Dentists are playing an expanding role in treating obstructive sleep apnea through oral appliance therapy. Oral appliances can effectively treat mild to moderate sleep apnea and are an alternative for patients who cannot tolerate CPAP therapy or prefer oral appliances to CPAP. Dental schools are beginning to recognize the importance of training dentists in dental sleep medicine so they can properly diagnose and treat sleep apnea patients.

1. e-supplement
Sleep disorders
and dentistry’s role

2. Dental Dental sleep medicine
sleep
more active and fulfilled lives, take fewer pills, and are less “Deciding to learn about and practice dental sleep medi-
likely to fall asleep while driving. Their minds function bet- cine is about becoming comfortable ‘switching hats’ and feel-
ter and they think more clearly, they control their weight ing excited about working in a different and new mindset,”
more easily, and have more energy to exercise and do the she said.
medicine
things they want to do,” Dr. Drake said. Dr. Katz said that many dentists who enter dental sleep
He said the most rewarding part about dental sleep medi- medicine are looking to try something challenging.
cine is helping to turn someone’s life around. Dr. Drake said These dentists must learn about other disorders in the
he was making an appliance for a gentleman who had his field, such as parasomnias, insomnia, and narcolepsy, in order
25-year-old son along at the appointment and learned that to know what they cannot treat with oral appliance therapy, as
the son had been in and out of school for years, was unable well as work closely with sleep physicians and other medical
to hold down a job for more than a month due to sleepiness, professionals.
Dentists treat obstructive sleep apnea patients with was taking meds for depression, and was living at home with Educational institutions have also started recognizing the
oral appliance therapy, expanding their practices his parents. importance of training dentists in DSM. Tufts University in
“We tested him for sleep-disordered breathing, and when Boston, Mass., launched the first Dental Sleep Medicine Pro-
by Emilee McStay the test came back and showed that he suffered from severe gram of its kind through the Craniofacial Pain, Headache,
sleep apnea, we made him an oral appliance,” Dr. Drake said. and Sleep Center, which is part of the Department of General
“Most people with OSA cannot achieve or maintain a “He wore it religiously, and a follow-up study confirmed that Dentistry.
deep, restorative sleep because every time they go into a it was treating his disease successfully. Two years later, he had Through the program, post-graduate dental students will
deep sleep, their airway collapses and they wake up to re- moved out of his parents’ house, held a part-time job, had receive both classroom and clinical instruction from experts
sume breathing,” she said. a girlfriend, was no longer taking anti-depression meds, and in dental sleep medicine. Students will work with a multidis-
Dental sleep medicine (DSM) focuses on the management was about to finish school.” ciplinary team of dentists, neurologists, chiropractors, physi-
of sleep-disordered breathing (SDB), which includes snoring Dr. Drake said that many dentists practice DSM because cal therapists, pain psychologists, occupational therapists, and
and OSA, with OAT and upper airway surgery. they enjoy helping people improve their lives and find it to be behavioral management therapists to help treat sleep-related
Dr. Pancer explained that OAT involves the customized financially rewarding and physically less demanding. breathing disorders, such as OSA.
selection, fabrication, fitting, adjustments, and long-term “Dentists are recognizing the benefit of adding DSM to “Tufts’ pre-graduate dental students have learned DSM
follow-up care of specially designed oral devices, worn dur- their practice,” Dr. Pancer added. “The AADSM has seen a course content for several years,” said Leopoldo P. Correa,
ing sleep, which reposition the lower jaw and tongue base 135% jump in our membership over the last five years.” BDS, course director of the Dental Sleep Medicine Section
forward to maintain a more open upper airway. Oral appli- Dr. Pancer said that when he learned about the AADSM in at Tufts Dental School.
e
ances (OAs) look similar to mouth guards, but should be se- 1996, it consisted of approximately 60 members, in contrast “Some of our students choose to incorporate DSM into
lected and fitted by a dentist trained in DSM to maintain to more than 1,600 members today. their practices upon graduation, while other students leave
unobstructed breathing while the patient sleeps. Despite the AADSM’s increase in membership, Dr. Drake Tufts with a better idea of how to identify patients who may
very night, an estimated 18 million Americans Once a patient is diagnosed with OSA by a sleep physician said that there is still a growing need for dentists qualified in have OSA and who should get tested at an accredited sleep
© Dreamstime.com
stop breathing for 10 to 30 seconds, sometimes at an accredited sleep center, he or she may be referred to a DSM because sleep physicians have difficulty finding a den- center,” said Dr. Correa. “By offering a hands-on post-gradu-
for a minute or longer, hundreds of times as they dentist or oral and maxillofacial surgeon for OAT or upper tist to whom they can refer their OSA patients. ate course, in addition to the course content in our pre-grad-
sleep. These men and women suffer from obstruc- airway surgery. Dr. Drake said that the number one reason dentists shy uate and continuing-education programs, more students will
tive sleep apnea (OSA) and, if left untreated, are at a higher “Approximately 25% to 50% of patients with OSA are away from practicing DSM is that they don’t understand it gain the skills and in-depth experience they need to integrate
risk for excessive daytime sleepiness, high blood pressure, unable to comply with Continuous Positive Airway Pressure and don’t take the time to educate themselves. He recom- DSM into their practices.”
heart attack, stroke, diabetes, obesity, and driving accidents. (CPAP), the standard treatment therapy, or do not tolerate mends that dentists take advantage of the mentorships, study Dr Correa said that post-graduate students and residents
“The American Academy of Dental Sleep Medicine it, leaving a large population of untreated OSA patients for groups, peer-reviewed journals, and introductory courses will participate in patient assessment, polysomnogram inter-
(AADSM) tries to make it as easy as possible for OSA pa- whom dentists can offer a much-needed service,” Dr. Pancer available through the AADSM to learn more about OAT. pretation, and the use of ambulatory sleep study monitors
tients to receive safe and effective treatment,” said AADSM said. Dr. Pancer added that dentists who have experience in when titrating oral appliances. The students will be trained
President, Jeffrey Pancer, DDS. The American Academy of Sleep Medicine has published DSM can take advanced courses in OAT or sit for the Amer- in selecting, fitting, and adjusting the dental devices used to
OSA patients can use the find-a-dentist feature on the practice parameters stating that OAT is indicated for treat- ican Board of Dental Sleep Medicine (ABDSM) exam. He treat OSA and understand the potential limitations and com-
AADSM’s Web site (www.aadsm.org) to search for dentists ment for those patients with mild to moderate apnea if they said that the diplomates of the ABDSM represent the highest plications of these devices.
in their area who practice dental sleep medicine (DSM) and prefer it to CPAP, or if they cannot tolerate CPAP, or if they level of education and training in DSM. “I think that in 10 years, DSM will be incorporated into
read more information about oral appliance therapy (OAT). are unable to use positional therapy or weight loss to control Established in 1991, the AADSM hosts an annual meeting, every dental school and that learning OAT will be a require-
AADSM President-Elect Sheri Katz, DDS, said that their apnea. OAs are also recommended for severe patients if offers educational courses for dental students and practicing ment for every dental student,” said Dr. Correa. “Dentists
when patients have OSA, they may feel like they are sleep- they are unable to tolerate CPAP. dentists, distributes cutting-edge information through peer- trained in DSM offer huge benefits to their patients and so-
ing a proper number of hours, but the quality of their sleep According to Richard Drake, DDS, who has specialized reviewed publications, pamphlets and DVDs, and establishes ciety.”
is often poor. in DSM for seven years and taught AADSM courses for four and maintains appropriate treatment protocol.
years, successfully treating OSA can reverse nearly all of the Dr. Katz said that practicing DSM requires dentists to Emilee McStay is the public relations coordinator
For more on this topic, go to www.dentistryiq.com and ill effects the disease may have on a patient. broaden their scope of knowledge to understand the field of for the American Academy of Dental Sleep
search using the following key words: sleep disorders,
“Patients better control their high blood pressure and sleep in general and the pathophysiology of OSA in addition Medicine. Contact her at (708) 273-9366,
obstructive sleep apnea, oral appliance therapy, sleep medicine.
diabetes, are less tired and sleepy, and therefore tend to lead to their skills as a dentist. emcstay@aadsm.org, or visit www.aadsm.org.
July 2011 | www.dentistryiq.com www.dentistryiq.com | July 2011

3. Sleep-disordered breathing: It’s not just a medical problem
Sleep-disordered breathing: tion that results in maximum patient comfort and efficacy. To learn more, I highly recommend attending the Den-
It’s not just a medical problem It passively allows the tongue to assume a forward posi-
tion conducive to better airway patency.
Sleep dentistry is professionally gratifying and may
tal Sleep Medicine Seminars by Dr. Allen Moses at Wil-
lis Tower (formerly known as Sears Tower) in Chicago.
Dates are August 26-28 and November 11-13. For more
by Dr. John T. Herald be financially rewarding. However, one must always re- information about The Moses or Dr. Moses’ seminars
member that we are treating a potentially deadly medi- visit www.themoses.com or contact Ashley Truitt, Direc-
THE HOTTEST TOPIC IN DENTISTRY at the moment contraction. Clenching of the muscles of mastication po- cal disorder, which happens to have a dental alternative tor of Dental Sleep Medicine for The Moses at ashley@
is Oral Appliance Therapy (OAT) for sleep apnea and tentiates the pharyngeal dilator muscles to help open the therapy. You will be held to the usual medical standard, moderndentalusa.com and (940) 395-4555.
primary snoring. The treatment of sleep apnea is para- non-patent airway. Tremendous forces are placed on the not the dental standard. Diagnosis is paramount. Always
mount to our nation’s health, especially due to its relation- teeth to facilitate this open airway. These forces may be have a diagnosis prior to treatment and verify objectively John T. Herald, D.D.S. lectures nationally and internationally
ship to hypertension, hyperlipidemia elevated A1C (insulin responsible for non-traumatic TMD, loosening of teeth, your results. There is never any excuse for not obtaining a about sleep-related pain and neuromuscular dysfunction. Dr.
resistance), and obesity. Hundreds of research articles year- fracturing of cusps, abfractions, and abnormal wear. The home sleep test that is read and interpreted by a qualified Herald has used oral appliances to treat sleep
ly detail the millions of dollars, if not billions, that could be body will enlist whatever mechanism available to survive. sleep specialist, or referring a patient for a polysomno- disturbances and related dental and medical
saved by the successful treatment of this disorder. It has been my experience that many dental problems and gram (PSG) overnight sleep study. problems since 1982. Dr. Herald is a found-
There are many oral appliance designs FDA cleared restorative failures often occur due to Sleep Disordered Many physicians feel that the dentist is the vanguard ing member of the Academy of Clinical Sleep
for the treatment of snoring and obstructive sleep apnea. Breathing (SDB). for diagnosis and treatment of this disorder. If you’re in- Disorders Disciplines and is also a Member of the
A key attribute to the design of a successful oral appliance Thousands of years ago, man developed the ability to terested, get in the game but know the rules. Your team American Academy of Dental Sleep Medicine.
is allowing maximum intraoral space for tongue posture speak. Residual components of our past still exist. For will also play a large part in the successful implementation Dr. Herald graduated from Case Western
and position, which includes a vertical and protrusive ele- the first 18 to 24 months, babies can breathe and swallow of Dental Sleep Medicine into your practice. I encourage Reserve University and is a member of the American Dental
ment. simultaneously. Afterwards, the uvula migrates cervically you to educate and involve your team as much as possible. Association and Ohio Dental Association.
In Phase 2 sleep, which makes up about 50 percent of and the epiglottis caudally. That short distance becomes
the normal sleep cycle, the brain turns off the highest a collapsible tube where most of our vowel sounds are
functioning recognition because the brain needs its rest. formed. It also is non-cartilaginous and prone to collapse.
Only essential body functions, heart rate, oxygen satura- Our body also provides us with several “hard wired”
tion, CO2 monitoring and other functions generally as- neuromuscular reflexes, the most important being the
sociated with the autonomic nervous system are vigilant. jaw-tongue reflex. Opening the jaw several millimeters
During a partial or full collapse of the airway, the body allows the tongue to reflexively reposition anteriorly. Tak-
produces large amounts of adrenalin to facilitate muscle ing advantage of this reflex is the single-most important
mechanism available to those who treat SDB with OAT.
The tongue is a hydrostat (mostly muscle and water)
that can change form but not mass. If given the oppor-
tunity, the tongue much prefers to be in the oral cavity
and not in the throat. Successful OAT requires that there
be maximum space for the tongue to move forward and
upwards. The key is providing room for the tongue to
reflexively move more forward than the mandible.
The newest and most
unique appliance on the
market that takes ad-
vantage of these reflexes
is The Moses™ device
(right), which perhaps
has the most tongue
space of all. It is designed
to be low-profile lingual- ®
ly, providing adequate
room intraorally, is ti-
tratable (adjustable) and
About the MediByte (above): Dentists can obtain top-down treatment
control of sleep dentistry by combining The Moses with the MediByte allows for full lip seal to
from BRAEBON. The MediByte is a convenient, accurate, and comfortable facilitate nasal breathing.
home sleep test device for patients suffering from snoring and/or sleep Oral appliances provide an exoskeleton to support pro-
apnea. Patients are sent home with the MediByte, they then conduct an trusion and vertical opening, thereby maximizing tongue
overnight home sleep test. Home Sleep Delivered then has one of its board-
certified sleep doctors interpret the results and posture and position. The innovative open anterior de-
send it back to dentists in days. sign of The Moses accommodates a forward tongue posi- DIQSam12h_Dntl_110331 1 3/31/11 2:47 PM
July 2011 | www.dentistryiq.com www.dentistryiq.com | July 2011

4. Dentists play important
role in treatment of
patients’ sleep disorders
by David P. Schwaber, DDS, ABDSM
A
s a dentist who has worked with
physicians for more than 12 years
in the treatment of people who
snore and suffer from sleep apnea,
I recognize that the dentist’s role
in helping those patients has become increas-
ingly important.
The medical problems associated with sleep
disordered breathing have been well studied and
documented. Hypertension, cardiovascular prob-
lems, and impaired cognitive functioning are but a
few of the possible health consequences. Untreat-
ed patients with sleep apnea can put themselves at
risk for increased morbidity and mortality. Public
awareness has improved, but unfortunately many
people still go undiagnosed.
Oral appliances, which are worn in the mouth
like dental retainers, have proven to be a comfort-
able and effective choice for patients who have
the symptoms of sleep apnea, such as tiredness,
snoring, and poor sleep. Many patients who are
unwilling or unable to use CPAP machines have
benefitted from using oral appliances, which have
been recommended by the American Academy ©
dreamstime.com
of Sleep Medicine in the treatment of OSA, ob-
structive sleep apnea. be returned to the office the next day. The results are downloaded
First, patients who have already been diag- into a computer program that provides feedback on apnea, hypoxia,
nosed by their physicians with a sleep study called and blood oxygen levels. With this information, further adjustment
a polysomnogram are referred to the dentist for of the appliance can be made if needed. A follow-up study by the pa-
evaluation. Our examination includes a sleep his- tients’ sleep center is always recommended.
tory and a complete exam of the upper airway and
dentition. A discussion regarding the different Dr. David Schwaber is a graduate of the University of Tennessee College of
types of oral appliances follows with an explana- Dentistry. He has studied orthodontics at the Institute for Graduate Dentists
tion of how they are designed to work. Patients and has a diplomate accreditation by the American Academy of Dental
who wear oral appliances often report improved Sleep Medicine. As a consultant to the Hospital of Central Connecticut and
comfort because they are able to sleep in any po- other Greater Hartford sleep centers, he has presented numerous lectures to
sition without using the cumbersome facial masks physicians and patient groups in the field of dental sleep medicine. His infor-
and hoses associated with CPAP. As the appli- mational Web site on dental sleep medicine is www.ctsleepdentist.com.
ances are titrated and adjusted over a period of
weeks, the dentist will often provide the patient Special thanks to Irfan Ali, dental sleep technician/consultant at CT
with an overnight at-home sleep monitor that can SleepDentist.com. Contact him at irfancda@gmail.com.
July 2011 | www.dentistryiq.com

5. Sleep apnea and the search for a solution through
dental-medical collaboration
I have had a personal experience with sleep apnea. My fa-
by Larry Twersky
materials that promote sleep apnea treatment such as OAT.
ther was an undiagnosed sufferer. Growing up, I remem- Regarding the educational opportunities he and his staff
ber him coming home from work and going straight to the have taken advantage of with 1-800-Snoring, Dr. Steven
couch to sleep instead of playing with my siblings and me. Greenman, in Westlake Village, Calif., says, “Once my team
Not having quality time every day is hard on a family. I def- and I learned how to identify and talk to the people coming
initely feel as though I missed out on having a stronger re- into the office with snoring and OSA problems, I have begun
lationship with my father because of this condition. Tooth to see dramatic results in both the lives and marriages of the
issues, such as decay, affect only one person, but snoring patients I am helping and the profitability of my practice.”
and sleep apnea affect entire families. Besides health conse- Dr. Eric Johnson, in Torrance, Calif., says, “1-800-Snoring
quences, these conditions can damage marriages, relation- is the best marketing investment we’ve made to date! We’ve
ships, and work performance. My goal is to educate people used many other mediums such as newspaper, health expos,
about sleep apnea and the options available to get help. Internet, but nothing has worked as quickly and as effectively
There are four ways to solve a sleep apnea problem: lose in bringing us new patients as 1-800-Snoring. No doubt about
weight, CPAP therapy, surgery, and oral appliance therapy it ... the business model works ... the experts at 1-800-Snoring
(OAT). For those whose apnea is not weight-related, that really know what they’re doing in terms of targeting our au-
leaves CPAP therapy, which many find to be intolerable, or dience and bringing us qualified patients. And, the additional
surgery, which is painful and only 50% effective. Unfortu- staff education and coaching is above and beyond!”
nately, most ENT specialists and cardiologists are unfamiliar As of today, 77% of those suffering from OSA are un-
with the success of OAT in treating sleep apnea; therefore, diagnosed. To put that number into perspective, 18,000 of
they only recommend CPAP, leaving many patients without the people who attended this year’s Indy 500 have undiag-
a choice. This is why both the general public and the medi- nosed OSA. That is a staggering number. This condition
cal community need to know that oral appliance therapy is can lead to fatal health issues such as high blood pressure,
FDA-approved and has been proven to be highly effective heart failure, stroke, and diabetes.
in cases of mild to moderate and certain cases of severe ob- Many patients don’t think their snoring or sleep apnea
structive sleep apnea (OSA). OAT is the only therapy offered problem is their problem. Treating snoring and sleep apnea
— other than surgery — when CPAP cannot be tolerated. is markedly different than performing standard dental care.
In the beginning, 1-800-Snoring was established with- In “regular” dentistry, patients call because they are in pain or
in the 1-800-DENTIST company to inform people that don’t like something about their teeth. With OSA, patients
OSA is a dangerous disease both physically and emotion- commonly call in because a spouse or significant other is
ally. The company has three distinct goals: bugging them ... because someone else is having a problem.
• To provide patients suffering from sleep apnea access We have to talk to patients who suffer from sleep apnea in
to effective, compassionate, and noninvasive treatment a way that makes them understand that the condition is not
from highly qualified dental sleep medicine providers just annoying to the spouse, but it’s a potentially fatal condi-
• To provide members with the marketing, education, tion — all without scaring them off. My team and I resolved
and support they need to be quality doctors to whom we this issue by adding a more personal touch to how we take
would want to send our friends and family for treatment phone calls. Our operators ask questions about the patient,
• To offer a cooperative marketing program so members find out the nature of his or her condition, and then refer the
can benefit from the full potential of our advertisements in patient to a provider who would be the best fit. By the end
their geographic areas of these types of calls — without dispensing medical advice,
Sleep apnea is a big picture condition, so we search for yet educating them about their condition and assuring them
doctors who are capable of seeing the whole issue and who regarding treatment options — patients will understand that
are willing to work with the medical community to provide a snoring and sleep apnea are dangerous, and that they are do-
total solution. We offer training and educational opportuni- ing the right thing by getting help.
ties for our members both in-person and over the Web. Our I have always found that when you do things exception-
range of continuing-education topics help members of the ally and for the right reason, the rewards are the greatest
dental and medical communities set up their practices to ac- and success comes in abundance. Today, it is about getting
commodate snoring and sleep apnea patients, recognize the things exceptionally right.
signs of these conditions in existing patients, and even how
to do medical billing. Every member of 1-800-Snoring pays Larry Twersky is the former president of 1-800-Dentist and the cur-
a monthly fee. We use that money to run ads and send out rent CEO and founder of 1-800-SleepMed and 1-800-Snoring.
July 2011 | www.dentistryiq.com