David Gergen CDT Leads the way in the Dental Sleep Apnea Field

David Gergen executive director of the American Sleep and Breathing Academy has worked very hard to position mild to moderate sleep apnea as a predominantly dental condition. Often patients with sleep apnea at these levels are treated with CPAP without the option of an oral appliance. Often because the sleep physician is unaware or untrained in the use of these appliances or because there are no suitably trained dentists in the local area.

It was for this reason that David Gergen founded the dental wing of the American Sleep and Breathing Academy. The ASBA as it is known in dental circles has established itself in just 4 years as the premier training program for dentists who treat sleep apnea clinically. Just this past weekend 20 dentists from all over the country came to Scottsdale AZ for an advanced course to prepare them for diplomacy in this prestigious organization. The next diplomacy review course is on March 12 2016 click here for information

ASBA Diplomate Review Course February 2016
ASBA Diplomate Review Course February 2016

The ASBA has an annual conference in Scottsdale AZ, This year it will be April 15 and 16 2016 click here for information. This conference is widely recognized as the most accessible sleep apnea dentistry program available.

David Gergen has worked tirelessly to advance the cause of Sleep Apnea Dentistry for the last 10 years. but it was not always so…

David Gergen rolled out of bed on December 4, 1982, and had his career “aha” moment. Gergen knew he was going to be an orthodontic technician, and he knew he was going to help people all over the country. Since then, he has built one of America’s most successful dental labs in Phoenix, Arizona, revolutionized the sleep industry through oral appliances and special programs, and was once voted top dental laboratory technician in the country.

For more than 20 years in Phoenix, Gergen spent the fall coaching POP Warner football and/or high school football. Most of the important lessons of his life were learned either watching football legends, creating challenges for himself on the field, or teaching children the values of courage and teamwork on the field.

It comes as no surprise that Gergen, father of nine children, would focus a good deal of his professional life to helping children achieve their goals. Gergen is a certified dental technician, and some would say a master technician that children and adults have relied on for excellent results.

In his professional life, Gergen worked to straighten teeth for cosmetic reasons, and to help create functional oral structures for patients with severe trauma or developmental issues. Recently, attention has turned to the effects of poor jaw position on children. “A small airway often forces children to breathe through their mouth and posture their head forward resulting in rounded shoulders and back problems,” explains Gergen. “Continuing this position over many years will create permanent changes in posture. Poor breathing habits can result in heart and lung problems in later life.”

After 30 years of establishing better jaw and tooth function through orthodontics, Gergen decided that he was going to focus on the airway. His pediatric sleep appliance is a direct result of all of this experience and experimentation. Despite the growing evidence, Gergen laments that, “Some clinicians still believe that oral appliances are ineffective. As a dental sleep industry, I don’t think we’ve done a good enough job educating the public and physicians.”

Other_side

Gergen’s pediatric sleep appliance is worn on the child’s upper and lower teeth, and gives dentists an opportunity to guide the growth of patients’ teeth— more importantly, the jaw and the airway. Expansion of the upper jaw will create more room for the tongue to posture forward and open the airway.

“The simple shape and construction of the lower appliance will help stage the growth of the child’s teeth allowing the dentist to control the growth rates of the teeth for maximum cosmetic and palliative effect,” enthuses Gergen. “One of the best parts of the treatment is that all the time this growth is being controlled, the jaw is held slightly forward creating an open airway leading to better and deeper sleep patterns.”

Gergen has been working with Hall of Fame NFL great Mike Haynes, whose son is Pop Warner age and grinds his teeth in his sleep. This is what drove Gergen to come up with the first pediatric sleep appliance.

Mike Haynes is no stranger to health issues from his experience with prostate cancer and concussions. Both Gergen and Haynes know the value of an oral appliance worn during the day, or while playing a sport. Proper jaw position has been shown to improve agility, performance, and strength.

David Gergen was the personal lab technician of Dr Ricketts widely recognized as an icon and innovative thinker in the field of orthodontics. Dr Ricketts developed and taught a phonetic bite registration technique that was all taught by Dr Ed Spiegel who is recognized as if not the father of sleep apnea dentistry certainly as a very well regarded uncle. David Gergen teaches the Ricketts phonetic bite at all ASBA meetings as the go to sleep apnea appliance bite registration. This is the same bite that is demonstrated at courses for $8 to $10K often renamed as some kind of vanity procedure. See below a demonstration of the phonetic bite registration as Dr Ricketts developed it.

 

In a 2012 dental conference in Las Vegas, Dr. Gelb paid Gergen a high compliment, saying, “David Gergen is the finest technician ever to live. He is heads and tails above the competition.” Gergen was honoring Dr. Gelb for his 65th year in dentistry at the presentation, and Dr. Gelb also mentioned, “There are two legends in this room.”

“To say that David Gergen is a leader in the field of sleep apnea is to describe the part that is most obvious to all,” adds Rudi M. Ferrate, MD, DABSM and Sleep medicine specialist. “The part most people miss at first is the strength of his character, his passion for excellence, and his humble desire to help as many people as possible. He could easily sit back and enjoy the fruits of his business, but instead he spends his time and resources promoting education and awareness about sleep disorders. He is single handedly the most important force bringing sleep physicians and sleep dentists together and now is using his skills and reputation to bring everyone else on board—from legislators to sports legends.”

 

When Gergen decided to change the world of sleep medicine, it seemed like something outside the realms of possibility. How could a certified dental lab tech from Arizona manifestly change the sleep industry? It began by assembling a winning team and deciding to help people treat their sleep disorders in partnership with their dentists.

In August 2011, Gergen’s first training program in sleep was presented to a group of 25 doctors in Sonoma, Calif. He continues to hold special seminars and educational meetings. In a market where there are companies running dental sleep medicine programs every week, each successive Gergen’s Orthodontic Lab program has gotten better in one really significant
way: the team.

Gergen’s Orthodontic Lab’s team is achieving a seasoned balance that makes these meetings better. Each educator has his specialty. Each topic is covered thoroughly without overreach that comes from trying to extrapolate data points to gloss over the unknown or unknowable. When Gergen was Arizona’s most successful POP Warner football coach, he learned that individual efforts often do not make the grade, and it is teams that win.

Gergen’s new meetings will be remembered as the first time that retired NFL players used their celebrity status to introduce the urgent need for sleep diagnosis and therapy to the general public.

He could easily sit back and enjoy the fruits of his business, but instead he spends his time and resources promoting education and awareness about sleep disorders.

“Pro Player Health Alliance was created to treat the sleep health needs of retired NFL players,” explains Gergen, “while at the same time raising awareness of sleep apnea as a silent killer.” Carl Eller, Larry Fitzgerald, Warren Moon, Roy Green, Dave Krieg, Isiah Robertson, Eric Dickerson, Mike Haynes, Tony Dorsett, Matt Blair, Chuck Foreman, and Derrek Kennard were all excellent football players, and some have been inducted into the Hall of Fame. They are all sleep apnea patients who are contributing to the field of sleep medicine and sharing their experiences with the general public.

With long-time friend, Dr. Elliott Alpher, Gergen met with the Secretary of the Department of Transportation, and his cabinet, on behalf of the Trucker’s Union, to begin using his oral appliance, made with a micro-recorder manufactured by Braebon. The micro-reader can monitor commercial
truck drivers’ compliance.

David Gergens works with Congress on Sleep Reform in Transportation
David Gergens works with Congress on Sleep Reform in Transportation

 

 

 

 

 

 

 

David Gergen At a Glance

• CDT and president of Pro Player Health Alliance and Gergen’s Orthodontic Lab;

• Honored as “The Finest Orthodontic Technician in the Country” by Columbus Dental in 1986.

• Executive Director the American Sleep and Breathing Academy, a national interdisciplinary academy dedicated to sleep training and education with over 60,000 members.

• Personal technician for Dr. Robert Ricketts, Dr. Ronald Roth, Dr. A. Paul Serrano, Dr. Clark Jones, Dr. Harold Gelb, Dr. Joseph R. Cohen, Dr. Rodney Willey, Dr. Allan Bernstein, and Dr. Thien Pham.

• Winner of the National Leadership award for Arizona Small Businessman of the Year in 2004.

Randy Clare

Randy Clare

Randy 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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Special Considerations in the Treatment of OSA by Oral Appliances in Commercial Motor Vehicle Operators.

Ever since the FMCSA issued its latest updated advisor on Sleep Apnea which specifically changed previous medical advisory board recommendation on certifying CMV operators with OSA treated with oral appliances there has been discussion about Dental Sleep DENTRAC BY BRAEBONMedicine offering treatment programs for commercial drivers. This interest expanded when Braebon announced the availability of compliance monitoring for oral appliances  . This article will attempt to give Dental Sleep Medicine professionals additional information they should consider when treating CMV operators or considering marketing to trucking companies.

DO YOU WORK IN CONJUNCTION WITH OR PARTNER WITH AN MD BOARD CERTIFIEED IN SLEEP MEDICINE?

Sleep Scholar Editor Randy Clare and frequent contributor Dr. John Viviano have both written excellent articles about the issue of whether or not treating OSA with oral appliances is within the scope of practice for a dentist or not. While this is a current controversy if you are going to treat CMV operators or persons employed in other safety sensitive occupations you WILL need to do so in conjunction with an MD board certified in Sleep Medicine. Whether this is as part of a group practice, collaborative referral agreement or other business arrangement would have to be arranged. There are several reasons for this.

  • Medical Certification of CMV drivers under FMCSA NRCME program guidelines.

The current guidance from FMCSA on sleep apnea includes language that “the issue of treatment is best left to the treating healthcare professional and the driver.” Whether or not a dentist would be considered an appropriate healthcare professional to certify “current and effective treatment” would be a potential issue. In general “treating healthcare professional” in FMCSA language is a person acting within the professional scope of practice laws and holding a license to practice. Unless you have a relationship with or have checked in advance with an NRCME certified DOT medical examiner you will be sending your patients to, this can cause major issues.

Another issue will be a reluctance of DOT medical examiners to certify your patients for work unless they have paper work from an MD attesting to current and effective treatment. There will be reluctance to certify from the statements of a dentist. This reluctance will in part be due to liability concerns outlined below. DOT medical examiners want an MD and their insurance coverage on the line. They will want to avoid potential negligence allegations for accepting the opinion of a dentist possibly acting outside their scope of practice in attesting to current and effective treatment.

  • Liability, malpractice, or errors and omissions insurance coverage.

John and Wanda Lindsay were traveling on I-30 when they were struck from the rear by a semi-truck driven by a driver with recently-diagnosed severe uncontrolled sleep apnea. John did not survive the crash. On June 26, 2009, a tractor trailer crashed into a line of stopped vehicles, killing seven people. Post-crash polysomnography of the driver showed an AHI of 15/hr. The driver had recently been released from the hospital with discharge recommendations that he be evaluated for sleep apnea (which he declined).

2009 Miami OK Sleep Apnea truck crash.  $ 66 Million is settlement costs.
2009 Miami OK Sleep Apnea truck crash. $ 66 Million is settlement costs.

Let’s assume as a dentist you were the treating healthcare professional in either of these cases. Assume the patients were in the process of having their oral appliance titrated and had not yet reached full effective treatment. Or, even if the patient was under effective treatment the plaintiff alleges you were negligent for practicing outside your scope of practice. The Lindsay case settled for $ 3.25 million. The 2009 case settled out of court for over $ 66 million. In reality the likelihood of your being sued by your patient is slim. The liability risk will be suits from the motor carrier’s liability carrier subrogating their losses.

  • Maintaining current and effective treatment during OA titration.

Another aspect of CMV driver treatment is the need to maintain effective treatment while the oral appliance is being titrated. A common approach is to maintain CPAP treatment and use the oral appliance as adjunct therapy. Use of auto-titrating pap and monitoring pap determined pressures as part of the titration process is often used. If a CMV driver is not under effective treatment they should not be cleared for work. Newly diagnosed patients will need to at least temporarily be put on CPAP while the oral appliance is fabricated and titrated. This requires working in conjunction with an MD.

TO USE COMPLIANCE MONITORING OR NOT.

The FMCSA guidance is silent on whether or not CMV drivers must use compliance monitoring. All of the major recommendations on CPAP treatment recommend to DOT medical examiners are that drivers should maintain a minimum of 4 hours 70% of the nights of use. DOT medical examiners normally want to see compliance data for the entire period of treatment. All drivers with OSA will need to be recertified by a DOT medical examiner annually. Being able to provide compliance data will greatly ease your patient’s issues or problems with recertification. DOT medical examiners will have a variety of training and experience with sleep medicine. Chiropractors are allowed to be trained and certified to perform DOT exams.

POST TITRATION SLEEP STUDY

Part of a CMV driver program oral appliance program will need to include a post titration sleep study. You will need to be able to document the effectiveness of treatment. Whether this is an HST or PSG is open.

TEMPERATURE SENSITIVE MATERIALS.

One of the early practical feedback points from truck drivers using oral appliances are issues with OA constructed with thermally sensitive materials.

DO NOT use materials or OA that would be affected by being left on the dash of a truck in the sun.

MODERATE TO SEVERE OSA

One of the major issues will be how well your patient with moderate to severe OSA is treated. Unless they are under good control showing no excessive daytime sleepiness you should have major concerns. With moderate and severe OSA being the areas of concern for DOT certification and OAT being less effective than CPAP for moderate to severe OSA this will be an issue.

MULTIPLE VISITS FOR TITRATION

Dentist need to work with drivers, especially those in the long haul over the road segment to address getting OAT titrated. Self-titration where medically appropriate needs to be considered. A long haul driver being able to make multiple office visits for titration is not a practical reality.

 

Dentist will be needed to work with MD’s board certified in sleep medicine to execute treatment programs for either CMV driver needing to switch from CPAP therapy or start OAT therapy in lieu of CPAP. It is exciting that oral appliance therapy is a treatment option for drivers. But, a dentist planning to work in this area needs to be aware of how what special issues will need to be addressed in developing their programs. Partnering with firms already working with trucking companies to add OAT to their treatment options may be a better approach than trying to approach trucking companies on your own.

Bob Stanton

Bob Stanton

just a truck driver with sleep apnea. Co-coordinator of the Truckers for a Cause a patient support group for truck drivers under treatment for obstructive sleep apnea. Active in lobbying and educational efforts as they apply to FMCSA medical certification guidelines and truck driver health and wellness.

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American Sleep and Breathing Academy and ProPlayer Health Alliance set a new Standard for Health Education

David Gergen President of the ProPlayer Health alliance and executive director of the American sleep and breathing academy lead the team to victory last Tuesday night in Phoenix Arizona. Initially the idea of NFL football, Sleep Apnea and the Phoenix Police foundation don’t seem to fit together very well. It is important to understand that Sleep Apnea is a pervasive disorder that affects all walks of life and whose impact on performance at every level is real and measurable.

Sleep apnea affects over 20% of the US population and unfortunately elevated body mass is a big part of the condition. The condition reached prominence with the death of Reggie White at age 43 he was a 13 time pro bowler who played at weights topping 290 pounds it was his size that put him in a group susceptible to sleep apnea. A study in the New England Journal of Medicine found linemen accounted for 85% of sleep apnea cases among the more than 300 NFL players tested. Sleep apnea is considered by some to be an occupational hazard for NFL linemen.

So what is the connection with the Police force? After Studying 5,296 law enforcement officers in North America, a Harvard Medical school group reported that 40% of active duty officers suffered from sleep abnormalities. These include Apnea, Insomnia, shift work disorders, restless legs syndrome and narcolepsy. Yet sleep disorders in cops often go undiagnosed and largely untreated, according to Dr. Rudi Ferrate. For example, “almost half the individuals diagnosed with obstructive sleep apnea [a dangerous condition in which impaired breathing can lead to a heart attack or stroke] do not regularly take treatment,” he says.

Phoenix police with David Gergen Larry Fitzgerald Roy Green Alan Hickey Randy Clare
David Gergen, Larry Fitzgerald, Roy Green, Phoenix Police Chief Joseph Yahner and the Phoenix Police Dept

The sleep apnea event Padre Murphy’s in Phoenix January 26th 2016 was really a triumph of timing and execution. The Arizona Cardinals football team and its Executive Director and owner Nicole Bidwill chose to cosponsor a public sleep apnea awareness event with the ProPlayer health alliance and the Phoenix Police foundation. The publicity for the event was electric, driven by a season that saw the Cardinals win a franchise high 13 regular season games and earned their third NFC West division title. Cardinal superstar Larry Fitzgerald and Retired Cardinal Roy Green lead the event with David Gergen.

David Gergen Larry Fitzgerald and Roy Green Randy Clare Alan Hickey
David Gergen Larry Fitzgerald and Roy Green

I have been attending sleep apnea events for over 20 years and have never seen more than 400 people (and that was a ProPlayer Health Alliance event in Tacoma Washington). Imagine my surprise when I arrived at the event in Phoenix and saw crowd control in the parking lot and out on the street. There was a huge parking lot overflowing with cars and people thronging into Padre Murphy’s Sports Grill. The Phoenix Police reported that there were over 3000 people in attendance. The main area was so packed that people were being turned away at the door. At a certain point entrance to the parking lot was blocked off to new traffic.

Inside the event everyone was excited to see Larry Fitzgerald and Roy Green. David Gergen in his roll as Master of Ceremonies was moving things along and the crowd seemed to really be enjoying themselves especially when they had the opportunity to get an autograph or participate in the phoenix Police Foundation auction (which offered many great autographed items).

This was a huge night with many great moments. A few of my favorites were when Phoenix Police Chief Joseph Yahner presented Larry Fitzgerald and Roy Green with honorary Police officer awards. The crowd yelled Larry…Larry…Larry and surged forward sparking some concerned glances by security however the mood was great and everyone was having a great time.

David Gergen Police Cheif Joseph Yahner Attourney General Mark Brnovich Roy Green Randy Clare Alan Hickey
David Gergen Police Cheif Joseph Yahner Attourney General Mark Brnovich Roy Green

Eric Dikerson was really great when he put his hand on David Gergen’s shoulder and said to the crowd “Thanks to David Gergen for waking up the world to the dangers of Sleep Apnea”

Mark Brnovich Arizona Attorney General who wears and oral appliance for his sleep apnea and Secretary of Transportation Alberto Gutier were also in attendance and wanted to make sure that the everyone understood the perils of sleepy driving and the importance to public safety of a good and restful night’s sleep. They are very impressed with the Sleep Herbst as an alternative to CPAP for commercial drivers including emergency response.

I was very impressed to learn that 8 of the 40 Phoenix police officers made appointments with ASBA diplomate Mark Castle at Koala of Arrowhead, to be treated for their sleep apnea

In Summary I think this event was really important milestone in the education of the public to the dangers of sleep apnea. The NFL players current and retired certainly had a great event. I understand from David Gergen Roy Green that he and Nicole Bidwill are in fact working on another sleep apnea event to kick off the 2016 season. I also heard that other teams around the league are considering adding sleep apnea awareness to their calendar. Congratulations to David Gergen and Roy Green for planning an excellent event that I’m sure laid a foundation for bigger and better public education events in the future.

 

Randy Clare

Randy Clare

Randy 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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ResMed Narval CC: The Force Awakens!

Since it’s introduction to North America in 2012, the Narval CC has experienced a number of design enhancements, all based on clinician requests. In keeping with the ResMed commitment to innovate based on end user feedback, this month, an “Anterior Contact Design” was added to the regular lineup of Narval CC offerings.

This new design provides full contact to the anterior teeth without actually engaging them retentively. Specifically, it provides contact to the facial and lingual surfaces of the central and lateral incisors on both the upper and lower arches, providing added surface coverage, without actually engaging the anterior teeth. Of course, the amount of anterior surface coverage varies based on dental anatomy.

I have had the opportunity to place a number of these full contact appliances during the controlled product launch period and experienced absolutely no issues on insertion or post insertion appointments. Although this design is being offered in response to the suggestion that full contact would aid in preventing or minimizing tooth movement, whether this was actually a concern, and whether the full contact design will provide protection in this regard, remains to be seen. Personally, I continue to prefer the non-contact lingual band with cap over to the labial, which protects the teeth from tooth tilting tongue pressures and also provides additional rigidity, enhancing retention.

However, I am excited about this new full contact design for a particular reason. Last year, Panthera added an anterior mid-point stop option (anterior discluding ramp) to their D-SAD appliance line up. Since its introduction, I have expressed concern about the implications of that design, which has no contact at all on the anterior teeth, resulting in the forces from the anterior mid-point stop to be transferred “exclusively” onto the cuspids and posterior dentition. It seems to me that ResMed’s new full contact appliance can incorporate an anterior midpoint stop design that results in a more even distribution of forces onto the mandibular teeth. I look forward to this enhancement from ResMed and understand that it is in the works.

ResMed offers two full anterior contact designs: “Full Coverage” and a “Lingual Band with extended Cap onto the Labial”. A new order form is now available that includes these new designs. Below, you see the original 5 designs and the new full contact additional designs (in blue below).

Narval choices

 

 

Since the introduction of 3-D printed Nylon appliances to North America, both the Panthera D-Sad and ResMed Narval CC have experienced many enhancements and additional design offerings, all of which demonstrate the benefits of working in a CAD-CAM environment. These are exciting times for OSA appliance therapy. As these two companies continue to outdo each other regarding features and design offerings, we as clinician’s and ultimately the patient’s continue to benefit. The Star Wars Saga continues!

 

 

John Viviano B.Sc. DDS Diplomate ABDSM

John Viviano B.Sc. DDS Diplomate ABDSM

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: SleepDisordersDentistry.com Website SleepDisordersDentistry LinkedIn Discussion Group

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Bruxism Therapy and Obstructive Sleep Apnea Therapy for Every Dental Practice

Appliance on models

Bruxism is a condition in which a person grinds or clenches his teeth. People who have bruxism may unconsciously or consciously clench their teeth together during the day or clench and grind them at night. Signs and symptoms of bruxism may include: sounds of grinding or clenching; teeth that are flat, fractured, or chipped; teeth that have abfractions present; increased tooth sensitivity; jaw or facial pain; tight and sore facial muscles; sore jaws; headaches; periodontal tissue damage; and indentations on the tongue. The cause of bruxism is unknown but is linked to such factors as stress, anxiety, fatigue, snoring, and sleep apnea. People who clench or grind their teeth during sleep are more likely to have some degree of apnea present.

Obstructive sleep apnea (OSA) is the most common form of sleep apnea. Sleep apnea occurs when the muscles in the back of the throat fail to keep the airway open despite efforts to breathe. Sleep apnea is a medical condition in which breathing is briefly and repeatedly interrupted during sleep. An apnea occurs when the muscles fail to keep the airway open and there is a physical obstruction such as the tongue, pharyngeal muscles, epiglottis, and uvula that blocks the airway. This obstruction causes the patient to stop breathing during sleep. An apnea is an event where the patient stops breathing for a minimum of 10 seconds during sleep. A hypopnea is an event where the patient has significantly reduced airflow because of a partially blocked airway for at least 10 seconds while sleeping. Patients with obstructive sleep apnea will have multiple apneas/hypopneas every night while they sleep, with the potential to severely impact their health. There are three different types of obstructive sleep apnea. These classifications depend on the number of apneas and hypopneas, divided by the number of drops in oxygen saturation. OSA deprives the body of oxygen and untreated is a potentially deadly sleep disorder. OSA can increase an individual’s risk for a heart attack, stroke, hypertension, and cardiac disease. Dentists have a unique position and can play a major role in their patient’s health because many patients are seen several times in a year.

medical grade sleep bruxism monitor with bruxism episode index (BEI)

As dentists we have familiarity and access to the oral cavity, airway, and neck. As dentists we examine and focus on the head and neck of our patients. We can view the patient’s airway, soft tissue, and dentition. We observe the tongue size, tongue shape, soft palate area, the patient’s neck size, periodontium, and the wear on the patient’s dentition. In the dental office, bruxism is seen in one out of every three patients. Two out of every five of these patients has undiagnosed or untreated obstructive sleep apnea. It is important to realize that patients who demonstrate bruxism often have obstructive sleep apnea. Sleep bruxism is considered a sleep related movement disorder. People who clench or grind their teeth during sleep are more likely to have other sleep disorders, such as snoring, pauses in breathing, and sleep apnea. Mild bruxism may not need to be treated. However, in some patients, bruxism can be frequent and severe enough to cause jaw disorders, damage to teeth, and headaches. Dentists can screen for teeth grinding and can tell if a patient is grinding their teeth at night. Bruxism can be treated with an appliance made to prevent grinding and /or clenching. Dentists can refer patients to their physicians for the diagnoses of sleep apnea and then dentists can treat sleep apnea patients with oral appliances as well.

medical Grade Sleep Bruxism Monitor Bruxism Episode Index (BEI)

medical grade sleep bruxism monitor Bruxism Episode Index (BEI)

However, because there is a link seen between grinding and sleep apnea, dentists need to play a larger role and have a relationship with a sleep physician and other medical doctors. Dentists can diagnose and provide the therapy needed for bruxism and provide the therapy for obstructive sleep apnea, once a physician diagnoses the apnea which is a medical condition requiring a medical diagnosis. Dental sleep medicine is a fast growing area of dentistry. There are approximately 40 million people in the United States with obstructive sleep apnea (OSA), with 90% of those undiagnosed. One in four patients with OSA suffer from nighttime teeth grinding. The ending of an apneic event may be accompanied by a number of mouth phenomena, such as snoring, gasps, grunts, and mainly teeth grinding. Teeth grinding occurs because of the significant attempts to open the mouth to breathe. Bruxism usually occurs after an apnea event. One of the ways the brain tries to reopen the airway, in an unconscious state, is by grinding and clenching the teeth. Teeth grinding is a major indicator that you are struggling to keep your airway open at night and might suffer from obstructive sleep apnea. When the airway collapses, breathing becomes compromised. This is where you get snoring, which is just the sound that’s made when air is getting forced through a partially obstructed airway. Once the brain senses that breathing is dangerously compromised, it exits the deepest stage of sleep to regain control of the jaw muscles and reopen the airway – to keep a person breathing and alive. These sleep apnea cycles can occur from five to up to 70 times per hour during sleep. These events prevent one from entering the deepest stages of sleep where the brain and body tissues can repair themselves from the wear and tear of the day. A dentist’s role in this process is to provide screening, therapy for bruxism, and therapy for obstructive sleep apnea when diagnosed. Dentists are not only qualified to provide the necessary dental treatment for this life threatening disorder but are uniquely in a position to screen and refer our own patients for sleep apnea diagnosis. Another screening application the dentist can provide is the Epworth Sleepiness Scale (ESS) to all patients. ESS is a scale, which measures a person’s average level of daytime sleepiness.The scale consists of eight different routine life situations. Each question is rated from zero to three, with three having the highest chance of falling asleep. If a patient scores nine or above and demonstrates excessive daytime sleepiness this needs to be discussed and researched further for explanation on why the patient is excessively sleepy. When it is determined that a patient is a grinder/clencher, snores, and has an ESS score of 9 or above, the patient is a prime candidate for a sleep test. Patients may be referred to a sleep physician, pulmonologists, or their personal primary physician for a sleep study. The home bruxism/sleep test (STATDDS Bruxism/Sleep Monitor) is typically used to diagnose bruxism and sleep apnea (Figure 1). In the dental office, dentists can administer a home test to measure the patient for bruxism and at the same time receive the apnea/hypopnea index which measures obstructive sleep apnea. The AHI can be shared with the patient’s physician. The dentist can work with the patient’s physician as coprimary healthcare providers and come up with a treatment plan together that can address the bruxism and the obstructive sleep apnea. As dentists, we only diagnose the activities occurring during sleep that are related to the clenching and grinding. Heightened bruxism events occur more frequently at the end of an apneic episode. The results of the bruxism/sleep study are sent to a certified sleep physician who gathers the information and provides a diagnosis determined by the total number of pauses that occur per hour of sleep. If the patient has only grinding/clenching issues and no apneic events or drops in the oxygen saturation then a night guard is treatment planned for the patient. Dentists should not be fabricating and placing dental appliances without objective data from a bruxism/sleep test and a proper diagnosis, to avoid creating an obstruction in the patient’s airway with the appliance for grinding/clenching (Figures 2 and 3). Moreover, if the study is returned with a diagnosis of mild or moderate obstructive sleep apnea, then a proper dental sleep appliance should be one of the recommendations for treatment. A mandibular advancement sleep appliance can be fabricated for that patient and can be titrated based on post testing with the home bruxism/sleep monitor. There are several types of sleep appliances for the treatment of obstructive sleep apnea (Figures 4 and 5). The devices move the

sleep bruxism

Sleep Bruxism

mandible and tongue forward allowing the airway to remain opened. There are appliances for a patient who is a bruxer and an OSA patient. There are oral appliances for an OSA only patient. Also, for severe sleep apnea sometimes a patient will wear a combination of an appliance with positive airway pressure therapy. Furthermore, for severe OSA who cannot tolerate a CPAP type device, an oral appliance is recommended as it is better for the patient to have some means of opening the airway and alleviating obstructive sleep apnea. Oral devices to treat obstructive sleep apnea must be prescribed by a physician and fabricated and fitted by a dentist. Dental oral appliances are convenient form of sleep apnea treatment. The compliance rate is higher than CPAP treatment with OSA patients. The devices offer the benefits of a significant reduction in apnea for mild to moderate OSA patients. Also, the elimination and or reduction in both grinding, clenching and snoring. Dental practices have the unique advantage of seeing their patients frequently and access to the oral cavity to identify potential sleep apnea patients.

 

Suzanne Haley, DMD

Suzanne Haley, DMD

Dr. Haley specializes in comprehensive dentistry for adults and children. For nearly two decades, she has been establishing her reputation for excellence in cosmetic, restorative, and reconstructive dental services in the Golden Isles. After graduating from Brunswick High School, Dr. Haley went on to attend the University of Georgia, graduating with a Bachelor’s Degree in Microbiology. She then attended dental school at The Medical College of Georgia, which is one of the 9 prestigious colleges of Georgia Regents University. Today, Dr. Haley maintains professional membership in the American Dental Association, the Georgia Dental Association, the ACLS for Dentists,the Dental Organization for Conscience Sedation, American Academy of Dental Sleep Medicine and the American Academy of Facial Esthetics, where she is a Distinguished Mentor.

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CPAs Are Not Tax Planners

There’s a myth floating around that Certified Public Accountants (CPAs) do tax planning. But, the CPA exam does not delve into tax planning. For your average CPA, tax planning is an independent subject, removed from accounting, tax preparation, financial reporting, audits and consulting. So, let’s dispel the myth.

1.  When has your CPA or tax preparer shared an idea that saved you       at least $1,000 in taxes? It’s not likely to happen in the future if it has not happened in the past. CPAs are generally not proactive tax planners. They are costing you amazing vacations, college tuition, or new cars. We, on the other hand, save our small business owner clients an average of $21,000 per year in income taxes.

  1. What does the “P” in CPA really stand for? “Public,” as in a publicly-traded company or the general “public?” Either way, the CPA designation was created to teach general accounting principles, not to help you or small business owners lower their taxes. This is a critical distinction. CPAs are not trained to help you lower your taxes. They aren’t even trained to do tax preparation, they are trained to be accountants; they are number historians.
  2. What are four primary tax strategies? If your CPA or tax preparer cannot immediately tell you, he or she doesn’t know. Do you want someone who doesn’t know the four strategies to do your tax planning? By the way, they are; Timing, Shifting, Code and Product

Now you know more than most CPAs.

CPAs are expensive bookkeepers and tax preparers for most people and small businesses. However, we NEED CPAs. We need them for audits and we need them for more sophisticated accounting, like public companies. They have excellent value if you take advantage of their strengths. They have many strengths in the field of accounting, but for tax planning, call us

 

Trintus Smith

Trintus Smith

Currently serving as an executive strategist leveraging over 15 years of leadership experience analyzing processes and creating growth strategies that support company goals. My broad, diverse background includes leading multiple large global projects, multimillion-dollar cost reductions, double-digit productivity/quality gains, and presenting strategic recommendations that established paths for ongoing success. CREDENTIALS ★ Master of Business Administration in Marketing- Northwestern University ★ Master of Business Administration in Management- St. Ambrose University ★ Master of Science in Industrial Engineering- University of Southern Mississippi ★ Bachelor of Science in Industrial Technology- Alcorn State University ★ Six Sigma Black Belt Certification ★ Vice Chair, Canyon State Academy (all-boys alternative high school for at-risk youth)

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CPAP sleep apnea machine for sale. Used once

Ernest Hemmingway is often credited with having written a 6 word novel. It goes like this… For Sale: Baby Shoes, Never Worn. Legend has it that Ernest Hemmingway was at lunch with a few writer friends he bets the table ten dollars each that he can craft an entire story in six words. After the pot is assembled, Hemingway writes “For sale: baby shoes, never worn” on a napkin, passes this around the table, and collects his winnings.

This morning I was poking around on the internet and I saw a 23 word essay on sleep therapy it was published on Craigslist.

CPAP sleep apnea machine for sale. Used once. I don’t have sleep apnea and need to sell. Paid $2400 asking $900. Call Amy

It got my attention because we spend so much time working with patients and helping them understand their condition; only to have the entire sleep therapy experience determined by a single night with CPAP. A device, which by Amy’s estimation cured her Apnea in a single night of use. Based on that claim alone you would expect she could charge a premium for the CPAP instead of losing $1500 on the deal. Sadly this is a story we hear all too often.

Patient compliance has been shown to be a direct result of education and relationship with the clinical team that sets up the CPAP and manages patient care. I hope Amy shares her essay with the clinical team that set her up initially. I suspect that they would have some additional advice, tips and tricks to help with compliance. I expect however that the clinical team will never get a chance to have the conversation.

Bradley Eli DMD, MS

Bradley Eli DMD, MS

Dr. Brad Eli is a nationally-recognized leader in sleep disorders treatment and pain management. His expertise in sleep led him to develop a patient-centered method that offers a variety of sleep treatment options and matches each patient with the best treatment for their symptoms and lifestyle. Patients diagnosed and treated by Dr. Eli consistently achieve better compliance rates and improved outcomes. Dr. Eli is the first Medicare and Tricare approved provider for multi therapy sleep treatment in Southern California. Dr. Eli earned a post doctoral Master’s Degree at UCLA where he received advanced training in sleep disorders. He remains the only expert with this unique skill set in the San Diego region. Dr. Eli is on the hospital staff at Scripps Memorial Hospital La Jolla and UCSD. He is a member of numerous professional associations including the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine. Dr Eli holds multiple patents in the fields of both sleep and pain. www.sleeptreatmentspecialists.com

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CPAP in Combination with OAD can lead to Better Outcomes

Dr Bradley Eli DMD MS fromSleep Treatment Specialistshas been a contributor and supporter of sleep scholar since its inception over 5 years ago.Over the last 20 yearshis practice has evolved from a TMJ, Headache and Pain practice to one that includes the treatment of Obstructive sleep apnea. Sleep Treatment Specialists has become thepoint of therapydelivery for sleep patients in the San Diego area. He has developed a CHAP certified DME that allows him to dispense and manage CPAP where required as well as using CPAP in combination with Oral appliances to provide the highest possible standard of care for patients who suffer from OSA.. Dr Eli and his team of respiratory therapists were recently featured in theAARC Timesa trade publication for the American Academy of Respiratory Care.

The Case presentation below is an interesting one because Dr Eli pulled out all the stops to find a therapy combination that would give the patient a restful sleep and a therapy that could be complied with.Body Position therapy, APAP and oral appliances all form part of the non surgical therapy offering. Dr Eli provides all non surgical OSA therapies at Sleep Treatment Partners – ed

High Risk Women Age 67 Poor compliance,unmonitored for 5 years

Complaint and AHI within normal limits after 4 months withSleep Treatment Specialists(STS) treatment

Case Highlights

  • Chief Complaints:
    • OSA/EDS/Snoring
  • Diagnosed severe OSA 2009
  • CPAP non compliant/failure
  • Elevated BMI & HPTN
  • Gastric bypass /Septaplasty
  • STS treatment plan with OAD. PAP and
    • positional therapy
  • AHI dropped from 72-3.5
  • Indicates feeling well and rested
  • Follow up visits
    • Every 3 months

Hx: Before Sleep Treatment Specialists

Patient X had a sleep study done in 2009. Results showed she had severe obstructive sleep apnea, with an AHI of 72.5. She was prescribed a CPAP, with a set pressure of 14 cmH2O. Over the years she experienced significant complications with her CPAP use due to removal during sleep and insufficient seal. Her medical history includes OSA, TMJ, HPTN, arthritis, and breast CA. She has undergone multiple surgical procedures over the years including gastric bypass and Septoplasty. She was referred to Sleep Treatment Specialists by her PCP July 2014 by for excessive daytime time sleepiness, non CPAP compliant, elevated BMI, HPTN and TMJ. She was interested in a CPAP alternative.

Sleep Treatment Specialists Plan & Treatment

Initial New Patient Consult:

APAP Resmed
Resmed APAP

07/21/2014 For the first consult we obtained full history from the patient. Impressions were taken for an Oral Airway Device (OAD). We gave her a 5 day Auto set PAP trial. We also went over the importance of positional therapy and weight loss.

07/28/2014 Patient returned APAP. She really liked the auto set pressure and was able to tolerate it a lot better than her set pressure. Her set pressure was too high for her. We ordered her a new APAP machine.

08/18/2014 The Patient picked up her OADAfter making a few adjustments she did a home sleep test to measure the efficacy of her OAD her AHI dropped from72to22!

images
Herbst by Gergens Orthodontic Lab

12/17/2014 The patient brought her new CPAP in to be adjusted to her settings. She came in a few weeks later. She is compliant with combination OAD and CPAP

Bradley Eli DMD, MS

Bradley Eli DMD, MS

Dr. Brad Eli is a nationally-recognized leader in sleep disorders treatment and pain management. His expertise in sleep led him to develop a patient-centered method that offers a variety of sleep treatment options and matches each patient with the best treatment for their symptoms and lifestyle. Patients diagnosed and treated by Dr. Eli consistently achieve better compliance rates and improved outcomes. Dr. Eli is the first Medicare and Tricare approved provider for multi therapy sleep treatment in Southern California. Dr. Eli earned a post doctoral Master’s Degree at UCLA where he received advanced training in sleep disorders. He remains the only expert with this unique skill set in the San Diego region. Dr. Eli is on the hospital staff at Scripps Memorial Hospital La Jolla and UCSD. He is a member of numerous professional associations including the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine. Dr Eli holds multiple patents in the fields of both sleep and pain. www.sleeptreatmentspecialists.com

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Recent graduates: The next step in your dental journey

Congratulations! You did it! You finally graduated . . . but now what? As a recent graduate your options are limitless. After graduation you might think you know everything you need to know, but you will learn quickly that dental school does not cover many of the most fulfilling and cutting-edge areas of dentistry. Even after graduating dental school, you will continue to learn and expand-especially if you wish to be successful in the dental field.
Continue reading Recent graduates: The next step in your dental journey

Mayoor Patel, DDS, MS

Mayoor Patel, DDS, MS

Dr. Patel received his dental degree from the University of Tennessee in 1994 and then completed a one year residency in Advanced Education in General Dentistry (AEGD). He also earned a Masters in Science from Tufts University in 2011. Additionally he served as an Adjunct Clinical Instructor at the Craniofacial Pain Center at Tufts Dental School from 2011-2014. Dr.Patel also serves as Adjunct Clinical Instructor in the Department of Oral Health and Diagnostic Sciences at the Georgia Regents University, College of Dental Medicine in Augusta Georgia (formally Medical College of Georgia). He is one of five dental professionals in Georgia to be Board certified in Dental Sleep Medicine (DABDSM). Additionally, he is the only Dental Practitioner in Georgia and in the southeast to be triple-boarded in Craniofacial Pain, Orofacial Pain and Dental Sleep Medicine.

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Bob Rutan’s Notebook – MedTrade Mementos

Here we are at the 2015 Medtrade Show in Atlanta, Georgia!

Dave and Dena, Adam, Bob and Debbie, and clinical support person Peter Allen are having fun talking with doctors, therapists, clinicians and students about how RemZzzs® is the answer for CPAP patient compliance! Peter will be the featured speaker at a breakout session Wednesday morning, on the very same topic of Compliance.

This year RemZzzs® is debuting a new Liner for the Respironics Amara View mask, and a brand new look for our product box. This redesigned box will be great for retail; featuring a slot for hanging up to display. It may still get a few “tweaks” as we are asking folks for their feedback and suggestions.

Remzzzs new liner

Another enjoyable part of being at Medtrade is the time spent networking over an evening meal. Tonight while dining at “Ted’s Montana Grill” on Ted Turner Ave, we had the pleasant surprise of sitting at a table next to none other than former owner of CNN, Ted Turner, and what appeared to be his family. I snapped a pic of co-workers Dave and Dena…and also got Ted in the background!

Ted in the background

Maybe I should’ve asked him if he wore CPAP…

Check out our video about Carl Eller and his experience using RemZzzs® with his CPAP therapy! Carl is an NFL Hall of Famer who played with the MN Vikings in the 60-70s. He was one of the legendary “Purple People Eaters!” http://youtu.be/uqwK3I3NG58

Bob Rutan

Bob Rutan

Inventor of RemZzzs® CPAP Mask Liners, the innovative solution for CPAP mask discomfort, air leaks and non-compliance. RemZzzs® was listed as one of the top ten finalists of the 2015 Medtrade Spring Innovative Products Awards, sponsored by Homecare Magazine. In March 2007, his wife was struggling to continue CPAP therapy for her moderate-to-severe OSA (obstructive sleep apnea), and Robert was desperate to find an answer for her. After much thought and prayer, he awoke one night with the idea of a fabric gasket to stop air leaks and increase comfort. By Jan. 2009 this “idea” became a reality when RemZzzs® became available online as the first-of-a-kind mask liner accessory. RemZzzs® is sold nationwide online and via Home Medical Supply stores. Internationally, distributors in Australia, Europe and Canada sell to their respective markets. Robert Rutan holds a patent on the product in the USA, Australia, Canada, China, Israel, and Mexico; with patent pending status in EU and several other countries. Mr. Rutan travels across the USA, speaking, presenting and demonstrating the use of RemZzzs® to doctors, nurses, sleep techs and individuals. His passion is to help people find success with their CPAP therapy.

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Sleep Scholar for Sleep Medicine Professionals