTracy Faulkner

Contributing Writers

Dr. Dan TacheDr. Michael P. Hnat Dr. Charles KravitzDr. Marty LipseyDr. George JonesDr. Jeff Horowitz

Dr. Barry FreydbergJohn NadeauHolly Jordano

Sleep Group Solutions (SGS)2035 Harding St. #200 Hollywood, FL 33020

Toll-Free (855) 475-3374Email: [email protected]

President’sLetter

Sleep Magazine the


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Charles Kravitz, DDS

THIS IS THE TIME FOR DENTAL SLEEP MEDICINEThe OpportunityIt was only three years ago that I read that less than 1% of American licensed dentists were practicing sleep medicine. In these few years that number has risen to 4%. If we have approximately 205,000 practicing dentists in the USA, then there are only 8,200 dentists serving the needs of the multitudes of people affected with sleep disorders.

According to a Harvard Health report there are 18.9 million undiagnosed cases of Obstructive Sleep Apnea and 40% (1.3 million) of CPAP users are non-compliant. So, without the addition of other considerations, that conservatively projects 20.2 million victims of Obstructive Sleep Apnea who may be helped by a Dentist trained in Oral Appliance Therapy (OAT). Is there any better opportunity in dentistry?

Dental Sleep Medicine: the hottest button in dentistry today.Awareness of sleep apnea in America is at an all-time peak. The fires of awareness are being stoked by the public media and by social media. Patients are understanding and becoming increasingly more concerned about the blockage of oxygen to the brain and other organs. Strokes. Heart attacks. Diabetes. Dementia. People are recognizing that they have the symptoms and are asking their doctors about it. Some doctors have the solutions. Every dentist would like to be “The Sleep Dentist”. Seminar training courses are now available through Sleep Group Solutions every week, in different cities, throughout the United States. Many of the instructors in those courses are published here in this magazine. They are training dentists to discover the victims of sleep apnea, and to treat them with the most appropriate modalities. Oral appliance therapy (OAT) is the most convenient and preferred therapy for the mild and moderate cases and for those patients who cannot tolerate the CPAP device. Fortunately, this is where the Dentist in shining armor rides in on a white horse to the rescue. Dentists, we like to say, are on the front line of the battle against sleep apnea. Dentists are in the optimum position to see the signs and symptoms and can offer the most preferred solutions to the problem.

Dr. Charles Kravitz


Dr. Charles Kravitz manages the Dental Study Club and Dental Society speaking engagement program for SGS. Organizations of dentists, from coast WR�FRDVW��KDYH�EHQH¿WHG�E\�KRVWLQJ�6*6�speakers at their meetings.He is also the SGS LinkedIn social medium coordinator, managing and

writing for 50 networks. LinkedIn has over 300 million members who are reached with educational messages from SGS and its lecturers. Dr. Kravitz received an early admission to Temple University School of Dentistry in Philadelphia after only 2 years of college pre-dental. He was President of his Freshman class, and he ranked eighth in his graduation class of 120. He took

the big step of opening a solo dental practice directly upon receiving his Doctor of Dental Surgery degree.+H�GHYHORSHG�WKLV�SUDFWLFH�LQWR�D�¿YH�GHQWLVW��WKUHH�K\JLHQLVW�JHQHUDO�GHQWDO�SUDFWLFH�LQ�3KLODGHOSKLD�7KLV�RI¿FH�EHFDPH�D�showplace for practice management sources and became a training ground for many of Philadelphia’s future successful private practitioners. In 1995 Dr. Kravitz founded Advance! Dental Consulting which effects the realization of Doctors’ dreams. He is a natural teacher and motivator and enjoys helping people ZKR�KDYH�WKH�GHVLUH�WR�EH�RXWVWDQGLQJ�LQ�WKHLU�¿HOG��$V�a Performance Coach he has helped dozens of dental SUDFWLWLRQHUV�DQG�WKHLU�WHDPV�OHDUQ�WR�VHUYH�SDWLHQWV�DIÀLFWHG�with sleep dysfunction.


Dr. Charles Kravitz

Keys to SuccessSuccess in treatment acceptance and end point attainment varies with, and depends upon, each individual dentist’s knowledge and determination and his/her patient’s cooperation. The training programs will present the tools, screening protocols, diagnostic equipment, techniques and verbal skills for success. As in other health-care therapies, a partnership between the professional provider and the patient is the key to success. The patient’s cooperation is essential. Take, for example, periodontal disease therapy (STM or CPT). The dentist and hygienist will remove the disease, teach the patient how to maintain periodontal health, and then monitor the patient’s progress for the patient’s lifetime. Sleep apnea can be considered an episodic disease like periodontal disease, diabetes and cardiac disease. For these there is no cure; only a lifetime of maintenance to keep these diseases under control. Failure of patients to comply will result in an episodic return of the symptoms in any of these cases. Compliance will keep them under control. So that explains the patient’s role in the “partnership for success”.

The Dentist’s Responsibilities.In the words of the Great Master Yoda, in the classic Star Wars movies, “There is no ‘try’; there is only ‘do’ or ‘do not’.”Beginning with the seminar training, the dentist must be 100% committed to success. (Anything we endeavor will be more likely to be achieved when we are positive that we will succeed.) The seminar training is only the beginning of the learning process. We must retain what we have learned, continue to study, to research all new ideas and to practice our treatment plan presentations with our teams. Everyone on the team must be skilled and committed.

You are in the right place at the right time. As a Care Giver, think of how you can serve an unfilled need of your patients.

Sourceshttp://kff.org/other/state-indicator/total-dentists/Bureau of Labor Statistics Occupational Outlook Young, T Sleep 1997Young, T, N Engl, J. of Med 1993

Engleman, H, Sleep Med Review 2003

Home Sleep Studiesinterpreted & diagnosed

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Mitsui Chemicals Enters The Playing Field By Partnering with Sleep Group Solutions

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Diabetes and Sleep Apnea

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Let Them Know What You’ve Got!

A marketing program to build your Dental Sleep Medicine practice.

Raising sleep health awareness is something that Sleep Group Solutions achieves each day. As a ‘newbie’ in the sleep industry my journey began back in 2010 when I was fortunate enough to land a role within the organization in the marketing department. At that time it felt like we were the only organization catering to dental sleep medicine education, instrumentation, and in-office training. Being pioneers in the industry, we have been able to witness first hand the growth, development, and popularity of dental sleep medicine around the world.

Through our dental sleep seminars, which are two-day lectures for the dentist to learn our turnkey protocol, we are able to reach thousands of dentists and help them instill this life-saving service within their practices. It has been most rewarding to not only introduce new techniques, cases and appliances to these eager doctors, but also to hear their success stories along the way. In the beginning, our trained doctors would ask us about finding new patients and if we had any insight on this. We advise them

to start with their existing patients to gain experience and get cases from an accessible target base. As most people in our industry know, there are over 50 million people undiagnosed with sleep apnea and there will come a point in your DSM career that you will need to reach outside your practice to those who suffer and provide them with solutions. This is a good time and exciting place to be in DSM- enjoy the ride!

Access to top Dentists, Physicians, Sleep Doctors, and other highly

qualified professionals has allowed us an insight into many different offices providing treatment for Obstructive Sleep Apnea. With so much exposure to different offices we have collaboratively developed a marketing plan that has proven successful in screening existing patients and also finding new patients outside the practice. Sleep Group Solutions clients will be happy to learn they can now call us for their dental sleep medicine marketing needs. We are excited about this as we have always outsourced our marketing efforts in the past. Pricing is discounted for SGS trained dentists and the marketing service is available for all dentists offering DSM treatment. The marketing package includes (custom): press releases, in-office signage, brochures, reception room DVD loop, letters for physician referrals, radio advertising spots, assistance with awareness lectures and much more.

We have even taken it a step further from ‘traditional marketing’ ideas to outside the box ideas. Our new Listings Optimizer service is fantastic. The newly implemented technology helps to maintain control of online listings so they stay correct, fresh and detailed, no matter where your patients are searching online.

The new service will update client listings on over 50 search engines and applications. This makes patient’s searching for a dentist to treat their possible sleep apnea seamless, correct and current. The new service also helps clients to enhance their current listings with pictures, videos and even new promotions.

By Holly Jordano

continues on page 13


Is it ADHD, or does your child have Sleep Apnea?

Here is a thoughtful question posed by a doctor at The Pennsylvania Snoring and Sleep Institute. Many of the symptoms in children of ADHD and OSA are similar and the two illnesses are often confused.

“Not much is understood by parents about

snoring or sleep apnea,

especially in their

children.“

By Charles Kravitz, DDS

The Stanford School of Medicine states that about 10% of children 10 years of age and younger snore and, of those children who snore, about 20% will have obstructive sleep apnea. Snoring can be a sign that your child has sleep apnea as it indicates, at the very least, that their airway is partially obstructed during sleep. Sleep apnea is a serious medical condition that can interrupt or stop your child’s breathing, prevent a normal night’s sleep, impair growth, and lead to a lower quality of life. It also can cause serious fatigue during the day which is why it is so often confused with ADHD. Sleep-disordered breathing such as snoring and obstructive sleep apnea (OSA) have long been associated with ADHD (Attention Deficit Hyperactivity Disorder). You should know that not every child diagnosed with sleep apnea has ADHD, just as not every child diagnosed with ADHD has sleep apnea. However, many studies have been performed indicating a significant correlation between OSA and behavioral issues. Children with obstructive sleep apnea do not get restful sleep, and as a result may complain of morning headaches, be irritable and have difficulty concentrating. Children with sleep apnea may complain of being tired during the day and, at the same time, exhibit hyperactive behavior or act impulsively. Herein lays the confusion of separating sleep apnea from ADHD because many of the classic symptoms of ADHD are often exhibited in children with OSA. So, as a parent of a child diagnosed with ADHD, what do you do?”

“It will be in your child’s best interest if you dig a little deeper into the root of what may be causing these behaviors. Watch your child sleep at night – and even record it if you can. Check for restlessness, mouth breathing, snoring, or breathing pauses. If they occur,

have your child evaluated for possible sleep apnea to ensure the proper diagnosis and treatment. Figuring out if your child has sleep apnea or ADHD may seem quite complex but it doesn’t have to be. Consult with a sleep apnea doctor if you can answer ‘yes’ to any or some of the following questions: – Does your child snore? – Does your child stop breathing for a few seconds at night? – Does your child frequently mouth breathe? – Does your child sleep through the night or is it a restless sleep? – Is there frequent bedwetting? – Does your child seem irritable during the day? Is there difficulty focusing? Are there periods of hyperactivity?”

“The good news is that sleep apnea is treatable. Enlarged tonsils and adenoids are the most common causes of sleep apnea in children. An Ear, Nose and Throat specialist can determine if your child’s tonsils and adenoids are enlarged and possibly blocking the airway at night. A tonsillectomy and adenoidectomy can successfully treat sleep apnea by removing the obstruction in the airway resulting in a complete elimination of symptoms in 80-90% of children.”

Take the Quiz at end of this article.


QUESTIONS1. A case study shows that of 100 children who snore, how many would have Obstructive Sleep Apnea?a. 20b. 10c. 2d. 50

2. Which is not a common symptom of child OSA?a. Bed wettingb. Daytime irritabilityc. coughingd. snoring

3. Surgical removal of tonsils and adenoids is a suitable treatment for children with sleep apnea.True or False

4. A study shows that most children under age 11 snore.

True or False

Dr. Lana B. Patitucci, D.O. is a Board Certified Otolaryngologist at The Pennsylvania Snoring and Sleep Institute. She is trained in all aspects of general and pediatric otolaryngology including endoscopic sinus, otologic, head and neck, and facial plastic surgery.

Take this short quiz after reading the article.

Did you hear about the SGS Customer Service Contact Center? That’s a new service we are offering to help connect dentists with nearby patients who suffer. A dedicated team is calling over 1.2 million people with known sleep disorders to let them know there is a dentist nearby that can change their life!

There are a lot of new companies out there marketing themselves as Sleep experts. A piece of advice for all dentists treating patients for sleep…There is no reason to reinvent the wheel. Sleep Group Solutions has been around the longest, has many success stories and is the most capable of helping you. When it comes to a marketing investment, investing in a winning product is what separates the amateurs from the pros. Reach out to a Sleep Group Solutions representative to learn more about our marketing support.

from page 11

has spent four decades as a dentist in Nebraska and has devoted himself to improving lives through dentistry. He has found the best way he can do that is by dedicating his efforts to sleep disorders dentistry – the use of oral appliances to treat sleep apnea. Dr. Roubal has received significant additional training and credentials in this area, and this is the sole focus of his practice. He is the only dentist in Nebraska to have earned Diplomate status by the American Board of Dental Sleep Medicine and his facility is the only one in the state to be accredited by the American Academy of Dental Sleep Medicine.

has been practicing as a general dentist in Alexandria, Minnesota for 23 years. He specializes in general, implant, cosmetic and sleep dentistry. He received his degree as a Doctor of Dental Surgery from the University of Minnesota, Twin Cities and completed his residency training in the United States Army. Dr. Tim co-owns Dental Health Associates with Dr. Arthur Hermes. The office has 8 active operatories and it employee four hygienists, 4 assistants and 3 administrative staff members. Integrating cutting edge technologies and techniques in to the practice of dentistry is core to Dr. Tim’s mission. The clinic employs some of the industry’s most advanced systems in the practice including soft tissue lasers, CAD/CAM milling and scanning, pharyngometer/rhinometer assessment tools, high quality intraoral photography, a caries detection device, digital panoramic radiography, a 3-dimensional CBCT, and Isolite dental isolation

Dr. Roger Roubal

Highlighting Top SGS Doctors

Dr. Timothy Gehring


The Call That Can Save Your LifeSGS OUT IN FRONT WITH A CALL CENTER

Once again Sleep Group Solutions is the innovator in Dental Sleep Medicine. An advanced Call Center, the first in the industry, in their Hollywood, Florida headquarters, is up and running to serve the needs of dentists, physicians and sleep disorder patients.

The Sleep Group Solutions Customer Service Contact Center has secured an exciting collaboration with an affiliate representing 1.2 million patients with sleep disorders. The first initiative at the call center will be reaching out to all 1.2 million people who suffer, and provide a viable solution. They will be connected to a dental sleep medicine expert in their area to seek treatment for their sleep apnea. They will also be given tons of helpful information on sleep, and the scary impact of untreated sleep apnea on the body.

Our agents have been educated by our team, their focus is getting more dentists to be aware and be able to identify and treat sleep apnea.

The call center will also act as a platform for sharing information and resources to the dental community. Connecting new sleep apnea patients with dentists is a great way to find an alternative to treatment, and raise awareness of sleep apnea at the same time.

If you are a dentist interested in joining this service, or a patient with sleep disorder symptoms and are looking for a treatment alternative, here is where you can find the Call Center:

Call us at 855-978-6088 or email us at [email protected]

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


Dealing with edentulous OSA patients can be a challenge. Sometimes, if we’re fortunate, wearing the denture at night keeps the jaw forward and that’s all the

patient may need to manage sleep apnea symptoms. We know that tongue-retaining devices can also work, but long-term compliance is very weak.

Presented here is an ideal oral appliance therapy for the mild or moderate OSA edentulous patient using the same principles as if she had a full dentition.

PATIENT HISTORY AND EXAM

This patient was referred to my mentor Gene Mendelson, by a sleep MD after the patient refused CPAP therapy. Dr. Mendelson has been practicing dental sleep medicine for around 20 years and his work stimulated my awareness and desire to learn DSM.

The patient is a 65 year old female with a BMI of only 19.4, She is 5 feet tall and weighs 100 pounds. Note that she does not fit the body type of the “typical (in most minds) sleep apnea patient”. This reinforces our need to not stereotype OSA patients as overweight when almost half are not.

She has a history of airborne allergies and takes Lipitor, Vitamin D and Mirapex.

Oral examination reveals a Mallampatti III, elevated hard plate, low draping soft palate infringing on her airway and minimal tongue room with lower denture in place. She complains of chronic jaw pain and says she is a chronic clencher.

Palpation reveals her TMJ is tender bi-laterally and her right external pterygoid is tender to palpation, as are the left and right anterior belly

A Report on a Creative OAT Solution for an Edentulous Patient.

Dr. Barry Freydberg


of temporalis muscles. She also reports daily headaches.

She wears 25 year old full upper and lower dentures with a dramatic loss of vertical dimension. The denture teeth are worn flat and there are gross prematurities.

Her maximum opening is 34 mm. with a deviation to the left of 1.5 mm. Her left lateral range of motion is 6mm and the right is 11mm. Her maximum protrusion is 6mm beyond end-to-end. The patient had a PSG in 2010 and her AHI was in the mild range of 5.4 and in REM 8.0. Even with this the sleep MD prescribed a CPAP.

Her RDI was 31.2 and that is pretty severe and dangerous. So, while the AHI might not make her look very sick, the RDI did. She also had very loud snoring with related arousals and other arousals of unknown origin. Her restless leg syndrome was under control with Mirapex. Her desaturations were mild but she was forever tired. On the PSG she spent 25% of her sleep time (91 minutes) with an oxygen saturation between 81 and 90%.

The patient was more concerned about her pain and headaches than her OSA symptoms.

THERAPY

A new set of dentures was made with the corrected vertical dimension and with good occlusion. Four implants were placed in the mandible and attached to the new lower denture. With this the patient reported a dissipation of jaw and muscle pain. This new denture was used as the baseline vertical and anterior-posterior position for establishing the jaw position for an oral appliance.

A dorsal appliance was fabricated. The upper was made as a denture and the retention was excellent. If retention were not successful a reline or perhaps adhesive might have been necessary.

The lower of the dorsal appliance was attached to two of the four implants and the other two implant areas were hollowed out in acrylic. The lower was very stable. The appliance was delivered on 4/18/2014.

RESULTS

Two subsequent sleep studies were performed, one on 5/19/14, and one on 6/12/14. The first to “check our work” and the second as a final sleep study for the sleep MD.

The first study revealed an AHI of 1.9 with an RDI of 3.1. The second showed an AHI of 2.4 and an RDI of 5.3. Both studies showed the appliance to be successful based upon AADSM guidelines. However, we feel the biggest health improvement comes from the dramatic drop in the RDI!.

The patient’s oxygen saturations, that initially were below 90%, moved into a normal range in all but 2-.4% of her sleeping time.

CONCLUSION

We took an edentulous “CPAP refusal” patient and made a modified classical dorsal fin sleep appliance for her. The appliance successfully reduced or eliminated her OSA symptoms.


In an editorial piece which appeared in The Journal of the Craniomandibular Practice and Sleep4 2013, Dr. Shapira reminded those of us who treat patients with orofacial pain and temporomandibular joint disorders (TMD) that oftentimes, these patients present to our office with a laundry list of symptoms which are seemingly unrelated to “the jaws and teeth” but often improve from our treatment, most notably symptoms such as:

Because our understanding of how such conditions might be related, has until more recently been poorly understood, i.e. a medical mystery perhaps, TM disorders have largely been viewed as psycho/social disorders best treated by “psychological therapy and drugs.” These medically unexplained symptoms, are now most often referred to as the Functional Somatic Syndromes8. Because our medical doctors view our treatment of TMD patients as solely orthopedic in nature, there has been a disconnect between medical science and the almost miraculous improvement in the health of many of our patients, TM disorders have for many years, been referred to as The Great Imposter and our treatment protocols as almost voodoo in nature.

As Dr. Shapira went on to explain, “Sleep is the magic ingredient that explains many of the amazing improvements seen in treated TMD patients.” Undetected and unmanaged sleep disturbances associated with TMJ disorders will often compromise treatment outcomes and reduce the effectiveness of our treatment to reduce these associated symptoms in TMD patients. Sleep disorders increase systemic inflammation which in turn can adversely affect the cardiovascular system because of the constant cardiac activation occurring during sleep microarousals; these microarousals lead to increased sympathetic dominance of sleep which also been implicated in diabetes and high blood pressure.

Newer concepts and techniques for diagnoses and analyses are changing the very nature of how we practice dentistry, which enable us to more fully evaluate and manage our patients. Availing ourselves of current technology and incorporating it into every day protocols of patient assessment will greatly enhance the ability of all dentists to identify patients at risk for sleep-related breathing disorders (SRBD) in our every day practice of Dentistry and because available technology can be delegated to support staff, we can conceivably extend this optimum level of care to every patient we see.

Temporomandibular disorders have been linked to sleep disturbances; a chief complaints of a majority of TMD patients is unrefreshing sleep and pain and residual fatigue upon awakening.10-13

A Unique Application of A Mandibular Repositioning Device to Manage Both Temporomandibular Joint Dysfunction and Sleep-Related Breathing Disorders When Co-existing in the Same Patient.

Daniel E. Taché, DMD, DABDSM


In several studies, a majority of TMD patients have reported unrefreshing sleep and furthermore that poor sleep quality and symptoms associated with TMD have a bi-directional relationship. Pain-related awakenings from sleep have been shown to have a profound negative effect upon the intensity and severity of masticatory myofascial pain and pain threshold.1-3 A polysomnographic study studies the prevalence of sleep disorders in TMD patients revealed that 45% of the population of patients studied were diagnosed with one sleep disorder and 26% with two sleep disorders.1 A population of patients whose primary subjective complaints of nighttime teeth grinding were found to have a prevalence of sleep-related breathing disorders, specifically obstructive sleep apnea, of 70%.7 How often do we hear such complaints from many of our non-TMD or sleep disorder patients? It is interesting to note that a repeated prevalence study looking at a general dental population found that 5% of all female and 32% of all male patients who visit their hygienist for recare are likely to have an undiagnosed SRBD.9

The table above is a summary of the findings of this study, which validates the results of a previous study performed by the same team of researchers. This statistically significant information should is very sobering and alarming considering that the average dental (or medical) student receives 3 or less hours of formal education on the subject of sleep during the entire 4 years of undergraduate Dental or Medical school. Practicing dentists share the burden of identifying such patients because as things are, currently, the patients’ primary care physician is currently no more likely to be prepared to identify patients at risk for potentially life-threatening sleep-related breathing disorders.

Herein is presented such a case. The patient presented here, has had multiple medical problems, among them complaints of TMD. Many of her medical problems, which were previously addressed pharmacologically or with reassurance only, fell into the category of “Functional Somatic Symptoms”. The adverse physical, emotional, and economic toll that her symptoms were having on the quality of her life was significant. Had it not been determined that the litany of physical complaints were likely comorbidities of another problem, namely, sleep-disturbed breathing, the outcomes of treatment would have been tragically insignificant. The outcome of this case, however, was quite the opposite and will continue to positively impact the well-being of this patient for the rest of her life because we were able to understand that her TMD symptoms were but a co-morbidity of a SRBD, not a stand-alone problem.

Case Study: “TMJ Pain of 5 years duration.”

Chief ComplaintsMeet LY; she is a 46 year old female who presented to our office with the following Chief Complaints:1. TMJ pain & clicking noises2. Facial pain - “both sides of my face”

History Of Present Illnesses

LY reports the onset of her symptoms occurred approximately 3 years ago. She also recalls that about that time that she began to awaken in the morning with tight jaws. She also reports that she was also began taking Adderall at that time for her “attention problems” and “fatigue” and wondered if her jaw clenching and taking the medication were related.

LY then visited her general dentist for help with her “TMJ” and “facial pain” she was provided with an intraoral splint; specifically a mandibular flat-plane appliance, which she was advised to wear at night; this splint seemed to make her symptoms worse. She continues to use it but only when her pain is acute and intolerable.

Past Medical HistoryLY has been under the care of a rheumatologist for a number of years for symptoms consistent with fibromyalgia. She was also diagnosed with psoriatic arthritis.

Additionally, she has more recently been experiencing symptoms which her primary care physician has described as heart “murmurs” as you can see from the segment of the patient questionnaire (PQ) LY often awakens with her chest pounding and with chest pain. An EKG was performed and was considered normal.

Since the EKG was normal, her physician advised her that her palpations may likely be “stress or anxiety” related and prescribed a number of medications to help control symptoms as seen below in PQ: medications.

Upon review of the entire patient questionnaire, it is clear that LY is and has been bothered by problems with sleep to the point that she had then been awakening with chest pain, sore jaws and often bothered by nocturia and diaphoresis (she revealed this at a later date during additional discussions). Symptoms of sleep disorders, excessive daytime sleepiness, headaches and other symptoms common to patient with TMD are often not volunteered by the patient because they do not often see the relevance. Mindful now that these afflictions often co-exist, we did indeed assess LY for risk factors for SRBD. I will also add at this time, as you can see from the responses in her questionnaire, that LY also had complaints of “restless legs”.


Although a discussion of movement disorders of sleep is not the focus of this article, as previously stated, 26% of TMD patient will likely have two sleep disorders1 so it was not surprising for LY to report these subjective complaints.The recommended protocol for managing RLS requires assessment of serum ferritin levels which we determined were normal (>50 ng/mL), hence, she was prescribed ropinirole, a dopamine agonist, which completely eliminated this “movement problem” and certainly contributed to the success of her treatment.

The Clinical Assessment

Extraoral ExaminationThis view from the side shows a retruded underdeveloped mandible.

Neck: cricomental spaceIn addition to retrognathia LV also displays a reduced cricomental space, i.e. the area and volume of space in front of the neck and below the jaw often seen in the OSA subject.

Evidence shows that a cricomental space of <1.5cm is a risk factor for OSA.6

Intraoral ExaminationThe intraoral examination revealed dental arches, which had previously been treated with extraction orthodontics.

Mandibular range of motion was relatively normal; there were noticeable wear facets on many of the teeth consistent with her history of sleep bruxism.

High tongue posture (Malampatti IV), crenations on the lateral borders (enlarged tongue), the tongue are coated due to mouth breathing.

I asked LV if she awakened with a dry mouth to which she responded, “Yes, because I cannot breathe well through my nose”. It should also be mentioned that some time after LY’s initial assessment that her PCP determined that she had developed hypertension and was given a prescription for hydrochlorthiazide. Over time, it was determined that the hydrochlorthiazide improved her HTN but insufficiently; consequently Tenormin was also prescribed concurrently with good results.

Malampatti Grade: Risk factor for SRBD

A high Mallampati score is well accepted as a risk factor for obstructive sleep apnea especially if it is associated with nasal obstruction.

The association of a high Mallampati score and nasal obstruction warrants the attention of the sleep specialist.14-16

Nasal airway assessment: Cottle Maneuver & Acoustic Rhinometry (AR)LY had informed us that she often awakened in the morning with a dry mouth; she thought that it might have something to do with her inability to breathe through her nose. The literature is in agreement as we noted above. Furthermore, in the non-obese patient, nasal airway function may be a significant component of SRBD.17

Acoustic rhinometry (AR) may be a useful screening tool in the evaluation and treatment of the SRBD patient.

We performed a Cottle Maneuver (CM) for our initial clinical assessment of

LY’s high upper airway (HUA). The CM assesses patency and adequacy of size of the nasal valves. The internal nasal valve area is the narrowest portion of the nasal airway, thus assessment of this region is valuable. LY showed significant nasal valve collapsibility so we elected to perform AR

The nasal valve area when assessed with AR was shown to be very reliable in estimation of nasal airway volume at the level of the nasal valve.

Acoustic Rhinometry Assessment Of High Upper Airway (HUA)

The Cottle Maneuver as a simple screening tool had proven productive. The Rhinometric exam seen above revealed significant obstruction at all levels of the high upper airway on both the right and left sides. We provided a decongestant for the LY after the first AR test and waited 5 minutes until retesting.

Radiographic Assessment: right and left TM joints, lateral viewsCone Beam Computerized Tomograms (CBCT) images of TM joints: lateral viewThe right mandibular condyle displays regressive changes; the left mandibular condyle shows evidence of degenerative changes; both condyles are retruded excessively in the fossa. This is consistent with LYs history.


As you can see from the AR screen above, decongesting did not appreciably improve nasal patency on either the right or left side of the nose.

Radiographic Assessment (Cone Beam CT): Airway AssessmentWith the volume of data taken to assess LYs temporomandibular joints, we were able to easily reconstruct views of the airway in cross section. CBCT airways which on cross-section found to be subnormal in diameter has been shown to be a risk factor for SRBD.5 A cross-sectional diameter of 4.6mm ± 1.2mm (A-P dimension) is predictive of OSA 70% of the time. LYs airway was 3.9 mm. in cross-section A-P dimension as we can see above. Also, the cross-sectional shape of OSA groups is often concave or elliptically shaped whereas non-OSA group

�

Axial view of LY’s airway; note (abnormal) elliptical shape

Example of a more normal-shaped airway (x-section / axial view)5

CBCT images of right & left TM joints-anterior view; the degenerative changes on the left side are evident in this view as well

Differential Diagnosis1. Bilateral disc displacement with

reduction with active degenerative changes affecting the left mandibular condyle,

2. Restless Legs Syndrome3. Sleep Bruxism4. Sleep-related breathing disorder

Treatment: Restless Legs Syndrome (RLS) / Sleep Bruxism (SB) LY, as previously stated, was provided with Ropinirole which she took 2 hours prior to hours of sleep; at approximately 0.5mg, she noted complete control of the RLS-related symptoms; LY felt less jaw pain upon awakening; the assumption could be made that In addition to the diagnosis of RLS,

presented a more concave, round or square shaped airway.5, 18, 19 We can clearly see that LYs airway is both subnormal in diameter as well as elliptically shaped.

the presence of a SRBD is strongly suspected; consequently, LY was provided with a Home Sleep Test monitor (Apnea Link), which was reviewed by a local sleep specialist. The report summary is shown below.

Treatment: Temporomandibular Joint DisorderA diagnosis of Upper Airway Resistance Syndrome (UARS) was provided confirming our suspicions of a breathing-related problem of sleep. Conceivably, controlling both the RLS and the SRBD could reduce microarousals during sleep, which could conceivably reduce the SB as well as reduce the increased sympathetic tone of sleep, which could favorably affect other health concerns such as her hypertension and anxiety. There was discussion of attempting nasal CPAP however, LY was not very excited about having “something on (her) face” and additionally, the results of her HST did not qualify for insurance coverage; she did however, remain open to the option.

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LY's EMA with expanded occlusal table for enhanced TMJ stability. Note, modified durometers to minimize irritation to buccal mucosa; this worked

very well.

The EMA in place

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Results: TMD

The reformatted EMA designed to provided excellent support for LY’s dysfunctional TM joints performed quite well. The appliance (above) was modified by expanding the occlusal table with cold-cure acrylic quite easily, intraorally. Since this initial trial utilizing an EMA for both TMD and SRBD management, we have had our laboratory makes the occlusal modifications at the lab, saving us valuable chair time. The EMA was titrated to initially control snoring by slowly and systematically reducing the airway instability by changing to a shorter and shorter durometers over a period of several months. LY was very compliant with treatment and wore the lower tray for most of the day, every day for a period of approximately 11 months. There was very little jaw joint noise or pain after several months of continuous use. The tooth pain and headache were also greatly diminished without any additional use of medications, other than the ropinirole, which LY continues to take every night. Physical therapy was part of the program and without question, enhanced outcomes as well.

Without question, the greatest benefit to LY’s overall health was realized from the positive effect that improved nocturnal airway stability effected upon her sleep. Not only was snoring eliminated, but also sleep bruxism and the consequent tooth pain were now well controlled. LY’s fatigued greatly improved as well and it was noted that she awakened less often with a dry mouth feeling far more refreshed each day. The most notable caveat of this combination therapy was perhaps the reduction in her hypertension. At the writing of this article, LY has been advised by her PCP to discontinue the Tenormin because her hypertension was more easily stabilized now. A follow-up HST is planned for the future to ensure that the UARS is controlled. Objective evidence is essential as false-negative outcomes from subjective improvement occur nearly 35% of the time.22

Conclusion:

The TMD patient should always be considered at risk for both sleep-related breathing disorders and/or movement disorders if there is a subjective report of symptoms of sleep bruxism or objective signs such as excessive tooth abrasion or gingival recession in the absence of periodontal infection. The availability of acoustic rhinometry, a non-invasive and highly effective screening tool enhanced our ability to identify and adequately address LYs problems. The use of the EMA when a patient presents with both signs and symptoms of TMD & SRBD proved very effective in controlling both the TMJ dysfunction and the SRBD disorder when employed the this described manner. This approach to treatment has been duplicated numerous times since then with excellent success. The attention to controlling occlusal changes and jaw discomfort from the mandibular repositioning while sleeping needs to be addressed prior to the institution of this combined treatment. Pre-treatment muscle stretching exercises, directed specifically at the lateral pterygoid, medial pterygoid and masseter muscles is strongly advised to prevent & control adverse effects from mandibular advancement. Informed consent for such combined therapy should include all of the information provided to the patient as is done before proceeding with MAD therapy for OSA alone.

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Why then, is there any debate with regard to vertical dimension as it affects Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA)? In this, the first installment of a two part article, a position as to the importance of understanding vertical dimension as an integral part of O.A.T. will be given. In part two, case studies will be explored, validating the testimony given below.

The controversy over vertical dimension can be traced back to several studies, though few are cited more often than the 2002 study which concluded that “bite opening induced by M.A.S. does not have a significant impact on treatment efficacy.”2 While this author firmly believes in evidence based practice, attention must be given to not just the conclusions, but to the methods and data. In this particular study, patients randomly received a mandibular advancement splint (MAS) with either 4mm or 14mm of inter-incisal opening and the results compared. There is an

immediate concern with the methods of this study, as it compares only the extremes of minimum space needed to fabricate most appliances to excessive vertical dimension that has never been necessary in any dental case this author has been involved with. The other concern with this study is that no consideration as to the location of the obstruction is discussed, nor is the skeletal pattern of the subjects. It has become apparent that an understanding of the therapeutic applicability of reasonable vertical dimensional changes must be explored.

In practice, we quite often refer to the part of the airway that we concern ourselves with as the pharyngeal airway, however to understand the role of vertical we must first agree that airway compromise can occur within any of the anatomic components. Nasal breathing may be affected by congestion, polyps, septal anomalies, and high palatal vaults. The nasopharyngeal airway or velopharynx can be affected by mid-facial skeletal pattern, airway curvature and adenoidal hypertrophy. As a common

cause of both CPAP and OAT failures, nasal breathing inadequacies can result in obligate mouth breathing. In these patients, patency of both the oral cavity as well as the oro-pharyngeal airway is critical.

Regarding the oral cavity, a large tongue, deep bite or constricted arch form can inhibit airflow before it reaches the oro-pharyngeal junction (OPJ). At the OPJ, tongue size, neuromuscular tone, redundant soft tissues, and retrognathia can have a negative impact on the airway. Beyond the OPJ, the skeletal pattern, tonsilar tissues, fat deposition and neuro-muscular tone are all major contributors to compromise, with skeletal pattern and tongue size having less of an affect downward toward the hypopharynx. 3

While open bites and high mandibular plane angles have traditionally been associated with airway compromise at the velopharynx and upper oropharyngeal airway 4, deep bites or low mandibular plane angles can adversely affect oral cavity patency

The role of vertical dimension increase with regard to airway improvement for edentulous patients has been well documented in the scientific literature.

RECOGNIZING THE ROLE OF VERTICAL DIMENSION IN SUCCESSFUL APPLIANCE THERAPY FOR O.S.A.

Jeffrey W. Horowitz, DMD, FAGD


back to the OPJ. The former have been shown to improve primarily by mandibular advancement 3, however for the latter, this author has observed through acoustic reflection and post-OAT therapy home sleep testing (HST), that objectively increasing vertical dimension can be of significant benefit.

So just how does one determine where the problem exists within a given airway? As of today, there are only four ways to visualize the active airway three-dimensionally and map the etiology for an individual patient. C-T ( or cone beam C-T) imaging 5, MRI 6, Sleep Endoscopy 7, and Acoustic Reflection 8,9. MRI is well documented to see contributing soft tissue location and enlargement however the test may be cost-prohibitive and differentiation between the airway and dense cortical bone may be difficult. C-T is a static image that could require multiple images to compare the patency of the airway, and in the case of a cone beam, variations in positioning, head posture, and timing of the image capture may necessitate retakes that expose the patient to un-necessary radiation. Both MRI and C-T are sufficient for assessing risk for the disease, but may not define it in the active airway. Drug Induced Sleep Endoscopy (DISE) is perhaps the most accurate way of determining the site or sites of greatest constriction in the active airway during sleep 7, however as the name suggests, this procedure requires sedatives or general anesthetic, which may be of risk to the many health-compromised patients we treat for OSA. Acoustic Rhinometry/Pharyngometry is an accurate, time and cost-efficient test that utilizes sound waves to safely map the cross-sectional area of both the nasal and oro/hypopharyngeal

airway to the level of the glottis. 8, 9 The test is performed on the awake patient using the Muller maneuver to simulate airway collapse. The Muller maneuver has been proven to be comparable to DISE in its’ accuracy at determining the offending structures in OSA. 10

As a practitioner, the author has used acoustic reflection to map the airway and simulated collapse of each and every OAT patient he has treated in the past three years. Over this time, a common theme has emerged. Patients who show greater collapse with Pharyngometry at the pre-OPJ and OPJ space tend to benefit from vertical opening to allow air past the space between the dorsal surface of the tongue and the hard and soft palate. (FIG 1) As a trend, this tends to benefit those with deep bite or low mandibular plane angle (MPA) tendencies and can be seen on lateral cephalogram or cone beam image as a lack of “tongue bubble” space.(FIG 3,4) With the addition of vertical in these patients, an immediate improvement in the anterior part of the airway can be seen with pharyngometry (FIG 2) For those with a higher MPA, vertical must be applied with discretion as these patients may worsen due to distal rotation of the mandible. With acoustic reflection, this will be seen as a decrease in the cross sectional area of the airway. 8, 9 The advantage of acoustic reflection is that the practitioner can determine the location of the compromised airway and apply vertical dimension enhancement as necessary with objective measurement. The most anterior problems can be immediately improved prior to A-P repositioning which may have more

About the Author: Dr Horowitz is a 1991 Graduate of the Medical University of South Carolina College of Dental Medicine in Charleston, S.C. He is the owner and director of the Carolina Center for Advanced Dentistry and Advanced Sleep and Breathing Centers in Conway, S.C. Dr Horowitz is a fellow and delegate of the Academy of General Dentistry and an active member of the American Academy of Dental Sleep Medicine, the American Academy of Craniofacial Pain, the American Equilibration Society, the American Academy of Cosmetic Dentistry and the Dental Organization for Conscious Sedation. He also serves as a mentor at the prestigious Kois Center in Seattle, WA., Dr. Horowitz lectures to dentists world-wide for Sleep Group Solutions and the Catapult Group, where he also serves as a Key Opinion Leader for several dental manufacturers..

continues next page


adverse effects on the musculature.11 If this happens to be the point of most diminished cross-sectional area, less A-P advancement may be necessary, improving comfort and acceptance for the OAT patient. Long term, patients where vertical is objectively introduced into OAT have proven to improve on follow-up sleep studies with less protrusion than would have been necessary without vertical enhancement.

Conclusion: While the indiscriminate use of vertical dimensional changes with OAT has proven to be of little benefit in the current literature, objective acoustic reflection measurement of the cross sectional area of the airway can reveal the anatomic location of the unstable airway. At certain locations, usually from the OPJ anteriorly, vertical dimension enhancement can improve the airway dynamics, at times with less protrusion than would have otherwise been necessary. Vertical must be effectively titrated with an objective method such as acoustic reflection as over-rotation could yield diminished results.

In part two. Detailed case reviews will be discussed further supporting the content of this article.

Fig 1. Acoustic Pharyngometry showing minimum cross sectional area (MCA) at 7-8 mm from wave tube. Corresponding to tongue and OPJ. Green line and data correspond to baseline (normal breathing) and pink line/data is simulated collapse with Muller maneuver. Note the drop in MCA to .76 cm2 during simulated collapse.

Fig 2. Acoustic Pharyngometry showing increase of MCA to 1.44 cm2 in same patient using only vertical enhancement (Blue line and data) vs simulated collapse (pink line /data)

Fig 3. Cone Beam C-T, saggital view showing no “Tongue bubble” space between the dorsal surface of the tongue and hard palate.

Fig 4 – Cone beam C-T saggital and coronal views showing a positive “tongue bubble” space between the dorsal tongue and hard palate.

References:1. Gupta P1, Thombare R, Pakhan AJ, Singhal S Cephalometric evaluation of the effect of complete dentures on retropharyngeal space and its effect on spirometric values in altered vertical dimension. ISRN Dent. 2011;2011:516969. doi: 10.5402/2011/516969. Epub 2011 Jul 42. Pitsis AJ1, Darendeliler MA, Gotsopoulos H, Petocz P, Cistulli PA Effect of vertical dimension on efficacy of oral appliance therapy in obstructive sleep apnea Am J Respir Crit Care Med. 2002 Sep 15;166(6):860-4.3. Isono S1, Tanaka A, Sho Y, Konno A, Nishino T. Advancement of the mandible improves velopharyngeal airway patency. J Appl Physiol (1985). 1995 Dec;79(6):2132-8.4. Tangugsorn V1, Skatvedt O, Krogstad O, Lyberg T Obstructive sleep apnoea: a cephalometric study. Part I. Cervico-craniofacial skeletal morphology. Eur J Orthod. 1995 Feb;17(1):45-56.5. Bruwier A, Poirrier AL, Limme M, Poirrier R Upper airway’s 3D analysis of patients with obstructive sleep apnea using tomographic cone beam. Rev Med Liege. 2014 Dec;69(12):663-7.6. Kavcic P1, Koren A, Koritnik B, Fajdiga I, Dolenc Groselj L Sleep magnetic resonance imaging with electroencephalogram in obstructive sleep apnea syndrome. Laryngoscope. 2014 Dec 15. doi: 10.1002/lary.25085.7. DE Corso E1, Fiorita A1, Rizzotto G2, Mennuni GF2, Meucci D1, Giuliani M1, et al.The role of drug-induced sleep endoscopy in the diagnosis and management of obstructive sleep apnoea syndrome: our personal experience. Acta Otorhinolaryngol Ital. 2013 Dec;33(6):405-138. Viviano JS Acoustic Reflection review and Clinical Applications for Sleep Disordered Breathing Sleep Breathe 2002; 6(3):129-1499. Deyoung PN, Bakker JP, Sands SA, Batool-Anwar S, Connolly JG, Butler JP, Malhotra A Acoustic pharyngometry measurement of minimal cross-sectional airway area is a significant independent predictor of moderate-to-severe obstructive sleep apnea. J Clin Sleep Med. 2013 Nov 15;9(11):1161-4. doi: 10.5664/jcsm.315810. Yilmaz YF1, Kum RO, Ozcan M, Gungor V, Unal A. Drug-induced sleep endoscopy versus Müller maneuver in patients with retropalatal obstruction. Laryngoscope. 2015 Jan 30. doi: 10.1002/lary.2516011. Clark GT, Sohn JW, Hong CN Treating Obstructive Sleep Apnea and Snoring: Assessment of an Anterior Mandibular Positioning Device J Am Dent Assoc 2000 Jun, 131(6): 765-71


Obstructive Sleep Apnea- Impactful Consequences for Children and AdultsSleep disorders that effect morbidity and mortality have been studied extensively and have been getting more and more attention in academia, in general and in specialty dental practices. Studies show that Mandibular Advancement therapy, when monitored by a trained and qualified dentist, has been effective both in prevention and treatment of Obstructive Sleep Apnea.

Obstructive Sleep Apnea is correlated with phisiometabolic dysfunctions, genetic and syndromic order problems. OSA studies show a predisposition to hypertension, blood pressure levels in hypertensive patients supported of the Sleep Disorders (reference). Passeri, in 2014, conducted a study that described an association of Diabetes Mellitus, Tooth Loss in Class III and Hypertension (reference). Patients with Metabolic Syndrome (MetS), decreased functional capacity and OSA are commonly fond associated in this syndrome and could worsen the prognosis in these patients (reference).In childhood, the Cognitive and Behaviour Changes in the presence of OSAS, increase the Risk of Cardiovascular and Cerebrovascular Diseases (reference). OSAS also is associated with tonsil and adenoid hypertrophy, obesity, allergic rhinitis, craniofacial malformations, neuromuscular diseases, genetic and metabolic syndromes, from the neonatal period to adolescence, being more common among preschoolers (reference). The need for an accurate diagnosis of OSAS led to the development of equipment and devices for measuring the characteristics of the airway (Pharyngometer and Rhinometer) and oxygen saturation in blood. Overnight studies, like the Home Sleep Test and oximetry monitors are used to record data in patients admited with Acute

Coronary Disease of OSA. Overnight oximetry in this study had a sensitivity of 88.9% and a specifity of 100% of OSA in 43% of 37 Coronary Disease Patients (reference). All this data must be measured and evaluated. A definitive diagnosis of the obstructive sleep apnea disorder (OSA) requires comprehensive testing. Insufficient knowledge of the details of the patient’s condition will influence both the diagnosis and the prognosis of the case. The consequences of misdiagnosed OSA are too serious to not utilize all existing testing technique.

Dr. Quintella Dr. Claudia Quintella is a member of the Brazilian Society of Orthodontics and a Founding Member of the Brazilian Association of Dentistry. She is a member of the World Federation of Orthodontics. For 11 years Dr. Quintella has been Editor Board Reviewer of American Journal Orthodontics and Dentofacial Orthopedics. As a University Postgraduate Professor she is recognized worldwide for her contributions to Science, Research in Orthodontics and Oral Biology in Zurich and at Hadassah University. She is the author of many publications on evidence based studies of Orthodontic research. Dr. Quintella is the founder of quintellaodontologia and is highly respected both in Dental Academia and for her social media commentary. 7KH�IROORZLQJ�VWXG\�RQ�HI¿FDF\�RI�2$7�in the treatment of OSAS was selected by 'U��4XLQWHOOD�EHFDXVH�RI�LWV�VLJQL¿FDQFH�to this edition of dental sleep medicine.


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One of my favorite things about teaching our dental sleep medicine seminars over the years has been hearing all the personal stories from our seminar attendees and clients.

My dental sleep medicine story 15 years of dental sleep education:

By John Nadeau

It’s amazing to me that when you put 30 people in a room and really get them excited and educated about all the aspects of sleep medicine how many of them have a personal connection to sleep apnea. Every single person has a story, every single person has a real world experience with sleep apnea. Not one person, not every other person, every single one. I think this is amazing when we look at prevalence and how widespread this problem is with your patients – every one of them has a story as well, your job is to uncover it.

I got my first appliance from a close friend and mentor when I was still a teenager. My snoring had gotten so loud that it was causing problems with my college roommates. After college I went on to work with this dentist in what was a very new field of ‘sleep medicine’ at the time. We traveled the country and did many small seminars educating like-minded dentists on how sleep health and airway are a major part of overall health and wellness. When I joined SGS in 2005 we focused on acquiring every piece of the dental sleep medicine puzzle to help dentists incorporate this valuable service in their practices. This year we have over 100 CE programs and are working with thousands of practices nationwide.

Despite all this growth we are still just scratching the surface of this problem. We need your help to uncover more of those sleep apnea stories. Recently I was teaching one of our CE courses and we had about 30 attendees in the room.

We gave a home sleep test to 9 of them who volunteered and all 9 had a diagnosable amount of sleep apnea. This is no different than the scope of the problem with your patients. Screen your patients! Let them tell you their sleep apnea story! Almost 97% of those suffering with Sleep Apnea are still in need of daily treatment, are you ready to help?

This gets me to my next point: CHANGE YOUR BEHAVIOR. If you didn’t identify at least 4 or 5 of your patients so far TODAY as high risk for sleep apnea it’s because you were not looking closely or having the right conversations with them. The day you decide to go down this path and begin offering help to these people nothing new will happen unless you change your behavior. People are not going to walk in tomorrow and out-of-the-blue tell you about the sleep study they recently had or the CPAP they struggle to wear. Change how to look at them, how you interact with them, the questions you ask and the conversation that occurs. Get them to tell you their story! This starts with your front office team, then your assistants and hygienists and finally yourself, everyone needs to be on point and on message.

I’ve been privileged over the years to have been in dental practices from coast to coast. From the most elaborate offices in New York or LA to the small town in-home dental offices in very rural areas. I laugh when people say “that won’t work in my town” or “not with our patients” or some other story about how special and/or difficult their patients


moved his general dental practice to McMurray PA-a suburb of Pittsburgh- in 2007 intending to add dental sleep medicine as an additional service to offer his patients and to help build his patient base in his new office. Eight years later dental sleep medicine has become the major focus in his practice. To demonstrate his dedication and commitment to helping patients with sleep-related breathing problems his facility received two national accreditations in this field and he personally achieved diplomate certification thru the American Board of Dental Sleep Medicine. “I envisioned the opportunity in this unique area of dentistry to collaborate with medical professionals in truly improving the quality of life …if not saving the life… of any individual afflicted with this condition. I believe my physician colleagues recognize my passion and the effort I have placed in learning all that I can about sleep medicine to confidently work with them to the benefit of these patients. I can honestly say that my “all-in” pursuit of dental sleep medicine has been the most satisfying and rewarding part of my thirty five years in dentistry”. Dr.Hnat is a highly respected speaker on Dental Sleep Medicine and presents training seminars nationally for Sleep Group Solutions.

earned his DMD degree from Boston University School of Dentistry in 1993. He has owned his private practice, All Dental since 1999 and for over 20 years has dedicated himself to excellence in his field as well as to continuing his education in many areas including implantology, orthodontics, sedation dentistry, Botox and sleep disorders.

Dr. Noor is a member in good standing of ADA, ICOI and AAFC and is ACLS certified. He was selected by TopDoc as a top dentist in the Boston area 2 years in a row.

Michael Hnat DMD

Highlighting Top SGS Doctors

Dr. Rashid Noor

are. What I can tell you all reading this unequivocally is that apnea does not discriminate and it is everywhere in every office, period. So how do you start talking to your patients? First set your goals, know what you want to happen as a result of a conversation. Keep your goals simple – your goal for a new patients who might snore or have hypertension is NOT to sell, or even discuss, oral appliances. Oral appliances are the therapy part, the end, the solution – first you need to identify the problem and get the patient to understand and be concerned about it.

Education >>>leads to>>> Ownership >>>leads to>>> Ideal Outcomes

How many oncologists struggle with getting patients to say “yes” to treatment? My guess is very few. Patients understand the dire circumstances and all other concerns about cost, deductibles and convenience go out the window. They are scared because they are educated as to the scope of the problem. This is the real first step for your sleep apnea patients – not selling solutions but instead diagnosing a problem. By far the biggest mistake I see new dental offices make when they are getting started with sleep medicine is that they focus too much on pushing a solution and not nearly enough on uncovering and diagnosing a problem. I encourage everyone reading this to try it. Ask ‘sleep health’ related questions but instead of immediately rushing to “sell” them on your

beautiful shiny new custom oral appliance just let them tell you their story, empathize and express concern, and then offer the next step as a diagnostic sleep test. Let each step sell them on the need for the next, after the sleep study and physician diagnosis/therapy order you’ll have what you need to present the solution to the patient.

This protocol and every conversation and tiny detail we have worked out is detailed as part of our dental sleep medicine training program. The next step for you would be to attend one of our 2-day seminars to learn more about this unique process and how you can help the hundreds of apnea sufferers in your practice have a happy ending to their story.


The Most Leveraged Procedure In Dentistry:The Treatment of Sleep Apnea As I have lectured on productivity across the country for the last 15 years people often ask me what is the secret to productivity? Is it working faster? Is it seeing massive numbers of patients every day? My answer is none of the above. Productivity is about leverage and getting people to say yes to treatment. Let’s look at these two keys to productivity.

Leverage in real estate is the concept of using very little of your own money to control a property that has a much greater value. The concept of leverage in the stock market may be described by owning options at a fraction of the cost of buying that stock, yet having control over that stock. That’s great but what does leverage in dentistry mean? You only have a certain amount of time in any given day. Let’s say you work 8 hours. We know that the average dentist in the country produces slightly less than $400 per hour. That means that they average around $3,200 per day. That day is spent doing fillings, exams, hygiene exams, emergencies and an occasional crown. The average dentists feel like they are working very hard every day and I certainly don’t dispute that. The secret to productivity is learning to do procedures that are highly leveraged. An example may be, for instance, a crown. Your fee is $1000 and it takes you a combined hour to do it. That’s a $1000 per hour procedure which is 2.5 times the leverage of anything else you are doing that day. A dental implant is another very leveraged procedure. Say you charge $1,600 for an implant and it takes you 1 hour. That is leveraged at 4 times your usual productivity per hour. Follow me?

Let’s now look at the treatment of sleep apnea. I have one team member who sees the apnea patient first and does a cursory evaluation. She uses the Pharyngometer and Rhinometer and takes a Cone Beam CT. She reviews patients’ insurance and Epworth Sleepiness Scale. Then I come in for 20 minutes to review the findings and discuss the dangers of apnea. I then recommend a home sleep study to screen the patient for the severity of their apnea and snoring relevance. For 10 minutes I review the findings and recommend appropriate treatment. For the severe patient I recommend an appointment with one of our sleep physicians. For all other patients I recommend oral appliance therapy. Impressions are taken and we move forward. My sleep technician does all the follow-up visits. I come in only when there are questions and this may take an additional 10 minutes through the course of treatment. The leverage here is incredible. Our fee is $3,600 for an appliance and I have spent around 40 minutes on that case. The leverage in this procedure is 13.5 times higher than the average dentist’s daily production. WOW!! Plus you may very well have saved a life!!

Bruce B. Baird, DDS


Bruce B. Baird, DDS has been named one of the nation’s most productive dentists. Comprehensive treatment planning and full-mouth restorative care set him apart in the Dallas/Fort

Worth, TX area. In 2004 Dr. Baird founded Productive Dentist Academy and partnered with Vicki McManus, RDH in 2005. He is also the founder of Comprehensive Finance.

Bruce Baird

High return on investment, a real opportunity to improve patients’ quality of life and practicing stress-free dentistry. How much better can it get? So how does a dentist get into this leveraged dental “niche”? It begins with a Sleep Group Solutions training seminar. These 2-day weekend courses prepare the dentists and their teams to begin screening their existing patients, and create a stream of new patients, for Obstructive Sleep Apnea. Now let’s look at the number one reason people deny

treatment. You know the answer- it’s money. Some patients are approved for 3rd party financing, but what about all the other patients? It is highly leveraged!! I started a company, called Comprehensive Finance, to change the way we think about financing. We have been told not to do our own financing. By who? By the people who make all the money—banks. That is simply not the way to do things. If a procedure can be done mostly by your auxiliaries and the down payment covers your cost, then why wouldn’t you

offer financing? By knowing the regulations in all 50 states and having clients in all 50 states we do all the work. You enter the patient’s information into our software and you get an answer in less than 2 seconds. We look into their banking history as well as their credit rating. There are many people who are payment worthy but not perhaps credit worthy. We charge $3,600 for our appliances, get $600-$800 down and we finance the rest. Depending on risk, the patient is charged between 9.9 and 17.9% interest. Payments are around $140 per month for 2 years or $100 per month for three. Almost all patients can afford this treatment and we do all the collection work. Defaults are surprisingly low and we do not have a single patient paying less than full fee. If you would like more information call Charles at 866-964-4727 for special pricing for SGS doctors.


Oral Appliance Therapy for the CPAP Intolerant Patient

A 77 yo female patient was referred for Oral Appliance therapy by her Physician. Her

medical history was significant for hypertension, GERD, hypothyroidism, glucose intolerance,

and severe obstructive sleep apnea with daytime somnolence. Her dental history was

significant for macroglossia and a retrognathic mandible with a class II jaw relationship.

Dr. George Jones

1. She was scheduled for a complimentary exam to determine her suitability for a Mandibular Advancement Device. She was found to be periodontally stabile, have no pending dental work and have no history of tempo-mandibular dysfunction.

2. A copy of her PSG was obtained from her referring physician. She has failed several attempts at CPAP therapy. She was diagnosed with Severe OSA with an overall AHI of 35.8, supine AHI of 112.9 and 0 minutes of REM sleep.

3. We then evaluated the patient’s airway using the Eccovision Acoustic Pharyngometer. The pharyngometer allows to evaluate the caliper of the patient’s airway using Acoustic Reflective Technology. We can manipulate the mandible and see its effect on the airway caliper in real time. A recent article in the Journal of Clinical Sleep Medicine by Atul Malhotra (Nov. 2013) found a subject is 35 times less likely to have OSA if you can increase the MCA (minimum cross-sectional area) of the airway by 1.0cm2.


4. The Pharyngometer was used to determine how much cross sectional area of her airway the patient loses during a simulated apnic event. The mean cross sectional area collapses 3.15 cm2 to .91 cm2. (a 71.2% loss of her airway caliper). Her minimum cross sectional area (MCA) collapses from 2.35 cm2 to .58cm2, an astounding 75.3% loss in the smallest point of her airway.

5. We then use the pharyngometer to evaluate changes in the patient’s airway caliper at different mandible positions. We position the patient in a reproducible (vertical and protrusive) orientation. Using a 12mm and a 6mm protrusive position, we were able to increase her mean cross sectional area from .91 cm2 to 2.71 cm2 , and her minimal cross sectional area from .58 cm2 to 1.49 cm2.

6. Once the optimum mandible position has been established, a bite relationship is recorded. This bite relationship is sent to the Dental Lab along with casts of the patient’s upper and lower jaws for the fabrication of the Mandibular Advancement Device.

7. A Herbst style Mandibular Advancement Devise was chosen for its ability for fine protrusive adjustments and lateral mobility. The patient was having persistent discomfort on tooth # 24, so we relieved it from the appliance.

8. A Home Sleep Test was ordered approximately 1 month after the Appliance was delivered. The results are uploaded to a website, Interpstudies.com, where it is interpreted by a North Carolina licensed, board certified sleep physician. Her response to therapy was amazing! Her overall AHI dropped from 35.9 to 4.3, and her supine AHI dropped from

112.9 down to 3.6. Note that she is still spending a significant portion of her night in the supine position. It should be noted that her SaO2 levels are somewhat worse than the diagnosing PSG, with the SaO2 nadir dropping from 90% originally down to 83% on the follow up HST. This is possibly due to the fact that during her diagnosis PSG she experienced 0% REM sleep. It has been documented that Apnea tends to be more severe during REM sleep, and now that she is having significantly fewer arousals she is likely achieving significantly more REM sleep. With that, she is likely having fewer, albeit more severe events.Subjectively the patient reports feeling more rested, with a significant decrease in daytime fatigue. Her husband reports that he hasn’t been disturbed once by her snoring since the Oral Appliance was delivered.

Eccovision - Base Line Eccovision - collapse Eccovision – Airway with bite jigs –

HUGE improvement!

continues next page


At her one year follow up I asked the patient to consider another HST to verify the appliance’s effectiveness.The results indicated there may be increased benefit with time. Her overall AHI hasdropped from 4.3 to 0.4, and supine AHI dropped from 3.6 to 2.Like her AHI, the SaO2 statistics continued to show improvement as well. With her time spent below SaO2 90% dropping from 6% of the time to 2.3%, and the oxygen saturationnadir rising from 83% to 87%.

While the results are good, this is obviously not the perfect case. I would prefer to havehad a HST that had the capability to measure REM sleep. I would like to see herSaO2 levels higher. But all in all, she has had a significant therapeutic benefit fromher treatment.

continued from previous page 35


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Out the Starting Gate and in the Lead with OSAWhen it comes to getting involved with sleep health we all start somewhere. No matter where that starting line is, whether you’ve been in practice 2 years or 22 years, the time to commit to helping your patients on an entirely new level is right now.

But like a NASCAR driver sitting at the start gate, not much happens until that remarkable machine gets thrown into first gear. Once that happens, the astounding capabilities of a finely tuned car start to show.

Maybe you’re a little like me and your practice is that finely tuned car. You’re undoubtedly committed to doing the best dentistry you can, looking out for the total well-being of your patient family. You and I both agonize over a crown margin that’s just not quite right. We strive to broaden a proximal contact that no one knows about. As dentists, that’s just how we’re wired.

Since my US Navy days serving in Japan, I adopted a personal motto from that country’s business culture: Kaizen, meaning continuous improvement. Applying it to my practice and personal

life, that one word has driven an evolution that won’t end until I hang up the handpiece for the last time. You’re no different.

For several years I wondered about sleep health. We all hear patients talk about their miserable CPAP and my wife threatened to move downstairs if I didn’t figure out my own snoring! I had a dental colleague who started marketing sleep health and pretty soon my patients were being sent to him by the regional sleep center. Kaizen kept nudging me.

I wasn’t even in first gear...but it was time to get moving.

After analyzing several educational programs, I stumbled on Sleep Group Solutions. Still unsure, I ended up with an edition of Sleep

Magazine in my hands and I was impressed by what I saw. At that point, I turned the key and attended a 2 day seminar with Dr. Marty Lipsey and the proverbial light bulb nearly blinded me. “You don’t know what you don’t know” never hammered me more clearly in 20 years of dentistry and thousands of hours of continuing education.

To put it bluntly, too many of my patients are dying due to poor sleep health...sometimes suddenly and other times slowly. At a minimum, they’re exhausted and irritable, struggling with diabetes, high blood pressure and depression while being handed still another prescription. It’s not a theory, it’s evidence-based. And Sleep Group Solutions provides a set of resources simply unmatched in this race to save your patients’ lives. What you discover will simply astound you.

Dr Greg Grillo


“Steve” is a recent patient of mine. In his 60’s, he’s been in absolute sleep agony for years. Never feeling rested, falling asleep at dinner, fighting anxiety and high blood pressure, he has seen dozens of doctors for his health concerns. Imagine my surprise when I asked him if he’d ever had a sleep test and he said NO ONE had ever suggested it. This isn’t uncommon.

After a simple home sleep test with the ARES Watermark unit and interpretation by the board-certified MD, Steve learned he has moderate obstructive apnea (AHI 27). 27 times per hour this poor man has compromised breathing severely effecting his sleep...AND his health.

Steve had no interest in CPAP (also not uncommon), but readily accepted an oral appliance as directed by the MD’s report. Airway mapping with the pharyngometer clearly displayed a very specific position for Steve to achieve with therapy and even a 1 mm change significantly altered his airflow. This drove home the point that it’s not enough to make an appliance. It must be calibrated! SGS helps me do that.

Steve is already a different man. It’s evident when you first see him and when he says he’s almost “scared” to feel this good. You know that feeling when someone cries over the new smile you just created? It’s a whole new level of horsepower when your first patient starts telling you how much you’ve changed their life.

For our practice, we’re just getting comfortable in first gear. But this is a long race and Sleep Group Solutions draws together so many exceptional resources to help you become a hero in your patients’ lives. We’re incorporating sleep health steadily into our practice, a rewarding and fascinating process. Hands-on training, seminars, exceptional equipment and connections for easy medical billing services make getting started something you can’t afford to not do.

Only 4% of dentists are treating sleep health in this country and yet 40 million Americans are afflicted with something that’s treatable right now. By you. The opportunity is enormous for your practice, for your

own satisfaction as a provider, and most importantly, for your patients.

By the way...My wife didn’t move downstairs and I can’t sleep without my appliance. I’m a different person with sound, healthy sleep...for that reason alone, I thank SGS for opening up a whole new world to me!

“The secret of getting ahead is getting started.” Mark Twain

GREG GRILLO:

Dr Greg Grillo is a native of Omak, WA and earned his Bachelors in Psychology from the University of Washington. He also received his Dental Degree from the University of Washington School of Dentistry in 1995. Dr. Grillo served as a dental RI¿FHU�LQ�WKH�86�1DY\�LQFOXGLQJ�tours of duty in Japan and South Carolina, before returning to private practice in 1999. A partner in Grillo Robeck Dental, he has helped develop a cutting edge rural practice incorporating many of the latest technologies and services including sleep health.

Dr Greg Grillo


The Mylo-hyoid Ridges: Troublemakers for Mandibular Advancement Devices

Robert E. Garfield, DDS, FAGD, [email protected]

Executive Director, Southern California AGD Component (SCAGD)

We dentists have been taught the importance and the benefits of having denture bases for removable prostheses fully extended to the functional muscular periphery. This principle is especially important with mandibular denture bases whether they are for full dentures, overdentures, distal extension removable partial dentures or mandibular advancement appliances to treat Obstructive Sleep Apnea.

Many of us have mastered the art of obtaining fully extended “muscle trimmed” impressions utilizing custom impression trays, border moulding and “wash” materials.Some clinicians even make a temporary denture of limited accuracy, then border mould it and do a wash impression, all with the use of tissue conditioner mixed to various states of viscosity. The patient then wears this out of the office, instructed on precautions, returning in a few days for peripheral additions and possibly another wash impression.

In this manner extremely accurate functional peripheral borders and surface reproduction can be obtained within a few days to weeks. The clinician then pours the impression of the temporary denture in stone, submerging it under cold water after the initial set of the stone in order to dissipate the heat of the chemical reaction upon final setting which could distort the tissue conditioner. Upon separation of the stone cast the temporary denture is returned to the patient with its tissue conditioner intact, and the clinician has a beautifully accurate stone cast to proceed to the next step of making a final denture for this patient.


The problem

As is often the case, after a day or so of wearing this fully extended mandibular denture, with its deeply extended lingual flanges that so effectively prevent lateral displacement of the denture during function, the patient complains of extreme pain and ulceration in the region of the lingual vestibules. After several spot-relieving appointments for these painful areas, none of which seem to help the situation, many clinicians acquiesce to a patient’s demands and trim away 50% of those wonderful stabilizing lingual flanges that took so much skill and perseverance to make. So what happened? The patient blames the denture for “cutting into my jaw.” However, exactly the opposite is true. The very sharp mylo-hyoid ridge cut through the oral mucosa from the lingual, pressing against the tissue side of the lingual denture flange which acted like a “cutting board.” The soft tissue was the “bread;” the mylo-hyoid ridge was the “knife; the lingual flange was the bread board.” The denture base was not the culprit, but now the stability of this denture has been compromised by its removal and that can be a serious problem to clasped teeth, implants and their superstructure retention screws.

Basically, the lingual flanges are the only stabilizing feature against lateral displacement or “fishtailing” of the denture base during function. The lingual surfaces of the mandible are vertical while the facial surfaces are sloped. It’s just simple mechanics. This constant lateral movement can loosen, fatigue or break the retaining screws that hold implant supported attachments or bar-clip retainers in place.

Moreover, it can cause the loss of integration of anterior implants and even cause implant fracture in some cases. It can also prematurely wear-out o-ring denture retainers and other denture retention systems. It’s just like having a long cantilever arm connected to the anterior implants.

The solution

The solution to this frustrating problem is to follow a strict denture examination protocol with every patient that requires either a reline of an existing full or partial lower denture, or an entirely new denture or a mandibular appliance device.. Remember, the cause of the pain is not the appliance, but the sharp mylo-hyoid ridge, and that ridge belongs to the patient. The patient’s mylo-hyoid ridge remodeled over the years and became knife-sharp as a result of bone resorption. It is as though a rainstorm and

flood had washed all of the smaller gravel particles from a dirt road leaving only the larger jagged rocks exposed. This is the patient’s problem, and you, the clinician, can solve it and still have fully extended lingual flanges. But first you must recognize the problem, demonstrate and explain it to the patient before starting any appliance treatment.

Protocol steps

Ask the patient to hold their breath (to keep from gagging), then place your index finger deeply into the patient’s lingual vestibule and palpate the mylo-hyoid ridge.If the ridge is sharp (it usually is) the patient will experience acute pain and flinch.


Understanding

Sleep DisordersEducation for Healthier Sleep and Healthier Life

5REHUW�*DU¿HOG��''6¶V�professional experiences include a former assistant professorship at UCLA School RI�'HQWLVWU\��¿[HG�SURV��DQG�VROR�SULYDWH�general practice with an emphasis on periodontal prostheses, occlusalreconstruction, implants and innovative laboratory technology. He hasauthored numerous clinical articles and presented at most major dental meetings. Dr. *DU¿HOG�KROGV�PHPEHUVKLS�LQ�ADA, Calif. Dent.,Assn.,Academy of Osseointegration �)HOORZVKLS��)$&'��),&'��Pierre Fauchard Acad., Beverly Hills Acad. Dent. At present he is the Executive Directorof the Southern California Component of the Academy of General Dentistry.His email address is GUUREHUWJDU¿HOG#DRO�FRP

Now take the patient’s index finger and guide it into their lingual vestibule and repeat what you just did yourself. The patient will cause himself/herself acute pain, but will now be convinced that the cause is from their own sharp area on their jawbone.

Tell the patient why their bone is so sharp ( bone resorption /gravel road) and explain to them why this will produce pain from any properly fitting denture base that you would make for them.

Suggest to the patient that you want those sharp bony ridges removed or smoothedaway before you start the new appliance, and to not do so will surely result in a poorly fitting and unstable denture. If you have surgical skills you can do this procedure yourself, one side at a time, with a one-month interval so as not to cause bilateral pharangeal edema that could restrict swallowing and frighten a patient. Otherwise send the case to an oral-maxillofacial surgeon.

Performing this procedure requires good local mandibular and long buccal nerve block anesthesia. A 2-3 cm. straight line incision is made along the posterior ridge crest from the retro-molar pad anteriorly to the #20 tooth position.

A periosteal elevator is used to reflect a full thickness flap separating the soft tissue from the lingual surface of the mandible.

Keep the elevator against the bony surface at all times.

This lingual soft tissue separates from the bone easily. Locate the mylo-hyoid ridge and with a sharp bone file patiently remove the sharp surface.

Gently irrigate and suction the area to remove bone debris. Never blow air from a syringe into the area as this could cause a

submandibular emphysema. Palpate the area to determine whether the bone removal is sufficient before suturing the flap.

Psychologically prepare the patient for some unilateral pharyngeal edema and moderate osteitis pain for approximately 5 to 10 days.


Understanding

Sleep DisordersEducation for Healthier Sleep and Healthier Life

Order Your Brochures Today!www.TheSleepMall.com

To place your order or customize each brochure for your practiceContact: [email protected]

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Educate your Current and Prospective Patients

Our Brochures explain the effects of snoring / sleep apnea. Our new patient education program is designed to provide insight for your patients, enabling them to make a self-evaluation, realizing the impact sleep disruption may be having on them and their families.

A common sense approach and a little guidance helps in the treatment for snoring and sleep apnea. Help your patients make an informed decision, place your Sleep Medicine Patient Education brochures in your waiting room today!

sleep apnea, including testing and well-fi tting

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The information within this brochure is for educational purposes

only, and should not be taken as defi nitive or binding medical advice.

Because each person is medically different, individuals should see

their personal physician for specifi c information and/or treatment.

© Copyright 2013 Sleep Group Solutions, Inc. All Rights Reserved.

Diabetes and Sleep Apnea

Name: Henry

Age: 40

Health: suffers

from diabetes,

loud snoring and

daytime fatigue

3/15/13 1:46 PM


Dental Continuing Education

WebinarsThe SGS webinars are a great way to get familiar with Sleep Apnea. The free webinars are available every week and can be joined at lunchtime or in early evening. The topics vary and include marketing to new and current patients, screening, protocol and insurance systems and billing. Here is a calendar of 2015 webinars: www.sleepgroupsolutions.com

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

Training SeminarSleep Group Solutions has a seminar schedule for 2015 with a two day accreditation seminar every week all across this country The dentist leaves the seminar with all the tools and information ready to step into his or her office the next day able to BEGIN serving his or her sleep apnea victims. This accredited course, taught by doctors with years of intense private practice experience, offers 16 units of CE credits.

In-office Team TrainingA practical, hands-on Team Training Program is available for every seminar graduate to increase their self-confidence in the stages of screening, using the equipment and treating their patients. The seminar program is analogous to the four years in dental school. You took the courses, you got your degree and now you’re ready and eager to present basic services.

You have some degree of clinical confidence, but you know you need more hands-on practice. So you take an internship or get some practice in an established dental office.

WEBINARS

Where do you begin?

So then. How does a dentist fast-SDFH�LQWR�D��FRQÀGHQFH�OHYHO�WR�EH�DEOH�WR�VHUYH�WKHVH��SDWLHQWV"

CONTINUING EDUCATIONSEMINARS JUMP IN


Dr. Charles Kravitz received an early

admission to Temple University School

of Dentistry in Philadelphia after only

2 years of college pre-dental. He was

President of his Freshman class, and he

ranked eighth in his graduation class

of 120. He took the big step of opening

a solo dental practice directly upon

receiving his Doctor of Dental Surgery

degree.

He developed this practice into a five

dentist, three hygienist general dental

practice in Philadelphia.This office

became a showplace for practice

management and dental school

sources. It proved to be a training

ground for many of Philadelphia’s

future successful private practitioners.


There is always more to learn to become efficient and confident. And so it is with the practice of sleep medicine. From the accreditation seminar you will emerge with all the basics. You will be able to do a proper sleep apnea

screening, you will learn how to use all the equipment and how to work with a sleep physician,how to provide your patient with a correct oral appliance, how to make adjustments (titrate) and how to bill medical insurance and Medicare.

As you learned in the general practice of dentistry that there is so much further you can go after dental school, you will see how much more there is to learn about sleep medicine. The more you do it, the better and faster you become. The In-Office Training Program provides the confidence and efficiency to assure success.

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

ConclusionThe current need, and “buzz”, is in discovering, diagnosing and treating sleep apnea. It is reported that less than 4% of practicing Dentists are able to assist the more than 50 million people who suffer from sleep apnea. There is a growing public awareness of the hazards that come from a nocturnal stoppage of breathing. Your patients are becoming increasingly more concerned about the blockage of oxygen to the brain and other organs. As a Care Giver, think of how you can provide an underserved need.

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

Dental Sleep Medicine SeminarS

SGS is pleased to be offering the

most comprehensive selection of

dental sleep medicine seminars in the

industry. Treatment of sleep disorders

PZ�VUL�VM�[OL�MHZ[LZ[�NYV^PUN�ÄLSKZ�VM�medicine and recent developments

have put dentists on the front line.

With Obstructive Sleep Apnea reaching

epidemic levels in our society you have

a unique opportunity to save the lives of

those suffering while adding a valuable

service in your practice. Many dentists

are looking to branch out from

traditional dentistry because they are

either ready to try something new or

because the economy has forced them

to look for additional revenue streams

– Dental Sleep Medicine is the perfect

solution.

Our Seminars Include:��%DVLFV�RI�6OHHS��6LJQV�6\PSWRPV�RI�2EVWUXFWLYH�6OHHS�$SQHD��0HGLFDO�,QVXUDQFH�%LOOLQJ��6LPSOH�3URWRFROV��+RZ�WR�ÀQG�SDWLHQWV�LQ�DQ�H[LVWLQJ�SUDFWLFH��2YHUYLHZ�RI�DSSOLDQFHV�DSSOLFDWLRQV�RI�XVH��0DUNHWLQJ�\RXU�SUDFWLFH��+DQGV�RQ�RSSRUWXQLW\�WR�ZRUN�ZLWK�WKH�3KDU\QJRPHWHU� ��5KLQRPHWHU�GLDJQRVWLF�WRROV�

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The Fastest Growing Dental Treatment


The Power of Medical Billing

You might see the title of this article and think you are going to read about big numbers next to a dollar sign. While that might be the end result of my message, there is much more to it than that.

How important is it to you and your team for your patients to know that you are really going out of your way to help them? I’m hoping you’ll agree that when a patient believes that you are concerned with their financial welfare as well as their health, you will have a complying patient.

With the Sleep Group Solutions medical billing system you will help your patients give you that “Yes”

Take off your usual hat for a minute and imagine yourself as the patient…..not as the doctor or team member. Imagine yourself walking in to see your new dentist. A friendly and courteous front desk person greets you and welcomes you to the practice. After a short conversation, you are also welcomed with the following;

“Mr. Patient, we welcome you to our practice and we’d like you to know that we go out of our way for our family of patients. In that effort, aside from your dental insurance card, we’d like to ask you for your medical insurance card. Some of your treatment may be covered by medical insurance. If it is, medical coverage will reduce your out-of-pocket

expense and preserve your dental benefits for procedures not covered by your medical insurance.”

What did you just hear? Did you really just hear that this dental practice works with medical insurance? I propose, that as a patient, you’ve heard the power of medical billing in action. I propose you’ve heard that you have walked into the doors of a dental office that’s above and beyond what you might have expected. I propose you’ve heard something that you have never heard at a dental office before today. Most importantly, I propose you might be thinking that you are definitely in the right place! If you have added sleep medicine or CBCT to your practice, you are missing the power of medical billing unless your team is making this announcement to every one of your patients. Of course you can’t make this announcement unless

you can deliver on your promise. The power of medical billing can be harnessed only when your team has mastered successful medical billing protocols or when you’ve partnered with a strategic partner to outsource your medical billing. Now, please put your regular hat back on and assume your usual role as dentist or dental team member. What else can the power of medical billing mean to you? It can mean that your patients are more open to hearing about their treatment needs instead of missing some of the important details because they are so worried about how much it costs. It might mean that you are truly helping more of your patients to accept more of the treatment they require because your team is able to look into assisting them beyond the paltry limits of their dental insurance. It might mean that you are the dental team that truly is a cut above. So getting back to my original thought………I hope you’ve realized that the power of medical billing is much more than adding big numbers next to a dollar sign to your practice. I also hope you can see that we certainly can add those big numbers through the power of medical billing.

Dr. Marty Lipsey

The Sleep Magazine

The Sleep Magazine is the only publication 100% dedicated to Dental Sleep Medicine- The dental treatment of snoring and sleep apnea. The Sleep Magazine is

on its 6th issue, which contains patient education articles, case studies, oral appliance overviews, dental continuing education, technology and much more.

Subscribe to the Sleep Magazine

Subscribing to the Sleep Magazine allows you to stay current in the world of Dental Sleep Medicine. Experiencing a difficult case? Revert to past issues of case studies, or reach out to a contributing writer! You can subscribe online at: www.TheSleepMagazine.com

View all Issues online, at www.TheSleepMagazine.com , it’s FREE!

Find FREE CEU’s in the Sleep Magazine

Interested in Learning more about Dental Sleep Medicine? The Sleep Magazine refers the Sleep Group Solutions Intro to Dental Sleep Medicine course. Find a course at www.SleepSeminars.com


Special Considerations in Diagnosing OSA for WomenAccording to an article in the European Respiratory Journal, “Obstructive sleep apnea occurs in 50% of females aged 20-70 years. 20% of females have moderate and 6% severe sleep apnea.”

Swedish scientist Dr. Karl Franklin and his team set out to find out how prevalent sleep apnea is among women and how often symptoms occur. Out of a population-based random sample of 10,000 women between the ages of 20 and 70 years, they gathered data on 400 of them. The test group were given questionnaires which included several questions regarding their sleeping habits and sleep quality. They also underwent overnight polysomnography.

Women are Less Likely to be Diagnosed for Sleep ApneaWomen with sleep apnea are less likely to be diagnosed compared to men. In studies of patients registering for evaluation for sleep apnea, the ratio of men to women has sometimes been extremely lopsided, with 8 or 9 men diagnosed with obstructive sleep apnea (OSA) for each woman found to have (OSA). However, we know from studies in the general population that the actual ratio is likely to be closer to 2 or 3 men with OSA for each woman who has the condition.Women make up about 45 percent of sleep study referrals and most sleep studies are still done to screen for sleep apnea.

Why are Women Less Likely to be Diagnosed for Sleep Apnea?First, there is an unfortunate predefined notion of the make-up of a sleep apnea patient. The stereotype is a middle-age, overweight or obese male. Physicians may not be thinking of this OSA diagnosis when the patient is female. Second, women may present with slightly different symptoms than the “classic” symptoms of snoring, witnessed breathing pauses at night and excessive sleepiness during the day.

Diagnosing OSA in Women: The differences

continues on page 51

Kimberly Guzman

Instead, women may present with fatigue, insomnia, disrupted sleep, chronic fatigue and depression morning headaches, mood disturbances or other symptoms that may suggest reasons other than OSA for their symptoms. Because these symptoms are not specific for OSA, women may be misdiagnosed and are less likely to be referred to a sleep study for further evaluation. Another problem is that women with sleep apnea have more subtle breathing disturbances and are more likely to have REM-related apneas, so they may be tougher to diagnose.

Some Differences in Symptoms Between Men and WomenSleep apnea in females is related to age, obesity and hypertension but not to daytime sleepiness. The “classic” symptoms of OSA are snoring, witnessed apneas and daytime sleepiness, but women may not experience these things. Weight gain, depression, waking up gasping for breath, hypertension, and dry throat in the morning may be tip-offs for women that they may need an evaluation.

Kimberly is a dental practice trainer with Sleep Group Solutions, visiting dental practices from coast to coast training them in the effective use of sleep diagnostic equipment. She began her career with SGS as a Client Relations Manager and her fascination with the treatment of Obstructive Sleep Apnea and her desire to help those who suffer from it has led her to become an educator .Her services to dental teams include instruction and practice in the effective use of the pharyngometer and rhinometer.

“I was given the opportunity to travel with our VP John Nadeau and got extensive experience while participating in our seminars and our dental practice installs. It is so rewarding to help dental practices identify the many signs and symptoms of sleep apnea. Each week we produce 30 to 100 more dental soldiers to fight the battle against OSA. I can’t think of a better and more rewarding avocation.”

Kimberly is a Florida native, has a boyfriend in the US Navy, and says she loves spending time with her family and working out with her dog.


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

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

InstrumentationEccovision Acoustic Pharyngometer

SGS Manufactures and distributes the Eccovision Acoustic Pharyngometer system. The Pharyngometer device has become a “gold standard” tool used by

AboutSGS


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

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

Women who are obese, pregnant women, and post-menopausal women all have a greater risk for OSA. Finally, women with the endocrine disorder, polycystic ovary syndrome, are more likely to have sleep apnea even after controlling for weight and should seek clinical evaluation.

The Differences Between OSA and Hypertension in Women and MenObstructive sleep apnea is a significant risk factor for heart disease . The prevalence of hypertension in people with sleep apnea ranges between 30-70 percent and is similar in men and women. However, when taking body mass index (BMI) into consideration, some gender differences emerge: men with OSA who are markedly obese (BMI > 37) have a two-fold higher risk of hypertension than obese women with OSA.

The Differences Between OSA and Diabetes in Women and MenWomen with OSA tend to be more obese and have lower AHI than males; however, studies have also suggested that women may have a higher mortality. OSA is associated with an increased risk for the development of type 2 diabetes independent of obesity.Women who are obese, pregnant women, and post-menopausal women all have a greater risk for OSA. Finally, women with the endocrine disorder, polycystic ovary syndrome, are more likely to have sleep apnea even after controlling for weight and should seek clinical evaluation.

Common Sleep Apnea MisdiagnosesWomen are often diagnosed in error with one of the following conditions, rather than sleep apnea.

��Anemia��Cardiac or pulmonary illnesses��Depression��Diabetes��Fatigue from overwork��Fibromyalgia��Hypertension��Hypochondria��Hypothyroidism��Insomnia��Menopausal changes��Obesity

SourcesDr. Karl Franklin, European Respiratory Journal

Grace W. Pien , MD, MS, assistant professor of medicine, divisions of Sleep

Medicine and Pulmonary and Critical Care at the University of Pennsylvania

School of Medicine.

Nancy A. Collop , MD, medical director at Johns Hopkins Hospital Sleep

Disorders Center and associate professor of medicine at Hopkins’ Division of

Pulmonary and Critical Care Medicine in Baltimore, Md .

Fiona C. Baker, PhD, sleep physiologist, Center for Health Sciences, SRI

International, in Menlo Park, Calif.

Anita L. Blosser, MD, with Duke Primary Care at the Henderson Family

Medicine Clinic in Henderson, N.C.

continued from page 49


Instrumentation (cont’d)

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

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

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


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

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

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

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HOME SLEEP TEST

CPAP

Eccovision

Sleep Seminars

Oral Appliances

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

www.sleepgs.com

7th Issue 2015- The Sleep Magazine

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Transcript of 7th Issue 2015- The Sleep Magazine