Arizona Cardinals Join ASBA, Phoenix Police, and Pro Player Health Alliance For The Worlds Largest Sleep Apnea Awareness Event

20160126_chadiwck_19.33.50                                                                                                                                                                                                                                                                                                                    Pro Player Health Alliance is an organization dedicated to helping treat former NFL players who suffer from obstructive sleep apnea (OSA). As a result these superstar athletes then become more than just patients, but every day people who publicly support and spread the awareness of OSA at events across the nation. With a combined effort of former NFL greats, local establishments and public figures, the community as a whole can unite to direct potential patients toward dental/medical professionals who can help.

 

The next Pro Player Health Alliance event, aimed at improving awareness and undersDavid Gergen Larry Fitzgerald Roy Green Alan Hickey Randy Claretanding of sleep related disorders in the general public, is also a fundraiser to benefit the Phoenix Police Foundation. In addition, it will be the first official celebration to kick off the new season for the Arizona Cardinals. Shining a light on life threatening health complications that can be caused by allowing OSA to go untreated has become a primary objective for the Arizona Cardinals since partnering with Pro Player Health Alliance. Location and time of the public awareness event and fundraiser will be Tuesday September 6, 2016 at 6:30 p.m. to close at Padre Murphy’s 4338 West Bell Road, Phoenix AZ 85308. It is expected that this event will draw over 5,000 thousand attendees.

Roy Green, NFL legend and former Cardinals WR/DB has said, “If I had met David Gergen years ago, I may not have had to experience having a heart attack, let alone three heart attacks and two strokes. I am extremely grateful for what he’s done for me and my former teammates and I’m glad to be a part of spreading awareness on sleep apnea so others don’t have to go through what I did.”

Pro Player Health Alliance President David Gergen, owner of Gergen’s Sleep Appliance Lab and Executive Director of the American Sleep and Breathing Academy is an icon throughout the dental sleep community and will be the MC for the event. David will be on hand to help the public meet their favorite player and to share his extensive knowledge of sleep disorders including the dental treatment of sleep apnea.

David Gergen on stage

 

 

 

 

 

 

 

“Over the years more and more retired NFL greats have contacted me regarding their sleep apnea. I am happy to refer them to a dentist or medical doctor who can help them. It became very obvious that the general population was having the same issue. Roy Green and I decided to help the retired players and improve awareness of sleep disorders by promoting large public events.” – David Gergen

ASBA First Amendment Action Time FMCSA-2015-0419

“In the Matter of Medical Certification of Transportation Workers in Safety Sensitive Positions; Individuals Exhibiting Risk Factors for Moderate-to-Severe Obstructive Sleep Apnea”

FMCSA-2015-0419 – Deadline for Comment is June 8, 2016

Dear Colleagues,

Following up on the FMCSA-2015-0419 presentation during the recent Sleep & Wellness conference on behalf of the American Sleep and Breathing Academy, please note the following important instructions with regards to comment.

a) Review comments

https://www.regulations.gov/#!docketDetail;D=FMCSA-2015-0419

b) Add comment

https://www.regulations.gov/#!submitComment;D=FMCSA-2015-0419-0001

When commenting:

i. Present your credentials and relevant experience. Be sure to mention you are a member of the American Sleep and Breathing Academy ‘ASBA’.

ii. Be concise and support your claims

iii. Add scientific evidence from dental sleep medicine sources and literature. Include scientific studies on oral appliance therapy and your own experience as an expert.

iv. Address trade-offs and opposing views.

v. Include the costs and benefits to patients of your approach.  It is especially important for oral appliance therapy to address costs and compliance.

Comments are not votes, but one well supported comment is more influential than a thousand form letters.

The ASBA needs to speak up with one voice about this important issue.

Attendee Feedback from the Mini Residency in Sleep Disorders Dentistry

A graduate of the recent Mini Residency in Sleep Disorders Dentistry held in Toronto Canada sent Dental Services Dental Lab the following email,

 

“Hi Kathleen (DSG Lab),

Thanks for all the goodies when you came to our office to talk and for your presence and support at Dr. Viviano’s course. Used your materials to create a great awareness display at the office. Hopefully I’ll be sending some cases your way in the near future!

Dr. Sean Robertson”

Mini Residency in Sleep Disorders Dentistry

 

Dr. Robertson can now consider himself a Sleep Disorders Dentist. After attending this Mini Residency in Sleep Disorders Dentistry CE program , he is motivated, understands the process, has the necessary communication skills to communicate with patient’s, physicians, insurance companies and litigation lawyers, and is set up to make “Patient Specific” case presentations with “patient appropriate” appliances.

“I have known John Viviano for over 20 years, and I can tell you that this is exactly the level of confidence and depth of knowledge that he strove to instill when he first spoke to me about the Mini Residency in Sleep Disorders Dentistry program; a Sleep Disorders Dentist, armed with all the information, verbal skills, technical knowledge and tools necessary to practice Dental Sleep Medicine with confidence.” – Randy Clare Editor SleepScholar

CE Certificate Sleep Disorders Dentistry copy

 

 

 

 

Over 4 days, the attendees obtained intimate, hands-on experience with a variety of appliances including the Narval CC, TAP Elite 3, MyTAP, Somnodent, EMA, AveoTSD and ApneaGuard. They also experienced baseline and post appliance insertion Home Sleep Studies with either a NOX T3 by Carefusion or ApneaLink HST. Some of the key areas included in the curriculum were:

 

  • Appropriate patient treatment alternatives as per the current “Standard of Care”
  • The “Lingo”, communicating with physicians, insurance carriers, patients and licensing bodies
  • Sleep Study results and utilizing their information to optimize outcomes
  • Appliance Anatomy as it relates to appliance selection and oral appliance side effects
  • Management of both short and long term oral appliance side effects
  • Various bite registration techniques from a literature perspective
  • Combining therapies to optimize outcomes
  • Home Sleep Testing for optimizing treatment outcomes and physician communication
  • American Academy of Dental Sleep Medicine Protocols
  • Documentation your licensing body expects
  • How to access the untapped potential in your practice
  • Conversing intelligently in an evidence based manner with patients and physicians
  • Dealing with obstacles: Re-imbursement, CPAP-bias, non-believers, our own insecurities

 

For more information on the Mini Residency programs offered by Sleep Disorders Dentistry Click Here

 

 

 

 

 

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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First Amendment Action Time!

Marty Russo, a retired Congressman, addressed the American Sleep and Breathing Association annual meeting last weekend with a strong call to action.

The commissions that oversee Railroad Operators and the Trucking industry have opened a public comment time for critical  rule making associated with treating Obstructive Sleep Apnea.  Marty talked about searching the current public comments and finding only one mentioning dentists at all, so he put together  an action sheet.  If we want the regulators to hear about oral appliances, it’s completely up to us to ‘petition our government,’ a right enshrined in our Constitution just for this very purpose.
Here’s what he advises us to do:
Dental Sleep Medicine Has A Big Opportunity
Speak Up To Federal Policy Makers – Let’s Be Heard In Washington
The Opportunity: 
The U.S. Department of Transportation has requested public comments on proposed rulemaking about screening, diagnosing, treating and tracking compliance for OSA in individuals occupying safety sensitive positions in highway and rail transportation.  These agencies need input from experts on the science of dental sleep medicine.
 Federal Motor Carrier Safety Administration (FMCSA)
Federal Railway Administration (FRA)
 How You Can Prepare:
Read the announcement outlining the proposed rulemaking. There are twenty specific questions about OSA that cover the areas of most interest to federal policy makers.  Address the questions that most closely align with your expertise.  The announcement can be located by going to your Internet browser and searching for these two docket numbers:
FMCSA-2015-0419
FRA-2015-0111
 What You Can Do:
Online:  Go to www.regulations.gov.  Search separately for each docket number listed above. Follow instructions to make comments on each docket number.
  • Present your credentials and relevant experience.
  • Be concise and support your claims.
  • Use scientific evidence from dental sleep medicine. Include scientific studies on oral appliance therapy and your own experience as an expert.  There is the ability to upload documents that support your position.
  • Address trade-offs and opposing views.
  • Include the costs and benefits to patients of your approach. It is especially important for oral appliance therapy to address costs and compliance.
  • Do not attempt any perceived commercialization for your product of services
  • Comments are not votes, but one well supported comment is more influential than a thousand form letters.
DEADINE FOR COMMENTS IS JUNE 8, 2016, 11:59 pm ET
DO NOT let this opportunity pass us by.  If we don’t impress our views on the rule-makers, years will  pass before we can have this chance again.
David Gergen CDT

David Gergen CDT

David Gergen, CDT and President of Pro Player Health Alliance, has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also has been appointed Executive Director of the American Sleep and Breathing Academy Dental Division, a national interdisciplinary academy dedicated to sleep training and education with over 60,000 members. David rolled out of bed on December 4, 1982 and had his career “ah ha” moment. He knew he was going to be an orthodontic technician and he knew he was going to help people all over the country to help treat their sleep disorders in partnership with their dentists. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. He was the personal technician for the likes of 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. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004.

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CBCT for OSA Treatment: A Critical Review

Consensus on Dental Use of CBCT for the Treatment of OSA

(Daniel Klauer, Rob Sutter, Stuart Rich, Steve Carstensen, Todd Morgan, Tim Mickiewicz, Bill Harrell, Dennis Marangos, Rebecca Layhe, Dan Tache, Bradley Eli, John Viviano, Harry Ball, Barry Glassman, Les Priemer, Dan Bruce, Ron Perkins, Ken Luco, Steve Lamberg, Christopher Kelly, Tony Soileau, Douglas Chenin)

The LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on CBCT use in Dental Sleep Medicine. Here is a consensus for all to ponder.

What was asked,

“The Why, When and How of CBCT use for treatment of OSA patients, a candid discussion of what clinicians are currently doing and what is actually supported by the literature. Does it really up our game or are we just complicating the issue?”

What was said,

To start, this topic turned out to be our most heated discussion to date. Who would have thought a discussion about the use of a diagnostic tool could be so contentious? Having said that, writing the consensus article was quite straight forward, let’s discuss the clinical utility of CBCT for oral appliance therapy by category of clinical utility, and see what the “Sayers” and “Ney Sayers” had to say.

 Patient Education and Motivation:

Yay Sayers:

CBCT was discussed as a patient motivator; using CBCT images in a “Show and Tell” fashion to help the patient better visualize their problem. An argument was made that successfully guiding a resistant patient into seeking therapy was a worthwhile tradeoff for the radiation exposure. In defense of this suggestion, it was pointed out that the newer machines use much less radiation. In addition, shifting the view when examining another area could help initiate a discussion about the airway with the patient, making the patient more “Airway Aware”. Finally, using and communicating with this diagnostic modality could help establish relationships with medical colleagues, building better alliances.

Nay Sayers:

Using CBCT “solely” to get people into therapy is unethical. CBCT does not predict the suitability for an oral appliance and does not assess the effectiveness of an oral appliance. Furthermore, there are many cost effective and non-invasive HST’s currently available. How can we justify using anecdotal, non-evidence based, “awake state” predictive factors that expose the patient to radiation when we have reliable, validated instruments that measure outcomes when the patient is actually in the “asleep state”?

Evaluate for dental pathology:

Yay Sayers:

The obvious benefits of evaluating and documenting dental pathology were discussed. In fact, the most meaningful information CBCT provides us pertains to the teeth, supporting periodontal tissues and bony structures. It is simply unsurpassed for this purpose.

Nay Sayers:

Of course, there were no Ney Sayers here, other than this was not the topic of discussion.

Evaluate cervical spine pathologies:

Yay Sayers:

Evaluating for cervical spine pathologies was mentioned a number of times.

Nay Sayers:

Clearly, CBCT is well suited to evaluate and document this issue. However, whether or not this diagnostic investigation should be done by a dentist rather than a physician opens a different discussion all together.

 Evaluate the nose, sinuses for patency and pathology:

Yay Sayers:

Evaluating the nasal airways for patency and pathologies was mentioned a number of times.

Nay Sayers:

CBCT is a very useful tool for evaluating the nose and sinuses for pathology and or major blockage. However, one would think that as a basic screening, simply questioning the patient and testing for patency by having the patient breath through one nostril at a time while blocking the other would suffice. It was also suggested that a Peak Nasal Inspiratory Flow Meter could be used to quickly assess the patency of the nasal airways, a very benign test that does not involve radiation.

Following a non-invasive and simple screening, should further evaluation be warranted, the required imaging could be ordered by the attending surgeon.

 Evaluate TMJ health:

Yay Sayers:

Evaluating the TMJ was mentioned repeatedly, which could provide information useful in appliance selection. When asked how this information would be used, the only thing mentioned was that if DJD was noted, an appliance with freedom of movement would be used facilitating healing of the joint.

Documenting the presentation of the TMJ prior to treatment was also discussed. This would serve to protect a clinician that delivered an oral appliance in a patient with asymptomatic DJD, should the condition be noted at a later date.

It was also suggested that the recent 4d capabilities will allow clinicians to evaluate the TMJ in motion and with protrusion, helpful for case selection, selecting VDO, and predicting TMD risk.

Nay Sayers:

Evaluation for DJD was suggested to ensure that an appliance that did not restrict movement was used for an afflicted patient. However, a number of clinicians mentioned that the exclusive use of appliances that do not restrict movement negates the necessity for this evaluation.

The question then becomes, in the absence of symptoms, is a CBCT of the TMJ necessary and how does it alter clinical decisions. Although I asked this several times, aside from using an appliance that did not restrict jaw movement, no one presented any other use of this information aside from the “CYA” argument.

Evaluation of the Airway to Establish Candidacy or Predict Outcomes:

airway-2

 

Yay Sayers:

It was suggested that in the near future airway space will have an algorithm with a defined risk factor useful for OSA management, and that CBCT is currently useful to verify where the obstruction is, the nasopharynx, oropharynx, or hypopharynx? Further along these lines, some clinicians mentioned that imaging the airway pre and post mandibular repositioning with the bite registration prior to making the appliance helps to ensure airway dimensional improvement that corresponds with literature recommended norms and also helps to determine the amount of advancement and VDO required for an optimum outcome.

Other clinicians were more conservative, stating that there is nothing in the literature at present that shows how an image points to responder vs. non-responder to oral appliance therapy, but perhaps users of CBCT can build data in support of this initiative. In other words CBCT documentation of airway changes associated with oral appliance therapy could provide insights and a body of evidence. It was also suggested that CBCT scans of the airway could be restricted to when the patient’s history suggests further evaluation.

The following citations were provided with the suggestion that there is a trend in the literature that supports using CBCT to predict responders to OAT, acknowledging that more work needs to be done.

Marcussen et al. Do Mandibular Advancement Devices Influence Patients’ Snoring and Obstructive Sleep Apnea? A Cone-Beam Computed Tomography Analysis of the Upper Airway Volume. J Oral Maxillofac Surg. 2015 Sep;73(9):1816-26. doi: 10.1016/j.joms. 2015.02.023. Epub 2015 Feb 26.

Abramson et al. Three-dimensional computed tomographic analysis of airway anatomy in patients with obstructive sleep apnea. J Oral Maxillofac Surg. 2010 Feb;68(2):354-62. doi: 10.1016/j.joms.2009.09.087. Epub 2010 Jan 15.

Cossellu et al. J Craniofac Surg 2015. Three-Dimensional Evaluation of Upper Airway in Patients With Obstructive Sleep Apnea Syndrome During Oral Appliance Therapy

Physical laws such as Poiseuelle’s Law and Bernoulli’s Law of fluid dynamics were cited as rational for using CBCT to ensure the airway increases in size with mandibular advancement.

Pharyngometry was also mentioned as a “Radiation Free” alternative tool to assess the upper airways. Enabling easy assessment of both protrusive and vertical jaw position alteration.

Nay Sayers:

Currently, no literature evidence supporting airway size as measured through CBCT while upright and awake is helpful in establishing a jaw position that ensures or predicts efficacy. Furthermore, physiological factors play a meaningful role too often for it to be exclusively about airway size.

Many clinicians discussed the “pinch point”, which refers to an extreme reduction in airway caliber in either the nasal or oral airways that can be documented using CBCT, representing this as the “source” of the airway problem. However, there is no evidence in the literature that this “Pinch Point” is actually related to the site of airway collapse. In fact, if one reviews the literature about the site of collapse during sleep, it occurs at multiple levels: velopharynx, oropharynx, and/or hypopharynx. Complicating the issue further, the majority of OSA patients exhibit more than one site of upper airway obstruction during sleep and the pattern of these obstructions varies with sleep stage and body position. We have actually known this for a long time.

Morrison et al. Pharyngeal narrowing and closing pressures in patients with obstructive sleep apnea. Am Rev Respir Dis 1993;148:606–611

Hudgel DW. Variable site of airway narrowing among obstructive sleep apnea patients. J Appl Physiol 1986;61: 1403–1409

Boudewyns et al. Site of upper airway obstruction in obstructive sleep apneoa and influence of sleep stage. Eur Respir J 1997;10:2566–2572

So, one has to ask, just how useful is documenting this “Pinch Point” anyway? And, how will it alter clinical decisions?

 We know that the hard tissue contour of a CBCT scan is not related to the soft tissue surface. Validation studies with Sensitivity and Specificity have been performed on hard tissues, but not on soft tissues. So, soft tissue findings on CBCT imaging begs the following question, is it accurate? Without evidence that soft tissue imaging of the upper airway through CBCT is accurate one must question the significance of the finding and whether it is of any importance to the treatment being considered.

On the other hand, the pharyngometer has been validated for accuracy at baseline habitual posture with good sensitivity and specificity. However, it has not been validated at other than baseline posture and this should be done before assuming that moving the jaw does not impact on accuracy of the readings. Then of course, there is the standard argument of awake vs. asleep and upright vs. supine, which applies to both CBCT and Pharyngometry.

It was also suggested that a dentist that does not use CBCT to evaluate the patient’s airway prior to proceeding with an appliance was behaving more like a technician than a dentist. My response to this was,

No, I don’t think we are behaving like technicians by staying on task and using literature based protocols, all the while reducing barriers to therapy by keeping things simple and cost effective.”

 There was no shortage of clinicians with over 20 years of experience expressing the following sentiments:

“Treating to symptom resolution results in better outcomes than treating to changes in airway dimension as documented by CBCT’

 “Surgical procedures such as those performed by an ENT could always be considered if the appliance fails to take care of the problem. Of course, the surgeon you refer to will have their own view on what type of subjective/objective documentation is required; naso-endoscopy, rhinometry, CBCT etc.”

 “CBCT imaging in a dental sleep medicine office setting presents more disadvantages (not useful for screening, possible radiation concerns)…..than benefits at this time”

I published an article entitled “Acoustic Reflection: Review and Clinical Applications for Sleep-Disordered Breathing” in Sleep and Breathing in 2004. At that time I was very excited about the role Pharyngometry “COULD” play in the management of OSA with an oral appliance. However, it is now 2016 and we are still waiting for evidenced based literature on the role it could play. Yet many clinicians’ have been using it routinely, all these years. Bottom line is, many articles have been published on the potential utility of CBCT, but protocols for its application need to be established in an evidence based manner, before we start using it for this purpose on patients, not the other way around as many have suggested. I have yet to see evidence based protocols as to how CBCT derived information can be used to alter appliance construction or adjustment decisions. So, why complicate things. What we do is either evidence based or not. I believe that if we are experimenting on our patients, that fact should be disclosed.

CBCT is very impressive and has many applications. I can definitely see an application for what we do, but further research is needed to establish meaningful protocols. It’s really “Cool” is simply not a sufficient reason to incorporate CBCT into your Dental Sleep Medicine practice. Eckert et al. published a very nice study in 2013 that I believe is relevant to this discussion. Their Conclusions:

“nonanatomic features play an important role in 56% of patients with OSA”.

With “nonanatomical features” having such a high level of influence, I ask, what value can simply evaluating the anatomy be?

Check it out…

http://www.atsjournals.org/doi/full/10.1164/rccm.201303-0448OC#.Vuru0xIrJE4

Quite frankly, regardless of how “Cool” it is and it’s diagnostic acumen regarding other areas, suggesting that CBCT should be a standard of care in Dental Sleep medicine complicates things unnecessarily and serves as a potential “Barrier to Treatment”, which is very much a concern.

To Sum Up:

A number of clinicians stated that the clinical use of CBCT imaging has been established in the trenches but the literature has yet to catch up. Quite frankly, such a comment would never fly in a discussion amongst physicians. Furthermore, any clinician using or providing a service to a patient that is not evidence based should be disclosing that fact to the patient. That disclosure could go something like this,

“we are going to image your airway with a really cool device called CBCT. The image we will be able to look at together will show us in 3D, the size of your airway both at rest and once I advance your jaw. It will be really cool to see the airway get bigger with jaw advancement and exactly just how much the airway enlarges. However, I want you know that there is no way for me to predictively use that information to alter my treatment plan, nor will this information be able to confirm that your oral appliance will adequately mange your sleep apnea. But I assure you, it will be really cool to see”.

Prioritizing the patients’ needs and providing the best service possible was prioritized by some clinicians over additional cost of CBCT imaging. Some pointing out that the cost of a CBCT scan is typically reimbursed by insurance (at least in the US). It was also suggested that perhaps the rational for those against using CBCT is their reluctance to spend the money to purchase a CBCT unit, all interesting points of view, but without literature support regarding how CBCT images can be utilized, these are simply rationalizations in the minds of those clinicians.

 Douglas Chenin, a clinician that is very involved with CBCT earned the right to be “quoted as he wrote it”. I believe Doug’s representation of CBCT is fair and literature based, I thank him for sharing and I feel it is a fair summary of what CBCT brings to the table regarding tha mangement of OSA patients with an oral appliance.

“CBCT imaging provides a tremendous value to us and our patients in helping us see our patient as a whole, as they are in 3D, and how we can better coordinate surgical care with other professionals when needed. The questions that I want to ask with my CBCT scans are:

 “Does my patient have any head and neck, dental/skeletal, sinus and/or TMJ pathology?

 What surgical treatments are essential, recommended, possible or ruled out based on their 3D internal anatomy?”

 As we get more research, perhaps we can add questions like:

 “how predictable” is OAT for specific patients / patient types?

 But by the time we get enough research on this, I hope and think that auto-titration devices with HSTs will be available and will be better for answering this type of question. 

 This does not devalue CBCT at all as CBCT imaging is extremely valuable for answering critical anatomy and pathology related questions that we can’t completely address with intra/extra oral exams, HSTs or health questioners.”

 Trying to answer other questions with our CBCT scans at this point is most likely premature and potentially distracting from the real value of what CBCT imaging can do for us and our patients. I say this as someone who has/is constantly trying to push the limits of CBCT imaging, but nonetheless it’s important to remember what it was designed to do and that it does that extremely well.”

 I would like to express a heartfelt thanks to all that participated in this discussion. As always, these consensus articles should be considered working documents, meant to guide those clinicians new to this field and also present some valuable insights to those of us that have been at it a while. I look forward to future discussions on our SleepDisordersDentistry LinkedIn group!

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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Opposition to Sleep Apnea Screening Testing and Treatment in Transportation grows

The Owner Operator Independent Drivers Association (OOIDA) has, and will probably always be, one of the most vocal trucking industry groups opposing sleep apnea screening testing and treatment in trucking. One of their major valid points of opposition has been the lack of clear peer reviewed studies making a statistically valid correlation between untreated sleep apnea and increased risk of crash. This is a point I have made in previous Sleep Scholar articles.

Recently Burks et al published a new study coming in the journal Sleep “Non-Adherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes.” Information requesting a pre-publication copy of the study can be found at http://www.aasmnet.org/articles.aspx?id=618.

The Burks study is good research using both excellent medical criteria combined with the best of transportation accident analysis to make not only a clear crash risk correlation but make it in preventable crash where all reasonably confounding variable from a transportation crash research standpoint were also controlled.

In an LandLine Magazine Article OOIDA questions the objectivity of the latest study.

www.landlinemag.com/Story.aspx?StoryID=30846

Sleep Scholar readers might enjoy reading how good peer reviewed research is criticized in trucking industry press.

The following was submitted as a letter to the Editor of Landline Magazine. Due to the length it is unlikely to be published by OOIDA.

It is provided here for your reading pleasure.

 

TO THE EDITOR – LANDLINE MAGAZINE

The article “Ooida questions objectivity of latest Sleep Study” got it wrong. Instead of being critical OOIDA should be celebrating it as a victory.

“They” finally did what we’ve been calling for. “They” published good research making a correlation between untreated sleep apnea and increased risk of crash in CMV operators in the US.

Ever since the 2008 MRB-MEP report came out, the research cited to justify sleep apnea screening and testing has been a joke. BUT… here is the problem. Trying to argue against a sleep apnea crash risk correlation is like trying to argue that when it rains water will not flow downhill.

Sleep apnea crash risk has been studied all over the world. It’s been studied in 4 wheelers and truck drivers. It’s been studied using insurance claims data, police accident data, and simulators. In Europe it is accepted as fact to the point that effective January of this year ALL drivers, not just CMV operators, have to be screened for sleep apnea. In the US when it’s been studied, it’s been like studying what happens to water when it falls on a perfectly flat truck stop parking lot. On a truck stop parking lot it doesn’t flow downhill. But, does that change the facts? On the other hand, if you want a truck stop to pay for an expensive storm water system, providing research it’s needed is just common sense. Demanding research like this is part of why public law 113-45 went through Congress with no opposition.

The Parks study showing no sleep apnea crash risk (FMCSA Technical Report 125) looked at older experienced drivers doing local pickup and delivery work where more of them had sleep apnea and compared them to younger drivers doing interstate line haul work. Other studies showing no increased crash risk have just asked drivers “How many accidents have you have in the past (x) years.” Not a good research technique.

This study not only used the most accurate method of testing for sleep apnea, it used reported accidents, DOT reportable accidents and analyzed them for preventability (eliminating accidents that clearly were not the fault of the driver). Drivers in the study had an option to appeal a preventable accident determination. I was a driver at Schneider during the study and was on an accident review board. This study went further than FMCSA has done in CSA. This study looked at accidents per mile driven and accounted for years of driving experience, type of work assignment, age of driver, practically any variable that was controllable that might statistically affect accident rates. The only variable they couldn’t account for was that drivers who refused treatment might have a more general disregard for safety regulations in general. It’s not ethical to conduct research that puts either the participants or the general driving public at risk. You can’t test drivers for sleep apnea and then let some drive without treatment to see what their accident rates are. This study used the best research methods available and did what good research is supposed to do. They discussed the limitations of the study in their conclusions.

The lead author is a former truck driver. The study was funded by 10 different sources of which Schneider was only one. None were groups with an “agenda” like The John Lindsay Foundation, National Sleep Foundation, American Academy of Sleep Medicine, Road Safe America, CRASH, or other safety advocacy groups we are all familiar with. VTTI has published non-peer reviewed research showing sleep apnea crash risk. Fusion Sleep has also published data from their own testing programs. But VTTI is the “pet” researchers for FMCSA and Fusion Sleep publishing its own data is just sales material. This was peer reviewed research published in one of the most respected research journals in the world. I’ve written for the Journal of Clinical Sleep Medicine. Peer review means that other researchers with expertise look at EVERYTHING about your study and critique it. If it’s not correct your study never gets published.

What’s sad is that Schneider has nothing to gain financially from a sleep apnea rule. Its program was actually started by a caring occupational health nurse Wendy Sullivan who was tired of doing return to work exams on drivers hospitalized for conditions aggravated by untreated sleep apnea. Wendy was saying the same thing Dr. John McElligott has been preaching to drivers since I first met him. Untreated sleep apnea is the engine driving many driver health problems.

This is not to say there are not LOTS of other problems to address with sleep apnea rulemaking. Even something as simple as, Who Pays? Just Friday I dealt with another driver popped for a sleep study by a medical examiner. He got a sleep study from a local sleep lab but his insurance denied the claim. The sleep lab is now holding the paper copy of the results hostage until he pays the $ 800 bill. I referred him to a reputable sleep lab (not the one I work for) that will retest him for the OOIDA member price of $ 250. Working with medical examiners we need to develop screening criteria that meet insurance requirements for “medical necessity”.

This study can do real good for drivers. A problem is that sleep apnea can be mild to severe. A problem is determining how bad a driver’s sleep apnea needs to be to warrant requiring treatment or a DQ on a medical card. I have severe sleep apnea. When I think back to what I was like before I got tested and treated it scares the begeebers out of me. But not everyone who has some level of sleep apnea poses the level of safety risk I did before treatment. This study now has accurate sleep study data with good accident records. Follow up research to help set the AHI requiring treatment will help drivers currently being forced into treatment by companies or medical examiners scared about liability, when medically it may not be required.

Instead of trying to question the objectivity of the study, drivers and OOIDA should be chalking this up as a win. Anyone who knows a lot about a particular subject has to make a living. In my opinion the conflicts of interest and objectivity problems raised in the OOIDA article are not valid. If we use the logic of the story, Todd Spencer and Andrew King have conflicts of interest in their quotes as they both receive support from OOIDA. Let’s get real.

Bob Stanton

Conflict of Interest Statement: The author Bob Stanton is a working truck driver and OOIDA member who has been under treatment for severe sleep apnea since 2002. He is the Co-coordinator of Truckers for a Cause a volunteer patient support group for drivers with sleep apnea. He has received consulting fees from Safety First Sleep Solutions and The Center for Sleep Medicine. He currently is an advisor to Dedicated Sleep. He has received donations of CPAP and CPAP supplies from a variety of manufacturers for distribution to drivers in need at major trucking shows. He has authored a variety of articles and made multiple presentations to sleep medicine conferences and groups on the issues involved with sleep apnea screening and testing in CMV operators. See LinkedIn profile for details.

 

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. Truckerdad57@sbcglobal.net

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First Ever Court Ordered Sleep Study

 

Greyhound bus lines recently reached an out of court settlement with 5 passengers injured in a 2013 accident in Monroe Ohio.

http://www.courthousenews.com/2016/03/09/sleep-test-leads-to-6m-greyhound-settlement.htm

The case will be interesting to sleep medicine in that this case may be the first court ordered post accident sleep study. Often the National Transportation Safety Board will obtain post accident sleep studies. But these are obtained under investigative authority of the NTSB.

In this case the driver had gotten a normal DOT medical exam about a month before the crash. At the DOT exam the examiner felt the driver was high risk for sleep apnea and issued a normal 90 day conditional certification pending completion of a sleep study. While waiting to schedule the study, the driver was involved in the crash where his falling asleep at the wheel was an allegation of the plaintiff. The driver and Greyhound claimed he choked on some coffee.

Originally the defense attorneys attempted to block having the driver submit for a sleep study. The trial court and a later appeals court upheld the order for the driver to undergo a sleep study. The driver was positive for moderate to severe sleep apnea. The exact AHI is not released.

At this time other facts about the case are in dispute and may be clarified later.

The concern of many in trucking and other CMV operations is that insurance carriers may not be willing to risk the exposure created by this case in allowing drivers screened high risk but waiting to schedule sleep studies to continue to work.

This may result in a much higher rate of “stat” sleep study requests.

Whether or not a driver screened high risk for sleep apnea should be allowed to drive while waiting for sleep studies is a question posed in the DOT ANPRM discussed elsewhere here on Sleep Scholar.

cpap in truck
CPAP set up on the sleeper of a truck

This case will complicate discussions about testing and treatment of CMV operators. Before HST became the norm for CMV operators often PSG contracts required MD interpretation before 9:00 AM the morning after the study. The intent of these contract requirements was to have the driver pick up a CPAP as per the interpreting MD orders before leaving the sleep lab in the morning.

Sleep medicine professionals should consider comments on the ANPRM about the logistical and managerial issues around executing large numbers of “stat” sleep study interpretations.

 

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. Truckerdad57@sbcglobal.net

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Breaking News “DOT seeks public comment for new regs”

 

DOT begins rulemaking on sleep apnea for CMV operators and rail crews.

The Department of Transportation (DOT) has issued an Advanced Notice of Proposed Rule Making (ANPRM) seeking information on sleep apnea in safety sensitive positions within the Federal Motor Carrier Safety Administration (FMCSA) and Federal Rail Authority (FRA). This link is to a press release on the ANPRM that will give you general information.

https://www.fmcsa.dot.gov/newsroom/us-dot-seeks-input-screening-and-treating-commercial-motor-vehicle-drivers-and-rail-workers

Links within the news release should let you access all 24 pages of the actual ANPRM.

If you are not used to the alphabet soup of FMCSA rulemaking you need to understand this is the first step in a very long process. Elaine Papp former Chief of the FMCSA medical programs office feels that developing a final rule on sleep apnea will take 4-6 years. A major complicating factor will be the new White House administration that will take office. The Administrator of FMCSA is a White House appointment requiring Senate confirmation. Elaine just did an excellent driver friendly radio show podcast explaining this process if you are interested.

http://www.blogtalkradio.com/truthabouttrucking/2016/03/24/driver-fatigue-what-you-need-to-know-about-fmcsa-rulemaking-for-sleep-apnea

Another hurdle this rulemaking will have is passing a White House Office of Management and Budget (OMB) cost effectiveness analysis. Prior to Burks et al discussed later, good research establishing the rate of sleep apnea crash risk was not available. Even with this new data the OMB cost effectiveness analysis will be a hurdle.

This ANPRM is open to public comments from anyone with an interest in the topic. Comments are not limited to medical groups or associations. As of writing there are already 113 comments submitted. While many are from drivers several are from either DOT medical examiners or sleep medicine professionals. The American Academy of Sleep Medicine (AASM) and American Sleep Apnea Association (ASAA) have both expressed plans to submit extensive comments. Comments are due by June 8, 2016. They can be submitted online via the Regulations.gov portal. Docket FMCSA-2015-0419.

The DOT has included 20 questions they are seeking input from stakeholders on. Skip to page 19 of the ANPRM if you want. You can comment on any or all of the questions or just make general comments. Comments that cite specific research or evidence to support your comment often are given more weight in agency deliberations.

Request for Comments

The Agencies request public comment on the questions below. In your response, please provide supporting materials and identify your interest in this rulemaking, whether in the transportation industry, medical profession, or other.

Questions Reprinted From DOT,  ANPRM

(public comment is described in the document)

 

The Problem of OSA

1. What is the prevalence of moderate- to-severe OSA among the general adult U.S. population? How does this prevalence vary by age?

2. What is prevalence of moderate-to- severe OSA among individuals occupying safety sensitive transportation positions? If it differs from that among the general population, why does it appear to do so? If no existing estimates exist, what methods and information sources can the agencies use to reliably estimate this prevalence?

3. Is there information (studies, data, etc.) available for estimating the future consequences resulting from individuals with OSA occupying safety sensitive transportation positions in the absence of new restrictions? For example, does any organization track the number of historical motor carrier or train accidents caused by OSA? With respect to rail, how would any OSA regulations and the current PTC requirements interrelate?

4. Which categories of transportation workers with safety sensitive duties should be required to undergo screening for OSA? On what basis did you identify those workers?

Cost & Benefits

5. What alternative forms and degrees of restriction could FMCSA and FRA place on the performance of safety- sensitive duties by transportation workers with moderate-to-severe OSA, and how effective would these restrictions be in improving transportation safety? Should any regulations differentiate requirements for patients with moderate, as opposed to severe, OSA?

6. What are the potential costs of alternative FMCSA/FRA regulatory actions that would restrict the safety sensitive activities of transportation workers diagnosed with moderate-to- severe OSA? Who would incur those costs? What are the benefits of such actions and who would realize them?

7. What are the potential improved health outcomes for individuals occupying safety sensitive transportation positions and would receive OSA treatment due to regulations?

8. What models or empirical evidence is available to use to estimate potential costs and benefits of alternative restrictions?

9. What costs would be imposed on transportation workers with safety sensitive duties by requiring screening, evaluation, and treatment of OSA?

10. Are there any private or governmental sources of financial assistance? Would health insurance cover costs for screening and/or treatment of OSA?

Screening Procedures & Diagnostics

11. What medical guidelines other than the AASM FAA currently uses are suitable for screening transportation workers with safety sensitive duties that are regulated by FMCSA/FRA for OSA? What level of effectiveness are you seeing with these guidelines?

12. What were the safety performance histories of transportation workers with safety sensitive duties who were diagnosed with moderate-to-severe OSA, who are now successfully compliant with treatment before and after their diagnosis?

13. When and how frequently should transportation workers with safety sensitive duties be screened for OSA? What methods (laboratory, at-home,split, etc.) of diagnosing OSA are appropriate and why?

14. What, if any, restrictions or prohibitions should there be on a transportation workers’ safety sensitive duties while they are being evaluated for moderate-to-severe OSA?

15. What methods are currently employed for providing training or other informational materials about OSA to transportation workers with safety sensitive duties? How effective are these methods at identifying workers with OSA?

Medical Personnel Qualifications & Restrictions

16. What qualifications or credentials are necessary for a medical practitioner who performs OSA screening? What qualifications or credentials are necessary for a medical practitioner who performs the diagnosis and treatment of OSA?

17. With respect to FRA should it use Railroad MEs to perform OSA screening, diagnosis, and treatment?

18. Should MEs or other Agencies’ designated medical practitioners impose restrictions on a transportation worker with safety sensitive duties who self- reports experiencing excessive sleepiness while performing safety sensitive duties?

Treatment Effectiveness

19. What should be the acceptable criteria for evaluating the effectiveness of prescribed treatments for moderate- to-severe OSA?

20. What measures should be used to evaluate whether transportation employees with safety sensitive duties are receiving effective OSA treatment?

There are several efforts underway related to this ANPRM. The AASM leadership along with the AASM Transportation and Safety Task Force are developing comments internally. The American Transportation Research Institute (ATRI) the research arm of the American Trucking Association (ATA) has a data gathering effort among drivers being launched at the Mid America Truck Show in Louisville starting March 31. They will also have data gathering efforts for motor carriers. A special data gathering effort will be directed to sleep medicine testing and treatment firms. Question 9 in the ANPRM asks about testing and treatment costs. An issue that has already come out is that major firms with trucking company contracts are reluctant to share actual cost data, as that is proprietary competitive bidding information. ATRI has a reputation within the trucking industry for doing compilation and aggregation studies of confidential salary, freight rates, turn over, and other sensitive information to produce industry average data. Look for more information on this in future Sleep Scholar articles and in sleep medicine on line news outlets like Sleep Review.

FMCSA Rules
This was a major reason there were calls for FMCSA to clarify OSA issues.

Another breaking news item on the transportation front has been the publication of Burks et al. in Sleep. This news release from the AASM on the study has information on how to request a pre-publication copy. http://www.aasmnet.org/articles.aspx?id=6186 Prior to the publication of Burks the research on sleep apnea crash risk was mixed at best. It has been the topic of a previous Sleep Scholar article of mine and a recent commentary in the Journal of Clinical Sleep Medicine. Burks used data from the Schneider National carrier long standing sleep apnea testing and treatment program. Taking drivers who refused or were never compliant on treatment it analyzed their accident records for the time between diagnosis and termination for cause for non-compliance. Improvements in compliance and removing unsafe non-compliant drivers more quickly has been done since. They used PSG sleep study data from 2005-2008 before HST was widely used. Using a matched pair methodology the study analyzed both sleep apnea and crash in a variety of ways. What is most striking about this study is that it addressed confounding variables in trucking safety such as miles driven, type of driving, experience of driver, and crash preventability. This type of in depth of collaboration between sleep medicine researchers and experts in transportation safety is to be commended. The lead author Stephen Burks is a former truck driver. I am personally proud to have been a driver for Schneider under treatment for sleep apnea during the study period. Research ethics preclude the author confirming if my data was part of the study.

Sleep medicine professionals should carefully address the questions relating to screening for OSA. A current recurring problem is that the screening criteria at times used by DOT medical examiners do not meet the definition of “medical necessity” for testing to be covered by insurance. This is especially true for tests negative for sleep apnea.

Another issue sleep medicine professionals need to address in their comments is striking a balance between screening and testing to ensure no sleep apnea to a medical certainty versus screening and testing to establish a reasonable level of highway safety. Some commenter’s in previous recommendations to FMCSA on sleep apnea have recommended that with a high pre-test probability for OSA that no negative HST be accepted. All negative HST should be confirmed by a PSG. The reaction from trucking has been “After spending $4-500 on an HST that says I don’t have sleep apnea you want me to spend another $ 2,000 on an in-lab study to prove the same thing?” In my personal opinion if recommendations from the sleep medicine community retain this approach to negative testing, the rulemaking will not survive the OMB cost effectiveness analysis.

All CMV drivers have to get a renewed DOT medical exam on a 1 or 2 year cycle depending on a variety of factors. Drivers who had screened high risk and were required to get a sleep study in the past which came back either negative or an AHI low enough to not require treatment (AHI or severity requiring treatment or disqualification for driving is another question) will often screen high risk again. The question requiring comments from sleep medicine will be how long should a negative sleep study be good for? This question was raised in public comments to the 2012 MCSAC-MRB recommendations. The MRB chose not to address it in the final recommendations. Fortunately, in a formal rulemaking like this, FMCSA is legally required to address all reasonable comments. Analysis of change in risk factors along with the type of original test (HST versus PSG) combined with research available on the progression on OSA over time in CMV operators may yield reasonable recommendations.

Those involved with dental sleep medicine should take a careful look at question 16 regarding credentials. They also should look at question 14 about restrictions while undergoing treatment. For oral appliances to be a cost effective option the issues around safety sensitive position workers being able to work while an OAT is being titrated would need to be addressed.

A major research gap dental sleep medicine may have is establishing that drivers being treated with OAT show the same or better actual safety performance than drivers under treatment with other methods such as CPAP. Potential research to address this issue has been discussed but accomplishing and publishing before the June 8 deadline is unrealistic. The problem is that since OAT was not a treatment option recommended by previous FMCSA expert medical panels the pool of study participants is limited. Additionally dental sleep medicine should offer its opinions if compliance monitoring of OAT should be required or just recommended.

A question not even addressed in the ANPRM is: Why isn’t the Federal Aviation Administration (FAA) in this rulemaking? As noted in the preamble to the ANPRM the FAA already has OSA screening and testing requirements for pilots and others requiring Aeromedical exams (AME). The current FAA requirements do NOT require a pilot deemed high risk for OSA by the AME to undergo a sleep study. The pilot’s primary care physician can clear the pilot.

Issues around how the Americans with Disabilities Act (ADA) may play into pre-employment screening or any screening outside of a DOT medical exam will have to be addressed. Those with expertise in sleep medicine may want to look at the base medical qualifications of DOT medical examiners. MD, DO, NP, PA and DC are allowed to train and test to enter the National Registry of Certified Medical Examiners (NRCME) which is required to conduct a DOT medical exam. How scope of practice regulations for Doctors of Chiropractic (DC) will play into screening should be commented on. Sleep medicine professionals should voice their opinion on the appropriateness of OSA screenings conducted by chiropractors. This may require FMCSA to revisit the issue of DC’s being able to conduct DOT exams at all. This is a topic hotly debated among occupational medicine professionals. In my home state of Illinois a DC offering an opinion on any medical condition not commonly treated by a course of chiropractic is a violation of the state chiropractic licensing legislation. On encountering a medical condition not treated by chiropractic a DC may only refer the patient to an appropriate medical professional and may not charge for their services. How this will play out with DC on the NRCME performing OSA screenings and conditional certifications pending a sleep study should be commented on by sleep medicine professionals.

Truckers for a Cause the patient support group for truck drivers with sleep apnea will be doing extensive written comments. We will be developing a collaborative “Google Doc” which we will make accessible through truckersforacause.com. If you have research or objective data addressing any of the ANPRM questions start compiling them or send me an e-mail (truckerdad57@sbcglobal.net) Also please submit your thoughts directly via the regulations.gov portal. From previous rulemakings often vendors or others that due to their employment feel direct public comments might be construed as being an official opinion of their employer are at times reluctant to submit comments. We will attempt to provide an option for these types of commenter’s to provide anonymous input. We hope to have this up in mid May.

Please pass this information on to others in sleep medicine. If you are having a meeting of conference before June, please consider adding this as a topic.

Given how long this has been anticipated the next couple of months will be interesting.

 

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. Truckerdad57@sbcglobal.net

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NFLPA 2016 former players convention with a focus on sleep apnea testing and treatment

Eric Dickerson and David Gergen at 2016 NFLPA Former Players Convention
Eric Dickerson and David Gergen at 2016 NFLPA Former Players Convention

This was the second year that the American Sleep and Breathing Academy and Proplayer Health Alliance attended the NFLPA former players convention. We were busy building relationships with retired players chapter presidents and VP’s. We also demonstrated home sleep testing with the Nox T3 by Carefusion and were able to provide oral appliance therapy for many of the attendees with the Quiet transitional appliance and the Sleep Herbst. We got a chance to catch up with some old friends like Eric Dickerson and Isiah Robertson who have been very helpful with our program and we got to make some new friends like Priest Holmes, Derrik Frost and Reggie Smith.

This is really a great meeting. I continue to be impressed by the work the NFLPA does with retired players and their families. This meeting has a wonderful family feel with ex players and their wives and children getting together for a three day convention the focus on health and wellness is evident with full cardiac screenings, hearing testing and treatment as well as the sleep apnea testing and treatment.

Dr Eugene Azuma from Oahu has earned the right to become the general and sleep apnea dentist for the Honolulu NFLPA former players chapter which is just now being formed. Dr Azuma participated in the NFLPA meeting in Maui where he met future chapter president Leo Goeas retired linebacker who played for the San Diego Chargers, LA/St Louis Rams and the Baltimore Ravens.

Dr Azuma and Erin
Oahu dentist Dr Eugene Azuma ASBA member with his Daughter and Assistant for the weekend Erin Azuma

Dr Azuma said “ this is truly the experience of a lifetime I examined over 20 retired NFL legends with the likes of Eric Dickerson , Priest Holmes and Isiah Robertson. I simply cannot put a price on this experience I recommend that you join the American Sleep and Breathing Academy. I watch a little football but would not consider my self a big fan. Even I know who Eric Dickerson is, he is world famous, and I got to deliver his Sleep Herbst appliance.”

Derrick Frost Nox T3 and ZQuiet
Derrick Frost former NFL punter wearing a Nox T3 by Carefusion and holding a ZQuiet transitional oral appliance

“The concept of using ASBA trained dentists came to me 3 years ago because we needed to deliver the highest possible level of care for the NFL greats. I know that this level of care would only be available if a national training and certification program was in place. My mission is to supply the former players with top trained ASBA dentists throughout the country.” said David Gergen

The next opportunity to become a candidate for ASBA diplomacy is April 17th at the Sleep and Wellness meeting. We have just learned that the room block for the meeting has been filled and registrants are being shifted to the overflow hotel. Shuttles will be running during the meeting to connect the two venues. The number of dentists seeking non vendor training with a diplomacy component is really unprecedented. ASBA is the fastest growing group in the industry. Sadly the meeting is almost fully sold click here to get one of the last registrations.

 

 

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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Sleep, Stress, Depression and the pursuit of a Happy Life

I have a great life! So why do I cry, get depressed, and then get angry so much?

· How does stress affect us?

· Does my sleep have anything to do with it?

· What can I do besides taking medication?

Everyone has emotional highs and lows though out their lives. High school. College. Finding a job. Opening a company. Marriage. Kids. Retirement. As soon as you think you have it all figured out it’s as if life pulls the rug out from under you again. Day to day stress can be overwhelming at times. Waking up on time. Traffic. Work deadlines. Bosses. Picking up kids. Getting to appointments. It never seems to end. The body and mind pays a price for the highs and lows. How much of a price depends on how well your body and mind deals with stress and recovers from it.

We deal with both physical and mental stress by balancing the compounds and hormones that control our emotions. This balance evolved back in time when we lived in caves and had to worry about a lion jumping out of the bushes to eat us. When the lion jumped out we had to make a decision to run for our lives or fight the lion. This is the flight or fight response. One of the main hormones in the flight or fight response is norepinephrine. Don’t worry I promise not to turn this into a biology lecture and keep it simple. Norepinephrine along with cortisol wakes us up in the morning, heightens our arousal, speeds up our heart, and focuses our mind. It helps us make a decision to run as fast as we can from the lion or fight as hard as possible. Too much norepinephrine and our focus turns to agitation, anger, fear, and anxiety. Too much norepinephrine all at once and we have a full blown panic attack. That’s a good thing if a lion just jumped out of the bushes to eat to you. But it’s not a good thing if you’re just trying to get through your day at the office. Too little norepinephrine and we have the opposite effect. We can’t get out of bed. Poor alertness. Memory loss. And eventually depression and ADHD.

GABA is a compound in your brain that lowers norepinephrine levels. We need norepinephrine levels to go up so we can get excited and focus on work and life. And we need GABA to help us calm down when we get too excited and are starting to have anxiety. Glutamate is a chemical that raises norepinephrine levels. We need glutamate to keep our norepinephrine levels up so we don’t give up on things and work through stressful situations. Glutamate helps us go to the gym when we don’t want to by raising norepinephrine levels. And then GABA comes along and helps us slow down so we can get to sleep at night.
To have a happy, productive, and fulfilled life we need to have our norepinephrine levels kept in balance by GABA and glutamate. There are many other compounds and hormones that play a role in keeping our emotions balanced. I am just talking about these three to illustrate the point without over complicating the issue.

When you talk to your doctor about emotional, anxiety, depression, or sleeping problems their first choice is usually to try to balance the hormones in your brain with medications. If you have anxiety, fear, irritability, tremors, and insomnia these are common symptoms with too much norepinephrine. In these cases medication is prescribed to lower norepinephrine levels by increasing GABA levels. Medications that boost GABA levels include Xanax, Ativan, and Valium. These types of medications produce a calming effect by boosting GABA levels and thereby lowering norepinephrine levels. The reason you should never stop taking the drugs suddenly is because your brain may be dependent on the drug for appropriate GABA levels. Sudden withdrawal can lead to high levels of norepinephrine. This can cause your brain to become extremely stimulated resulting in seizures.

Treating depression and ADHD caused by low levels of norepinephrine is the opposite approach. Stimulants such as Prozac, Paxil, and Zoloft promote increase levels of glutamate to raise norepinephrine levels. The reason to never stop taking stimulate type medications suddenly is because the sudden drop in norepinephrine can lead to sever depression and suicide.

So at this point I hoped I have done a good job of explaining why you may be having problems with your emotions and what your medical doctor is trying to accomplish with anxiety and depression medications. And certainly there are natural ways to deal with our norepinephrine balance using exercise, medication, and diet. But we still have not asked a very good question. WHY are the hormones in your brain unbalanced in the first place? You’re not just crazy. Did you just have a very stressful event such as a divorce or death of a loved one? Or maybe a serious physical injury? Certainly this can upset the balance of our emotions. And for a brief time you may need help with medications to keep the balance in check. But after a brief time you should be able to bounce back as the hormones become balanced again.

Taking antianxiety meds to fall asleep and highly caffeinated drinks to get going in the morning is not a good way to live. What’s keeping the balance from coming back?

I certainly don’t have all the answers to what’s keeping your emotions unbalanced. But I can share a common reason that is often overlooked. Sleep apnea. Sleep apnea is when you don’t get enough air at night while you are sleeping. It starts as snoring. Snoring is when the air is starting to get hung up in your throat and makes the tissue vibrate. Then the air gets completely blocked for short periods of time. This is sleep apnea. Remember earlier when we talked about the lion and flight or fight response? Well drowning would cause the same response. You would panic and fight to stay above water. Sleep apnea is a form of drowning. Instead of not getting air because you’re underwater you’re not getting air because your throat is blocked. The body responds in the same way. The fight or flight response kicks in and glutamate is increased causing an increase in norepinephrine. This response wakes you up so you take a breath of air and causes your heart to race to get more oxygen to your brain. This is a needed response. But it also broke your sleep cycle. So you woke up feeling exhausted because you had norepinephrine stimulating your brain all night.

If this pattern of not breathing while you’re sleeping continues to flood your brain with norepinephrine it will eventually begin to affect the control of your emotions.

Will treating your snoring and sleep apnea fix your emotional problems? Maybe. At the very least it will help you feel better and may allow your doctor to cut back on your medication levels. I am confident your doctor will agree getting deep therapeutic sleep every night is essential to emotional wellbeing.

The only way to find out if you have sleep apnea is with a sleep study. A sleep study can be done at home or in a sleep center. The home studies are the type my patients most often choose. It’s very easy to take. You wear a measuring device that is about the size of a cell phone. It has a strap that goes around your chest. A pulse ox meter goes on your finger. And a nasal tube is secured by your nose. You wear it overnight. You sleep in any position you want and in your own bed. The next morning you bring it back to our office or FEDX it to us. We then download the data. It tells us all we need to know about what’s happening while you sleep.

If it turns out you do have sleep apnea we can fit you with a dental mouth piece that allows air to get past your tongue and into your lungs. You do not have to sleep with a CPAP if you do not chose to. In a short time your sleeping will improve. I share all your sleep progress with your other doctors. They can then start to lower your medication as possible until you no longer need them. And you’re now waking up feeling amazing every morning.

If you live in the Lafayette Louisiana area we put on free seminars each month to the public about sleep apnea, the health problems associated with it, and how we can treat it without a CPAP. We are in network with most medical insurance companies. Call our Louisiana Sleep Solutions office and my team will be happy to answer any questions you may have.

If you don’t live near us talk to the doctor prescribing your medications about a sleep study. Or ask your dentist if he/she treats sleep apnea.

Tony Soileau DDS

Tony Soileau DDS

Dr Tony is a general dentist from Lafayette, Louisiana. He was born and raised in Pine Prairie, Louisiana. His practice focuses on restorative, cosmetic, and family dentistry as well as sleep apnea treatments other than a CPAP and TMJ. Dr Tony graduated from LSU School of Dentistry in New Orleans in 1994. He has been president of his local dental society and is an associate professor at LSU School of Dentistry. He has been a faculty member of the Institute of Oral Art and Design (IOAD) in Tampa, Florida and the Pacific Aesthetic Continuum (PAC~Live) in San Francisco. He is a member of the ADDA, LDA, ADA, AGD, AACD, and has his Fellowship in the Academy of Comprehensive Esthetics. He has published over 50 articles on cosmetic dentistry. In addition to being a published author he has and continues to lecture both nationally and internationally on cosmetic dentistry as well as treatment of sleep apnea.

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