Beyond Bruxism

Beyond Bruxism

Measuring How Treatment Can Impact Airway

One of the most common dental diseases is bruxism, which research suggests may affect nearly one in every three patients. It’s time to start paying attention to bruxism for a number of reasons, especially because your treatment may be exacerbating other medical conditions. The most common treatment for bruxism is to create a bruxism appliance for the patient. Many dentists fall in love with one type of bruxism appliance and they use it for all of their bruxism/temporomandibular disorder patients. The patient goes home with said appliance, and the prescribing dentist hopes the patient’s condition will improve. Sometimes the condition does get better, sometimes it doesn’t, and, other times, the appliance just doesn’t make much of a difference.

Beyond Bruxism
Beyond Bruxism

I want you to consider this: Would you treat periodontal disease without a periodontal probe? Would you treat caries without taking a radiograph? Would you place an implant without doing any diagnostics? Of course you wouldn’t—because you can’t treat what you can’t measure. Bruxism has been the exception to this rule because, in the past, we have not had the ability to measure for bruxism. With modern advances, however, we now are able to measure bruxism and use this data to provide better bruxism treatment.

Measuring more than bruxism

 With advancement in the areas of bruxism and dental sleep medicine, dentists now have the capacity to objectively and effectively collect data to measure bruxism and, at the same time, obstructive sleep apnea (OSA) in their patients. The

STATDDS™ Bruxism and Sleep Monitor is worn by patients at night while they sleep. This effective home test costs less than $20 to administer. The software that comes with the monitor is made specifically for dentistry. It analyzes the testing data and provides the dentist with a simple to understand report that highlights the patient’s bruxism episodes index (BEI) and the apnea/hypopnea index (AHI). The BEI measures the number of bruxism episodes per sleep hour, while the AHI measures the number of apnea-hypopneas per sleep hour. These numbers provide us with the data we need to determine how often and how intense a patient’s bruxism is. Let’s take a look at the two main data indicators, the BEI and AHI numbers. We use the rule of 5 when looking at these numbers. If the BEI is greater than 5, the patient has clinically significant and destructive bruxism, which needs to be addressed not only with an appliance but also perhaps with restorative dentistry, whether via crowns, bridges, implants, etc. If the AHI is above 5 and less than 30, then either a CPAP or mandibular advancement appliance for OSA needs to be considered as primary therapy. An important note is that OSA is a medical condition that requires a diagnosis by a physician. As a dental professional and primary provider, I am able to discuss the patient’s bruxism with his or her physician, and following a medical diagnosis of OSA, I can take care of both conditions with the right appliance.

Nox T3 by CareFusion
The STATDDS™ Bruxism and Sleep Monitor can be used by patients for
overnight home testing.

Reviewing a case presentation

With the advent of new technologies, bruxism treatment plans now can be data-driven and not such a guessing game. In addition, we as dental professionals now can test and evaluate our treatment so that we can make the proper adjustments if necessary. In this way, dental professionals can get the best possible therapeutic outcomes by objectively knowing whether our treatment is working or not. We also will be aware if our bruxism treatment is affecting the patient’s airway—which involves the area of sleep medicine, specifically dental sleep medicine. Let me share with you a case presentation by my colleague, Robert W. Renger, DDS, which he was gracious enough to share with me. This case is an excellent example of why it is vital to test every patient in your office, and it demonstrates how you can use this testing data to help treatment plan a patient, allowing you to provide the best care possible. Dr. Renger had made one of his patients a popular anterior plane appliance approximately two years ago for severe bruxism. After being trained in the use of the STATDDS Bruxism and Sleep Monitor at a combined bruxism therapy/dental sleep medicine course, Dr. Renger wanted to objectively evaluate whether the appliance he made was appropriate and effective for this patient when he came into the office for a recall appointment.

Let’s take a look at the STATDDS monitor’s initial home bruxism and sleep test report results from when this patient was wearing the appliance. The patient has a BEI of 4.7, which means the patient has some bruxism activity in his muscles even while wearing the appliance; however, the number is less than 5, so it is acceptable. From a bruxism standpoint, the appliance is effective. Now let’s look at the AHI number, which tells us about the patient’s airway and OSA. At 19.4, the AHI is a very worrisome.

Let’s analyze this case as if we were the treating dentist. The provided appliance is working for bruxism, but it may be causing or exacerbating the patient’s OSA. I can personally tell you that, in my more than 35 years of dental practice, I have never seen a patient die of bruxism—but they can die of complications related to OSA. This report clearly indicates that this anterior plane appliance is not only inappropriate for this patient, but it may be potentially dangerous.

“A bruxism appliance that closes the airway and makes a patient’s OSA worse will constantly disrupt their sleep and worsen their overall health.”

As the treating dentist, Dr. Renger then decided to use the STATDDS monitor to test this patient again without the overnight anterior plane appliance. The BEI was now 15.8, while the AHI was 9.5. There is no question that this patient is a very destructive bruxer, and this should be addressed. However, it is clear that the patient still exhibits an AHI greater than 5, and he has OSA—a diagnosis that was confirmed by the patient’s physician. Based on this patient’s data, the treatment choice was now clear to Dr. Renger. Upon consultation with the patient’s physician, a mandibular advancement device—that doubles as a bruxism appliance—was selected for this patient. It is important to note that not all oral appliances for dental sleep medicine are appropriate for bruxers, and training is needed to understand which appliances best fit each clinical situation based on the obtained data. Dr. Renger provided me with additional testimony on this case:

“I just thought I would forward you these two airway EMG [electromyography] reports, which I found very interesting. I took abruxism and dental sleep course, and I’m very glad I did. You showed a result similar to this one in the course I attended, but I can’t believe the quantitative difference in this patient. This patient had been wearing a NTI-type anterior appliance I had made for him a year or two ago for severe bruxism. I was so happy to see how well I had helped his bruxism, and then I saw what it was doing to his airway. He had undiagnosed mild OSA, which was made significantly worse with the appliance. I hate to think how many dental patients are experiencing this phenomenon worldwide. We do indeed have so much more to learn in dentistry….”

 Dr. Renger’s experience shows just how important measuring for bruxism and OSA can be. So, before you make another “bruxism appliance,” consider its possible impact on OSA. With education, medical partnerships, and new testing devices, you can improve your treatment plan and raise patient care to an entirely new level, ensuring the best therapeutic outcomes for the patient’s dental and medical conditions.

This article was previously published in:

AGD Impact | www.agd.org | February 2015

Louis Malcmacher

Louis Malcmacher

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE). You can contact him at 800 952-0521 or email drlouis@FacialEsthetics.org Go to www.FacialEsthetics.org where you can find information about live patient Frontline TMJ/Orofacial Pain training, Dental Implant Training, Frontline Dental Sleep Medicine, Bruxism Therapy and Medical Insurance, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter.

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www.silencerproducts.com

Documentation of Bite Change in Oral Appliance Therapy

To Serve and Protect

The debate on whether or not there is a place in the practice of sleep medicine for oral appliance therapy is long over.  The goal of oral appliance therapy, as with other modalities in health care is to “serve” the needs of our patients as well as “protect” them from the threats to health that come as a result of sleep disordered breathing. As “sleep dentists“ we have ventured out from our usual and customary dental roles into a field of medicine. What protection does the sleep dentist need, and protection from whom?

A fact of life for the sleep dentist is the statistical probability of tooth movement and bite change.

The “sleep dentist” will be routinely treating the patients of other dentists.  Is the patient’s regular dentist informed as to the relative benefits of a life saving therapy vs the potential oral changes that may become involved?  If not, then what may be that dentist`s reaction to a substantial bite change that may or may not have challenged some restorative procedures over which that general dentist may be very sensitive?  Is that dentist likely to be “friendly“ when called by the patient`s lawyer?  It would be folly to believe that everyone in the sand box is our friend.  It is not enough to seek shelter behind the fact that MAD is a therapy for a serious life threatening medical condition – ”Get over it” is not a good answer!
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Wayne Halstrom

Wayne Halstrom

Dr. Halstrom graduated from the University of Alberta with his D.D.S. in 1960, after obtaining his B.A. from the University of Saskatchewan in 1956. He maintained a prosthodontic / general practice in North Vancouver, B.C. from 1961 to 1991. Since 1991, Dr. Halstrom has limited his practice to the treatment of Snoring and Sleep Apnea. He is the Past-President of The Canadian Dental Association (CDA) and The Association of Dental Surgeons of British Columbia (BC Dental Association). He has served as a member of the Board of Governors and a Director of the CDA. Currently an Adjunct Professor, Respiratory Therapy at Thompson Rivers University, Dr. Halstrom has also served with the University of British Columbia as a part-time clinical instructor in the Department of Prosthodontics at various times over the years. Prior to his position of Diplomate of the American Board of Dental Sleep Medicines, he was a member of the Joint Medical-Dental sleep research team from 1989 to 1993, and carried a rank of Clinical Assistant Professor. As a visionary and leader in the field of Sleep Apnea Therapy Dr. Halstrom has traveled the world speaking to health professionals on how best to offer therapy to one of the world’s most serious undiagnosed medical conditions.

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The Use of ApneaRx in a Diagnostic Setting

Recently I addressed a meeting of hospital administrators who had a very simple request. “Please explain how we can implement oral appliance therapy to our current programs in order to reduce our costs, and give our physicians the confidence that the oral appliances they prescribe will address the patient’s need?”  I prepared the slide presentation below to address the questions at hand. I tried to make each point research based.

I introduced a few new concepts like combination therapy and explained the use of the Nox T3 as a way of introducing home sleep testing . I really believe that testing patents during titration with an HST device will really help avoid over and under titrations.

At the end of the meeting we had a spirited discussion to say the least. The take away from the meeting was that oral appliances are here to stay. We may need to develop a reasonable way to guide patients through a diagnostic protocol to help establish candidacy.
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Randy Clare

Randy Clare

Mr. Clare brings to Sleep Scholar more than 25 years of extensive knowledge and experience in the sleep field. He has held numerous management positions throughout his career and has demonstrated a unique view of the alternate care diagnostic and therapy model. Mr. Clare's extensive sleep industry experience assists Sleep Scholar in providing current, relevant, data-proven information on sleep diagnostics and sleep therapies that are effective for the treatment of sleep disorders.

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Getting MAD Right – Choosing Oral Appliances

“It doesn’t matter if the guy is perfect or if the girl is perfect, as long as they are perfect for each other.”  – Matt Damon “Good Will Hunting”

Keep that thought in mind as you sit with your patient and decide which of the over 100 FDA cleared or mandibular advancement devices (MAD) is the right one to open the airway.  There is no universal appliance, just like there is no ‘standard’ patient!  So how do we go about this decision?

Dr. Pankey taught us a philosophy that includes the relevant parts: “Know Your Patient, Know Your Work, and Apply Your Knowledge.”  Let’s see how this applies to Oral Appliance Therapy.

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Steve Carstensen DDS

Steve Carstensen DDS

Steve Carstensen, Diplomate, American Board of Dental Sleep Medicine and Diplomate, American Sleep and Breathing Academy, is in private practice of dental sleep medicine in Bellevue, Washington, and is Editor-in-Chief of Dental Sleep Practice Magazine. He is most interested in helping dentists and other health professionals work together to improve community health through better sleep breathing. DSP Magazine’s vision is ‘Supporting Dentists through Practical Sleep Apnea Education.” Always interested in hearing what works in practice, it is the sharing of accumulated wisdom of experienced colleagues that can give the dedicated dentist hope of incorporating sleep medicine into everyday patient care. Steve also serves as Sleep Education Director of Pankey Institute and Spear Education. He can be found teaching offices, study clubs, and groups of dental professionals at conferences internationally, and is a proud member of the education teams at Nierman Practice Management and SomnoMed, Inc.

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sleep position - Bryan Keropian DDS

Home Sleep Testing is Essential for Dental Treatment of Sleep Apnea

The subject of the Home Sleep Test (HST) seems to always invite much debate regarding accuracy of “HST compared to in-lab polysomnography” and of “auto-scoring outcomes vs. technician scored outcomes”. I believe that these issues have been, and continue to be adequately addressed in the literature. What is clear to me is this; these devices are not all created equal, but a carefully selected HST can provide reliable auto-scored data that can be of great value in the titration process of an oral appliance intended to manage sleep apnea. However, I am not in any way suggesting that the auto-scored data provided by an HST can replace a verification in-lab sleep study.

sleep position -John Viviano DDSThe statistics suggest that in North America, current in-lab sleep diagnostic facilities are not sufficient to provide diagnostics, titration and verification studies for all those currently afflicted. Yet, the debate regarding the validity of HST continues with little regard for what it brings to the table. At least two provinces in Canada use the HST as a standard of care (scored by technicians); Canada is far from being a Third World Country. It’s as simple as this, when it comes to OSA, the available in-lab resources in those provinces simply dictate that their population’s needs are best served by the utilization of a literature validated HST.
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John Viviano DDS

John Viviano DDS

John Viviano B.Sc. DDS Diplomate ABDSM; from Mississauga ON Canada,obtained his credentials from U of T in 1983, he provides conservative therapy for snoring and sleep apnea in his clinic, Limited to the Management of Breathing Related Sleep Disorders. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally regarding management of Sleep-Disordered Breathing and the use of Acoustic Reflection. Dr Viviano has also conducted original research, authored articles and established protocols on the use of Acoustic Reflection for assessing the Upper Airway and its Normalization. For more info or to contact Dr Viviano click: Sleep Disorders Dentistry

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Nox T3, www.homesleepstudy.com, http://bit.ly/1ImTQAN

Titration End Point; What Standard of Care are You Striving For?

When I first became involved with Sleep Disorders Dentistry circa 1995, I remember feelings of frustration regarding the lack of an objective way to establish the titration endpoint of an oral appliance. During that era, as Dentists, we would have to wait until the in-lab sleep study results revealed how effective our titration efforts were. With experience, we’ve learned that titrating through subjective feedback alone often results in under-titration of an oral appliance. Since these early days, we have come a long way, this journey involving the use of various literature validated questionnaires, measurement of variables closely associated with sleep apnea such as nocturnal oxymetry and more recently, what I believe to be the current titration standard of care; the “Home Sleep Test” (HST). There simply is no other more dependable way for a Dentist to evaluate the efficacy of their titration end-point than through the use of a HST.

One common practice regarding appliance titration has involved training and allowing the in-lab sleep technician to fine tune titration of an oral appliance a Dentist has made. Pre the affordable and reliable HST era, perhaps this made sense, but not today. This protocol is a bit like the Wedding Cake you ordered arriving with the Icing dispenser on the side so you can put the names on the way you wish? Madison Lee’s Cakes of New York, NY would never consider letting someone else put the icing on one of their cakes. After all, they are professional’s and are extremely proud of their work! If we expect to be treated like professionals, we should be absolutely on top of our game and return the patient back to the referring physician with the appliance optimally titrated along with objective verification of our efforts. Presently, there is no better way to do that than with an HST. In-lab testing is expensive and often not covered by insurance; it should be reserved for initial diagnosis and for confirmation of treatment. The HST is useful to the treating Dentist to titrate or calibrate the oral appliance for maximum effect before the final in-lab sleep study is used to confirm efficacy of the appliance titration.
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John Viviano DDS

John Viviano DDS

John Viviano B.Sc. DDS Diplomate ABDSM; from Mississauga ON Canada,obtained his credentials from U of T in 1983, he provides conservative therapy for snoring and sleep apnea in his clinic, Limited to the Management of Breathing Related Sleep Disorders. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally regarding management of Sleep-Disordered Breathing and the use of Acoustic Reflection. Dr Viviano has also conducted original research, authored articles and established protocols on the use of Acoustic Reflection for assessing the Upper Airway and its Normalization. For more info or to contact Dr Viviano click: Sleep Disorders Dentistry

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Chmura’s practice screens every patient—both adults and children—for sleep apnea. Parents of every
child are asked to complete a pediatric sleep questionnaire (PSQ).

A Personal Story- Louis Chmura DDS, MS

For Louis G. Chmura, DDS, MS, carving out a role for orthodontists in treating sleep apnea is personal By Alison Werner Photography by Dave Trumpie

Previously publish in Orthodontic Products Magazine

 

LOUIS G. CHMURA’S WIFE OF 24 YEARS, Penny, often used to say it was a comfort to hear her husband snore at night. It reassured her that he was there. What she and Chmura, DDS, MS, didn’t know was how unreassuring his snoring should have been. According to the National Sleep Foundation, more than 18 million American adults suffer from sleep apnea, or obstructive sleep apnea (OSA). These patients experience periods in which their breathing is briefly and repeatedly interrupted during sleep. These interruptions, or pauses in breathing, Light curecan last anywhere from a few seconds to minutes and may occur 30 or more times an hour. When breathing restarts, it is often with a loud snort or choking sound. OSA occurs when the muscles in the back of the throat fail to keep the airway open. The airway can be obstructed by the tongue, the tonsils, and/or adenoids, which prevent air from flowing. Not only does it cause poor sleep quality, it also causes low blood oxygen levels. As a result, people with sleep apnea often experiencea number of comorbidities, including hypertension, heart disease, and mood and memory problems. Chmura’s introduction to sleep apnea came in the 1980s, when he and his future wife, Penny, worked midnights at a Lansing, Mich, hospital—he as an orderly and she as a nurse. There, Chmura’s job was to turn coma patients every 2 hours during the night, then sit by one particular patient’s bed. “It was really quite comical,” Chmura recalls. “He would breathe for a while, then stop. So I would poke him. He would swear and resume breathing, but I would have to again poke him every few minutes all night long.” What Chmura didn’t realize until 2 decades later was that this was sleep apnea, and he was helping to keep this patient alive.

In high school, Chmura was in good shape. He remembers playing basketball all morning, tennis all afternoon, then running a 5-minute mile to make sure he kept in shape. Then came college. While he still played basketball and tennis, he fell victim to the “freshman 15.” Then about 10 years ago he tore his Achilles playing basketball, and his active lifestyle came to a halt. With the resulting weight gain, his history of snoring became a huge concern. During the long recovery from his injury, Chmura slipped into a more sedentary lifestyle. With the inactivity, he felt more exhausted than ever. In addition, he could tell his health was declining. Meanwhile, his wife suddenly found herself staying up all night and poking Chmura when his breathing stopped. The snoring was no longer the comfort it had once been. Chmura was on a downward spiral, and he feared he wasn’t going to survive it. He sought help. The diagnosis: sleep apnea. The Achilles injury and the resulting lifestyle change had been the trigger. “I had compensated for my airway anatomy for a long time, and suddenly I stopped the activity that had kept sleep apnea at bay. As a result, I got sicker and sicker,” he says. To help those who don’t understand how debilitating sleep apnea can be, Chmura likens it to a college finals week—except this one has no end. “You know how you get to
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Louis Chmura DDS

Louis Chmura DDS

Dr. Chmura is member of the American Dental Association, Michigan Dental Association, the American Association of Orthodontics, the American Board of Orthodontics, the Academy of Laser Dentistry, and the American Academy of Dental Sleep Medicine. He is actively involved in two local professional study groups and three national study groups. He has taken numerous continuing education courses in orthodontics, periodontics, and cosmetic dentistry. Each year he attends over 100 hours of continuing education, and in 2006 Dr. Chmura was invited to write a chapter on the innovative uses of a Diode laser in an orthodontic office. Also, Dr. Chmura has been invited to lecture nationally on "Uses of a Soft Tissue Laser in Orthodontics" and "Treatment Planning in an Era of Innovative Technology".

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Dr. Erin Elliott

ONE-ON-ONE with Dr. Michael DiTolla

This interview was previously published in Chairside Dental Magazine Digital Edition

Interview with Dr. Erin Elliott
Erin Elliott, DDSMichael C. DiTolla, DDS, FAGD
INTERVIEW of Erin Elliott, DDS
by Michael C. DiTolla, DDS, FAGD

Dr. Michael DiTolla: I’m happy to have with us today Dr. Erin Elliott, who I met not too long ago when I was up at the Idaho State Dental Association meeting. I really liked what she had to say about her practice, because I think her two areas of emphasis are great for any dentist just getting out of school, or for those whose practices are in need of a boost. These two areas that seem to be almost ignored by general dentists are orthodontics — specifically, accelerated adult orthodontics — and snoring and sleep apnea. Erin, before we get to that, let’s go back to dental school. Tell me a little bit about what inspired you to become a dentist, and what you did when you got out that got you to where you are today.

Dr. Erin Elliott: Well, my dad is a dentist. He practiced in Long Beach, California, and I grew up in Orange County, but I didn’t grow up hanging out at his office or anything. I went away to college in upstate New York, always figuring I’d have a career in health care. I never had expectations of becoming a dentist myself; but as it turned out, dentistry was for me, and I absolutely fell in love with it.

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Erin Elliott

Erin Elliott

ERIN ELLIOTT, DDS, is in private practice in Post Falls, Idaho, where she provides general and cosmetic dentistry, short-term orthodontics, and dental sleep medicine. Dr. Elliott is an active member of the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine, as well as a diplomate and sitting co-President of the American Sleep and Breathing Academy. She has authored several articles and lectured extensively on dental sleep medicine.

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New Apnearx

The Economics of Oral Appliance Therapy for Sleep Apnea

CPAP has been the gold standard for treating obstructive sleep apnea, but custom oral appliances (OAs) are steadily gaining increased respect in the medical community. The problem is that while OAs lack the history of CPAP, the price of custom oral appliances is distinctly the gold standard, with most custom oral appliance therapy appliances in the $2K to $4K range. Sleep physicians who determine that CPAP is just not working for their patients want to help, but many are hesitant to recommend a pricey alternative that may, or may not, work. Dennis Hwang, MD, has seen the dilemma too many times during his 6-year tenure at Kaiser Permanente’s Sleep Disorders Center in Fontana, Calif.

Less costly prefabricated devices have long been used as a “predictor”, but formal peer reviewed studies are lacking. Hwang wanted to know: If patients have a good experience with prefab devices, is that truly a reliable predictor of success with the more expensive custom devices?
Hwang explored the question with his patients, eventually presenting the results at the 2014 Associated Professional Sleep Societies (SLEEP) convention in Minneapolis, in a poster titled,“Feasibility Pilot Evaluating the Use of Pre-Fabricated Titratable Mandibular Advancement Device for Management of Obstructive Sleep Apnea.” Along with nine colleagues, Hwang used a simple-to-fit, pre-fabricated titratable OA device called ApneaRx, made by the Aliso Viejo, Calif-based Apnea Sciences Corp.

New ApnearxApneaRx is a one-step boil-and-bite device where the lower tray can be advanced (relative to the upper tray) in 1 mm increments (up to 10 mm), which is similar to custom OAs. “The ApneaRx served as a predictor response mechanism,” explains Hwang, a 42-year-old pulmonologist who was a sleep researcher at New York University prior to his arrival at Kaiser in 2009. “We believe that this mechanism accurately predicts whether patients are going to physiologically respond to a custom OA. It can also act as a transitional or temporary device while a patient is waiting for their custom OA.”
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Randy Clare

Randy Clare

Mr. Clare brings to Sleep Scholar more than 25 years of extensive knowledge and experience in the sleep field. He has held numerous management positions throughout his career and has demonstrated a unique view of the alternate care diagnostic and therapy model. Mr. Clare's extensive sleep industry experience assists Sleep Scholar in providing current, relevant, data-proven information on sleep diagnostics and sleep therapies that are effective for the treatment of sleep disorders.

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Narval CC Resmed

Narval CC & D-SAD Strap Failures: Where would you place the Fuse?

Although 3D printed nylon appliances such as the Narval CC by ResMed & D-Sad by Panthera have demonstrated themselves to be extremely robust, it turns out that they do have an “Achilles Heel”; the advancement strap. Even though this only applies to those patients that adequately challenge their appliance through extreme bruxism, it would be prudent, to have a plan in place to manage this issue.

 

Let’s start by understanding the “raison d’etre”. The easiest way to explain this is by comparing the advancement strap to an electrical fuse. Patented in 1880 by Thomas Edison, a Fig 1 Strapsfuse protects from catastrophic surges of electricity. By placing a ‘Fuse” between the electrical source and the electronic circuitry, the integrity of the circuitry is preserved in the event of an electrical surge, protecting from catastrophic events such as damage to Hard Drives, Mother Boards, Circuit Boards etc.

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John Viviano DDS

John Viviano DDS

John Viviano B.Sc. DDS Diplomate ABDSM; from Mississauga ON Canada,obtained his credentials from U of T in 1983, he provides conservative therapy for snoring and sleep apnea in his clinic, Limited to the Management of Breathing Related Sleep Disorders. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally regarding management of Sleep-Disordered Breathing and the use of Acoustic Reflection. Dr Viviano has also conducted original research, authored articles and established protocols on the use of Acoustic Reflection for assessing the Upper Airway and its Normalization. For more info or to contact Dr Viviano click: Sleep Disorders Dentistry

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