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Documentation of Bite Change in Oral Appliance Therapy

To Serve and Protect

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

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

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

Wayne Halstrom

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

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The Use of ApneaRx in a Diagnostic Setting

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

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

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

Randy Clare

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

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sleep position - Bryan Keropian DDS

Home Sleep Testing is Essential for Dental Treatment of Sleep Apnea

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

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

John Viviano DDS

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

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

A Personal Story- Louis Chmura DDS, MS

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

Previously publish in Orthodontic Products Magazine

 

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

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

Louis Chmura DDS

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

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Dr. Erin Elliott

ONE-ON-ONE with Dr. Michael DiTolla

This interview was previously published in Chairside Dental Magazine Digital Edition

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

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

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

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Erin Elliott

Erin Elliott

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

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Narval CC Resmed

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

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

 

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

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John Viviano DDS

John Viviano DDS

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

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Dr Chmura Orthodontist

Oral Appliance Therapy for OSA the Orthodontic Approach

I just finished presenting strategies for home sleep testing and the Nox T3 at a Henry Schein Orthodontic sleep course in Savannah Georgia. These courses are designed for the orthodontist who wishes to add Sleep Apnea Therapy to their practice. The presenter was Dr Lou Chmura a Michigan orthodontist who has an terrific presentation style, engaging and passionate.  I have been attending meetings like this for over 20 years. This series of lectures are presented from an orthodontic perspective (naturally). I was surprised at the different point of view from the meetings I typically attend which are geared to general dentists. I highly recommend this lecture for Ortho minded practitioners with an interest in Sleep Apnea. I also have to commend the organization team, lead by Marie Gerson, this program is extremely well organized and the followup and implementation program is the best that I have seen.

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Randy Clare

Randy Clare

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

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Richard Klien

American Sleep And Breathing Academy – A Great Group to Join

Below is a letter I recieved from Dr Richard Klien after that 2015 ASBA Sleep Conference in Scottsdale Arizona. It is great to have positive feedback as the course come to a close and we begin planning ASBA Sleep Conference 2016.

20150410_101013 (1)
David Gergen with Congressman Marty Russo at ASBA 2015 meeting in Scottsdale AZ

 

 

 

 

 

 

 

 

 

There comes a time when an organization or a team has its epiphany on its path to greatness.  I saw this moment in Scottsdale.  “A real team consists of many people of different talents, different personalities and different abilities working together for a heartfelt mutual goal and who look at each other as equals in the fabric of life and soul mates in the concert of their jobs.  They work together and outclass other teams who consist of even one individual is not a team player.”  That is a statement I coined 25 years ago and  is on the wall at my office.  Most of my staff who have been with me almost all of those years, adhere, understand and believe in that statement.  I got that feeling in Scottsdale again.

 

In comparisons to other conventions and seminars I’ve attended over the past several decades, I was pleased that not one of the multiple presenters simply read one of their published articles.  I enjoy reading these topics in the comfort of my own home. I also refreshingly didn’t have to listen to a presenter rehash in their own words, a topic already explained by a previous presenter.  Credit and kudos to David Gergen and Alan Hickey for organizing this excellent event.  The 2 days of advanced education and professional mingling were worth every dime donated and moment spent.

Dave Gergen promises next year will be even better.  I can’t fathom how that could possibly happen, but I certainly look forward to finding that out.  I hope to see you there and agreeing with David’s prediction for next year.

Among the multiple physician and dental speakers was a presenter, Mack Newton. Marks credentials in tae kwon-do and athletic training are unsurpassed. He not only holds multiple ASBA Crowdworld championships, but his life’s work includes  long term conditioning coaching for the MLB and NFL.  His message was clear and as emotionally poignant as any I’ve heard from  world famous motivation speakers.  Believe in what you do, be a champion at it and you will be a champion.  Those of you who have spent many more hours dedicating advancing your career in TMD and Sleep Apnea are indeed champions, as he stated.  Toward the end, and at the end, of his time on the podium, you could not only hear a pin drop…  I believe I heard some tears drop.  The man’s message was heard through the ears and felt into the hearts of everyone in that auditorium.  It was at that moment I felt the realization spreading through the entire hundreds in attendance.

This is a special organization.  It was obvious, as that diverse encompassing and sharing of sleep knowledge with sleep professionals in all aspects of sleep, looked around at their surroundings and looked into their hearts with understanding.

It truly takes a team to extend, enhance and save a sleep apnic’s life.  A third baseman, a guard, a quarterback, a goalie while standing alone cannot win at their game.  The american sleep and breathing academy is well positioned to exponentially help all professionals correlate their care, salvage sleep, unbachlorize  the bedroom, activate more accurate public awareness.

It is an organization I and we all should be quite proud of belonging to.  .

 

Richard KlienRichard Klien Treats and teaches Temporomandibular Disorders and its pain management, as well as Obstructive Sleep Apnea , for 30+ years.
He teaches Grand Round noon lectures monthly for over a decade at St John Oakland and Macomb Hospitals as well as a Henry Ford Hospital. He often lectures to resident doctors and typically focuses on topics such as pain management, temporomandibular joint (TMJ) disorders, sleep medicine and obstructive sleep apnea. I also interject experiences

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Randy Clare

Randy Clare

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

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Dr. Erin Elliott

Turning Consultations into Impressions, or ‘The tale of three blondes’

This article was previously published in the March 2015 issue of DE Dental Economics

IT HAS RECENTLY COME TO MY ATTENTION that patients who
visit my office are often confused — but not because we don’t
explain ourselves clearly and not because we don’t answer
questions proficiently. Instead, it happens because we have three
blondes as part of our dental sleep medicine (DSM) team.

You see, it is our goal to take impressions at every consultation appointment for patients who have had sleep
studies. In order to do so, Bri handles our iPad consultation, which includes overviews of sleep apnea,health sequelae, sleep hygiene, treatment options, and finally, the oral appliances we provide.

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Erin Elliott

Erin Elliott

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

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www.statdds.com

Stop Making Bruxism Appliances Immediately: Louis Malcmacher, DDS, MAGD

This article was previously published in DE dental economics March 2015

ONE OF THE MOST COMMON CAUSES OF BRUXISM will surprise many of you reading this article. Here’s a hint: It’s related to sleep. Let’s look at some facts: Dental sleep medicine is a fast-growing area of dentistry. Of the approximately 40 million people in the U.S. with obstructive sleep apnea (OSA), 90% are undiagnosed. Simply put, obstructive sleep apnea is a medical condition whereby a physical obstruction ( for example, tongue or pharyngeal muscles) blocks the airway, which stops the patient from breathing while he or she sleeps. Patients with OSA will have multiple apneas/hypopneas every night while they sleep, which can severely impact their health. OSA is comorbid with and dramatically increases the incidence and severity of diabetes, hypertension, stroke, and heart attacks in patients (and let’s not forget that dentists are patients too). Bruxism, TMJ, and orofacial pain are also very commonly comorbid with OSA. As a matter of evidence-based fact, sleep-disordered breathing causes bruxism. The connection is this: What is the brain’s mechanism to get patients to breathe when they have a blocked airway causing an apnea? The brain needs to open the airway and get the muscles of mastication to start working hard and fast, a process we know as bruxism. The masticatory muscles move the jaw forward, the airway opens, and the patient takes in a deep rescue breath. The patient falls back asleep, the airway gets blocked, and the process repeats many times during the night. This is known in evidence-based studies as sleep bruxism.Nox T3 by CareFusion

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Randy Clare

Randy Clare

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

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