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Short Presentation - Managing Obstructive Sleep Apnea with Oral Appliance Therapy

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MJ Glass

on 14 September 2013

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Transcript of Short Presentation - Managing Obstructive Sleep Apnea with Oral Appliance Therapy

Why Treat OSA
79% of Loud Snorers have OSA (often undiagnosed and Dx may be 1° snoring)
OSA Takes 8-10 years off patient’s life.
Smoking takes 7-10 years off patient’s life.
Diabetes takes 5-10 years off patient’s life.
OSA increases risk of death 43%.
OSA pt 12x more likely to be in Auto Accident:
Tired driving #1 killer – MORE THAN Alcohol Related Deaths
50% of all MVA’s are due to too little sleep
35% of FATAL MVA’s are due to too little sleep
Atlas OMS Surg Clin N. Am., 15 (2007)
Atlas OMS Surg Clin N. Am., 15 (2007)
Managing Obstructive Sleep Apnea with Oral Appliance Therapy
In 2006 it was recommended by the governing and credentialing bodies of sleep that dentists fabricate oral appliances as a first line treatment for mild to moderate OSA.
The days of a dentist saying “I made my patient a snore guard” are over!
Physicians don’t toy with OSA treatment, dentists shouldn’t either. Making an appliance and patting the patient on the back in hopes that it stops their snoring is no longer the standard of care!
Dentists should be responsible for educating themselves and treating to the medical standard. Dentists are the first line of treatment!
Apnea: “Without Breath”

Sleep Apnea: Without breath – during sleep

Obstructive Sleep Apnea: Breathing stoppage caused by mechanical obstruction of the airway

Central Sleep Apnea: Breathing stoppage caused by neurological condition
Why is high blood pressure a symptom? – Two reasons
There is a sympathetic (emergency) response in the body every time an apnea or hypopnea occurs.
Heart rate and blood pressure increase
OSA Patients have hundreds of events per night, thus the body remains in a constant state of elevated blood pressure.
Because the body is not getting sufficient oxygen, it is not converting enough into nitric oxide.
Nitric oxide is a vasodilator, without nitric oxide blood vessels narrow.
The endothelial lining of the arteries breaks down, making them more susceptible to plaque and fatty tissues building up.
Narrow arteries with high risk of blockage = High Blood Pressure, heart attack and stroke.
OSA increases hypertension risk by 45%
In the Practice Parameters Report published in Sleep, Vol. 29, No. 2, 2006, the American Academy of Sleep Medicine makes the following recommendation: "Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. Until there is higher quality evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA before considering OAs. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the over- all care of oral health, the temporomandibular joint, dental occlusion and associated oral structures."
S.T.O.P.
Do you
S
nore?
Are you often
T
ired?
Anyone
O
bserve you stop breathing during sleep?
Do you have high blood
P
ressure?

High Blood Pressure (45%)
Strokes and other cardiovascular issues
GERD
Headaches (migraine corelated to decrease in REM and Delta sleep cycles, cluster & dull morning headaches relate to Increase in O2 desaturation)
Diabetes
Sexual Dysfunction
Psychological, social, familial and work related sequelae


Alzheimer’s Disease
Dementia
Multiple Sclerosis
Acceleration of Atherosclerosis
How can the Dental Community and the Medical
Community work together to help manage Obstructive Sleep Apnea?
Common Screening Guides:
Epworth
Berlin
S.T.O.P. - B.A.N.G.
American Sleep Association Sleep Disorder Screening Questionnaire
Devise your own screening questions
Ask if the patient has ever had a sleep test done
Most commonly accepted types of overnight sleep studies:
Polysomnogram (PSG)
Home Sleep Study
Types of Overnight Sleep Studies
Polysomnogram (PSG):
In lab
Considered most comprehensive
Most amount of Data
Most tests use similar protocols and derive similar data
Patients don't always accept sleeping in unfamiliar surroundings
Much more expensive
Insurance companies are starting to prefer alternative studies
Some geographic areas difficult acess
Options for the CPAP Intolerant or non-compliant patient and Co-Therapy (combined Medical and Dental therapies)
Neck Size, Shape
and Position
Oral Cavity and Pharynx
(Mallampatti, Tonsils)
Intra-Oral Appliance
OPAP: A special adaptation of OAT and CPAP
Patient with History of Massive Facial Trauma
As a result of a motor cycle accident the patient has had a series of facial surgeries.
The patient was being treated for OSA with CPAP prior to the accident.
As a result of the surgeries he was unable to wear any devices that touched his face.
He was recieving no support for OSA with an AHI above 70. He could never stay awake and he could never sustain sleep for any length of time all day and all night long.
An oral appliance was fabricated that hooked directly to his PAP air supply. The patient was able to modify the humidity and pressure to his comfort and to acheive effective therapy. This is an example of Co-Therapy with medical and dental management working together!
The most rewarding words were on his first post op appointments when he reported
"Doc - I can dream again!"
OSA can only be diagnosed by a
sleep study

interpreted by a qualified
physician
Home Sleep Study:
Patients find it more comfortable and less intimidating
Often easier to order and administer
More limited in comprehensive data obtained
Derived Data depends on which test is taken
More cost conservative
Insurance Companies are often prefering this method
Excellent for titration study for appliance effacacy
Connected to PAP air supply (humidified
and pressure controlled)
Common Screening Guides:
J.P.
47
5'6
330#
133/82
20.5
53
17
Loud
Yes
Yes
BiPolar, Depression, DM (Type II)
Yes
12.3
12.5
Patient
Age
Height
Weight
BP
Neck
BMI
Epworth
Snore
Daytime Tired
Observed Apnea
Co-Morbidities
TMJ
AHI
RDI
Why is there need to manage OSA
OSA has an investigative relationship to:
OSA has DIRECT causative relationships with:
(cc) image by anemoneprojectors on Flickr
M.H.
56
5'8"
125#
111/75
14
19
12
Loud
Yes
Yes
Thyroid
No
10.7
15.1
Patient
Age
Height
Weight
BP
Neck
BMI
Epworth
Snore
Daytime Tired
Observed Apnea
Co-Morbidities
TMJ
AHI
RDI
R.W.
50
5'10"
190
102/71
17
28
18
Very Loud
Yes
Yes Frequent
Motorcycle Accident, nearly fatal. Multiple facial surgeries.
Mild Symptoms
74.7
81.6
Patient
Age
Height
Weight
BP
Neck
BMI
Epworth
Snore
Daytime Tired
Observed Apnea
Co-Morbidities

TMJ
AHI
RDI
David Rawson, DDS
Acess to Medical Care (PSG's) in Canada by province
Acedmy of Clinical Sleep Disorders Disiplines
Efficacy of an adjustable OA and comparison
with CPAP for the treatment of OSAS
Holley A.B. et al., Chest 2011;140(6) 1511-16

Effectiveness of OSA Therapy:
A Randomized Parallel Trial of OA vs CPAP Therapy
Aarnoud Hoekema
Doctoral Thesis

Evaluation of Variable Mandibular Advancement
Appliance for Treatment of Snoring and OSA
Jeffery Pancer DDS
Victor Hoffstein MD
Chest Vol. 116, Dec. 1999

Its not all perfect, there can be some complications with mandibular advancement Therapy.
POSSIBLE COMPLICATIONS: Some people may not be able to tolerate the appliance in their mouths. Also, some individuals will develop
temporary_adverse side effects such as excessive salivation, sore jaw joints, sore teeth and a slight change in their "bite". However, these usually
diminish within an hour after appliance removal in the morning. On a rare occasion, a permanent "bite" change may occur due to jaw joint Changes
and/or tooth movement. Generally, this can be prevented with the exercise bite tabs or other techniques you will be shown. These complications may
or may not be fully reversible once appliance therapy is discontinued. If not, restorative, orthodontic, and/or surgical treatment may be required for
whiCh you are responsible. Oral appliances can wear and break. The possibility that these or broken parts from them may be swallowed or aspirated
exists. For patients with sleep apnea, the device must be worn nightly. Discontinuation of use is a hazard to your health and can lead to a heart
attack, or stroke, and even death. See your prescriber before discontinuing use and for recommendations of alternative therapy such as CPAP
and/or surgery.

Intolerable in mouth
Excessive salivation
Sore TMJ
Sore teeth
Change in bite
COMPLICATIONS MAY BE:
temporary (daily)
More permanent (may need further treatment)

Treatment is ALL researched based
Pre-Treatment Informed Consent
Options for treatment of OSA:
PAP; C, Bi, A.
Surgery; UPPP, Pillar, Mandib Advance, Tongue Position, Tonsil, Nasal, etc.
Sleep position, hygiene, weight loss, smoking cessation, etc
ORAL APPLIANCE THERAPY (may include Orthodontic Treatment as well)
Tongue Retaining Devices
Full Breath Solution
Orthodontic Devices (Appliance or Braces)
Many, many more!
Appliances should be FDA CLEARED
AM Positioner for all appliances
My History with Obstructive Sleep Apnea and
why I am so pasionate about this treatment.
PAS Normal = 11mm
Restricted in OSA
MP-H Normal = 15mm
Longer in OSA
MP-H
PAS
MP-H
My History with Obstructive Sleep Apnea and
why I am so pasionate about this treatment.
B.A.N.G.
BMI
Over 30
AGE
Over 50
Neck
Over 17 Males, 15 Females
Gender
Male
Full Breath Solution

Member of:
The Academy of Dental Sleep Medicine (A.A.D.S.M.)
The Academy of Clinical Sleep Disorders Disciplines (A.C.S.D.D.)
American Dental Association
Academy of General Dentistry
Arizona Dental Association (CADS)
Certified Trainer – Dental Writer Certified Training Network

Michael J. Glass, D.D.S.
Managing Obstructive Sleep Apnea
with Oral Appliance Therapy

Today's Dental
10850 South 48th Street
Phoenix, AZ  85044
    Office: (480) 893-CARE (2273)
     Fax: (480) 496-9363
michael@todaysdental.com
SmileDoc111@aol.com
Starting AHI 84.8 in 2009

OAT AHI 8 in 2013

Sleep Study (HST)
With Oral Appliance in Place

Cricomental space
In order to remain compliant with medical insurance requirements, Oral Appliance Therapy for Obstructive Sleep Apnea must be medically necessary and prescribed by a Medical Provider on their own prescription order form.
Please provide a separate prescription on your own prescription form with the following information:

1)Rx: Oral Appliance Therapy for Obstructive Sleep Apnea
2)Your NPI #
3)Dx Code: (ICD-9): 327.23
4)Procedure Code (CPT): E0486

Medicare Requirements:
Sleep Study ordered by Medicare Provider
Patient having had a 99214 60 minute face to face visit with medicare provider physician
A copy of the medical chart maintained with the DME providers records
Full transcript