AMA Sounds the Alarm on “Massive Job Loss” Under Sequestration

The government calls it “sequestration,” but various health care sectors may soon refer to it as “slash and burn.” A report n the American Medical Association’s sounded the alarm last week, raising the specter of a whopping half million jobs lost in 2013.

Advocates have warned throughout the year that mandatory, across-the-board spending cuts to Medicare in 2013 were set to take effect, but a study by a Pittsburgh-based research firm called Tripp Umbach has brought new urgency. According to the AMA report, the study examined the likely economic fallout of the 2% cut to the Medicare program over the next 8 years, which experts say is the result of disputes over the Budget Control Act of 2011.

The AMA’s analysis of the Tripp Umbach study concludes that the automatic budget reductions amount to between $10.7 billion and $16.4 billion in annual cuts to Medicare, and will lead to 496,000 jobs being eliminated in 2013— and a loss of 766,000 jobs by 2021.

According to Charles Fiegl, writer for amednews, representatives of the American Hospital Association, which funded the study, joined the AMA, American Nurses Association, and researchers for a September 12 briefing at the National Press Club in Washington to discuss the report’s findings. Fiegl quotes Paul Umbach, senior researcher, as saying that sequestration “would pretty much wipe out all the gains that we’ve seen since 2008” and “You pretty much see a net decrease in as many jobs that have been created.”

Physicians would reportedly not escape the effects, with 62,000 jobs predicted to disappear. The losses would stem from “hiring freezes, layoffs, holds on capital projects, and delays in other practice investments.”

Click here for the full American Medical Association report.

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Heated Wall Tubing: Ahead of its time?

The benefits of CPAP heated humidification are numerous, but why hasn’t the establishment fully embraced heated wall tubing as a way to minimize rainout? Sleep veteran Thomas K. Speer, PhD, D,ABSM, believes the answer lies in an all-too-familiar tendency of industry organizations to drag their feet when it comes to something new.

As the owner/founder of Houston-based Sleep Interpretations Unlimited, Speer works on the opposite end of the spectrum where he is quick to adapt what works. “If you look at the practice drivers at the American Academy of Sleep Medicine, they don’t even mention heated wall tubing,” says Speer. “They probably have not addressed the issue in 5 years. It’s just not on their radar.”

While Speer’s company primarily provides sleep interpretations of polysomnographic evaluations for physicians, he also works with patients and has a vested interest in finding out what works. That interest has lead Speer to several studies over the years, the latest of which explored the “effect of heated wall tubing with heated humidification on PAP usage at 30 days post CPAP initiation.” In this study, Speer acknowledges that under a variety of temperature settings the problem of condensation has interrupted sleep and lead to limited use. The study compared heated humidification using heated wall tubing in a closed system that adjusts temperature in the tube to a system that has constant temperature in the heated wall tubing under real-use conditions.

Study Methods
Study enrollment included 42 patients diagnosed with OSA who had been referred for initiation of PAP therapy. All randomly selected patients had successfully completed 30 days of usage.

Group one used heated wall tubing that was added to the system with its own power supply (Hybernite from Plastiflex Healthcare), while group two used integrated heated wall tubing with auto heat control of the humidifier (ClimateLine™ from ResMed Inc). The matched control group used an integrated heated humidifier with device.

The humidifier setting for group one and the control group was set at two.

Average daily use was statistically different between the two treatment groups and matched controls over the first 30 days of use. Average time of use for group two (ClimateLine) was 6.8 hours, while the average time for group one (Hybernite) and the controls was 5.8 hours.

Average CPAP pressure in the combined groups was 11.4 cm H2O with SD = 0.29. There were no statistical differences on general demographic parameters and severity of OSA (average AHI = 28.8 and SD=3.1).

After evaluating all data, Speer concluded that heated wall tubing could produce improved adherence to PAP therapy. However, temperature and humidity at the interface affect overall usage.

Hybernite Improves with Humidifier Setting
Speer determined that the Hybernite’s performance could be attributed to the humidifier setting. “When you have the humidifier set at two, there is not enough heat from the plate to make it that much different then the control,” explains Speer. “We had the ResMed ClimateLine on the auto setting, which means the heated plate would increase and decrease automatically based on a hose setting at 82 to 85 degrees.

“In a follow-up, we increased the temperature on the Hybernite from two to four, and we got much better results,” continues Speer. “The takeaway is that most people don’t turn the humidifier up above two.”

The existence of both brands points to the fact that people need humidification and rainout must be controlled for maximum compliance. “If you take away humidity, you are going to have to increase pressure because of nasal resistance over time,” says Speer, who also serves as a sight visitor for AASM accreditation. “If you increase humidity without rainout, you lower pressure and increase usage. That is a great combination.”

Large Corporations Bring Marketing Muscle
With ResMed and Respironics throwing their hats into the heated tubing ring, awareness is bound to grow. While Speer believes that added visibility is a good thing, he is also convinced that smaller companies such as Plastiflex Healthcare’s Hybernite can ultimately compete.

Other companies such as Fisher & Paykel have invested in heated tube technology, but the largest corporations will inevitably transform the market. “Everybody else that makes a box is going to have to find a way to put heated wall tubing on it just to compete,” muses Speer. “For the moment, there is a reimbursement differential for heated wall tubing. That is, you can make more money with it. And if you generate more money with something, it will probably thrive.”

The Big Picture
Speer laments that the sleep field has not historically done well with compliance, and the big issue is usually nasal dryness, dry mouth, and oral breathing—especially now that CPAP pressures are increasing. Ultimately, CPAP borrowed from another piece of technology. “Ventilators have been using heated wall tubing for 20 years in the ICU,” says Speer. “When it became available with ResMed’s S9 platform, it was not available for other units. Plastiflex came along and had a universal heated tubing that could be added to any device. The resulting Hybernite is cost effective to the patient and delivers a positive outcome.

Ultimately, heated tubing is another option, one of many, that can boost crucial compliance rates. More options, says Speer, will lead to more patient diversity. “The average patient in the sleep labs is an overweight male in his 50s with comorbidities,” he says. “Various things such as provent therapy and oral appliances are of value in getting these patients into the stream of treatment. I’ll use breathe right strips or whatever it takes to get a patient into treatment. There is no need for turf wars. This is about helping patients and there are plenty of patients to go around.”

Thomas K. Speer PhD, D, ABSM began his sleep medicine practice in Houston in 1992.  He was the director of the Institute of Sleep Medicine at the Diagnostic Clinic and has served as the director of Sleep Centers of Texas.  For the past ten years, he has had his own practice, focusing on therapies for sleep apnea and other therapies for insomnia (cognitive behavioral therapy – insomnia), CPAP desensitization and support, and circadian rhythm disorders, including bright-light therapy. He is a Fellow of the American Academy of Sleep Medicine and has been an accreditation site visitor for the Academy since 2007.  He is board certified by the American Board of Sleep Medicine and is licensed as a psychologist by the Texas State Board of Examiners of Psychologists and a member of the American Psychological Association since 1988.

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Sleep Bruxism Clinical Decision Matrix based on Objective Evidence

Introduction: There are a number of decisions many clinicians make with regard to patients with craniofacial pain and sleep related issues that could be enhanced and\or supported by objectively measuring the jaw EMG musculature.  It is widely understood these issues are sometimes related and at other times are not related.  To further complicate sometimes sleep and jaw-EMG  problems exist as two separate issues or one is masked by the other.

For example, a 48yo male patient, BMI 33, is in your office complaining of jaw pain, regular headaches, damaged teeth, and jaw clicking and excessive daytime sleepiness (EDS).

  • Are the headaches from hypoxemia or bruxism?
  • Is the EDS from chronic pain or OSA?
  • Does a relationship exist between apneas and teeth grinding?

We propose to measure these types of patients with an HST which includes jaw EMG monitoring   to objectively measure the status of these complex complaints.  However because there is not a

Nox T3 by Carefusion medical grade sleep Bruxism monitor
Home Sleep Test Nox T3 by CareFusion

large body of evidence on these types of patients we would like to propose the following:

The purpose of this document is to standardize criteria of bruxism\Jaw EMG activity for data collected in the home environment using typical HST equipment and associated software.

Monitoring jaw EMG during sleep can provide critical insight into a patient’s condition as it relates to TMJ, jaw pain and sleep complaints.  Moreover, progress can be measured during the therapeutic process over time to correlate with patient feedback.

Measuring the jaw muscle while the patient is awake many times does not measure the problem but rather measures the patient’s ability to respond to a verbal command to use the jaw muscle.  The issue as it relates to TMJ is largely an involuntary muscle problem.  Moreover, much of the activity which causes tooth damage and TMJ symptoms occur while the patient is asleep or sub-consciously.  For these reasons, it makes sense to measure the issue during sleep.

Another reason to standardize scoring of jaw EMG activity is to categorize the physiological environment in which these jaw EMG events occur.  For example, some EMG events occur in apparent isolation, no obvious trigger or observed association, while other jaw EMG events appear to be caused by other events occurring in relative close temporal proximity.  Many of us are tempted to associate a causal effect.    With enough observed and standardized data, we believe good data can be used to make more effective clinical decisions.

Previous work in this area by Gilles Lavigne and others have yielded basic event types
Phasic, Tonic and Mixed which have gained acceptance but is not typically measured, even in the attended sleep lab environment.  The reasons for this are outside the scope of this document but I call upon the leadership in dental sleep medicine and craniofacial pain to come together and coalesce around the idea that collecting this data can be routine and of immense benefit to treat patients with some combination of these disorders.

Sample events described by Giles Lavigne et. Al.  top-Phasic, middle-Tonic, bottom -Mixed

3 types of events - Phasic, Tonic and Mixed

In addition to Phasic, Tonic and Mixed events we propose another criteria for categorizing jaw EMG activity which takes into account the overall physiological environment in which these events occur.

In order to achieve a more complete physiological environment more data needs to be collected and we collect the following parameters:

  • SPO2,
  • Heart Rate,
  • Pleth waveform,
  • 2 channels of respiratory effort (RIP) ribcage and abdomen,
  • Body position,
  • Audio recording (snoring and tooth clicking),
  • Pressure nasal\oral flow
  • Actigraphy – predicts movement associated with arousal-wakefulness
  • 2 channel amplifier – user defined (ExG)

It is important to remember the average patient with limited instruction can successfully collect this data.  Technically speaking this type of data was only available in the sleep labs which in of itself presented a barrier to the majority of clinicians treating patient with craniofacial pain and\or TMJ issues.  HST technology has advanced sufficiently to allow for both the jaw EMG and HST parameters to be collected.  These advancements will contribute to the success of dentist practicing sleep medicine and craniofacial pain clinics as the Sleep\TMJ link can now be monitored by a specialist on patients using HST technology.

Tonic - Isolated



EMG Proceeds Apnea

Jaw EMG with tooth sound

Low amplitude frequent

Frequent low amplitude and some high amplitude

Snoring and Jaw EMG


Glossary of Jaw EMG Activity

ISOLATED GROUP – No observed proceeding event

Idiopathic 1




ASSOCIATED GROUP – The Jaw EMG event occurred during any type of respiratory event or within 5 seconds after a respiratory event. Often times occur with other types of EMG activity associated with a respiratory event.

Infrequent high amplitude


End run

Summary:  The purpose of this document is to develop clinical decision support (CDS)  matrix based on objective evidence from a fairly large body of evidence.     The CDS recommendations will be born from experts reviewing the type of data contained in this document collected in the home environment using controlled data collection techniques.
Jeffory Wyscarver, RPSGT

For more detailed information on the Nox T3 by Carefusion click:

Jeff Wyscarver RPSGT

Jeff Wyscarver RPSGT

I have extensive experience managing medical products (downstream) as well as developing new products (upstream). Furthermore I excel at thinking strategically in rapidly changing markets. Recently I and my business partners were issued a provisional patent. Once our product is cleared by the FDA, the business of commercializing this innovative approach to treating symptoms of snoring, apnea and bruxism will be first and foremost. Specialties: Regulatory Affairs, Product Development and Management Registered Polysomnographic Technician (RPSGT)

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American Legion Sleep Apnea Awareness

David Gergen CDT President of Pro Player Health Alliance and Dr Steve Marinkovitch DDS of Tacoma made a presentation to the 4th district of the American Legion on the dangers of untreated sleep apnea and daytime sleepiness.  This talk was attended by over 130 veterans many of whom have been diagnosed with sleep apnea and have completed a CPAP titration or were currently under treatment for their condition. Dr. Marinkovitch lead an in depth discussion on the treatment modalities available including CPAP, Oral Appliances and Surgery. There were many questions about comorbidities such as diabetes, congestive heart failure, hypertension and obesity. The dangers of daytime sleepiness and drowsy driving was also very much on the minds of the Legionaires.

After the presentation, David Gergen CDT conducted an oral appliance therapy “show and tell” where Seth C Bowles 4th District Commander was heard to say “I am so surprised at how small the Herbst and Respire appliances are compared to wearing that mask”. Mr Bowles has been on CPAP for some years and while he feels that the CPAP is “like a vacuum in reverse” he is generally compliant with his CPAP.

David Gergen CDT was very clear in his talk that “treatment is a necessity for quality of life. Make sure you see a physician for a diagnosis, then get treated. It is important that you sleep well and are able to stay awake when you are driving”. The VA has a very good sleep diagnostic facility in Seattle and I would expect that their phone was ringing this week.

Dr. Steve Marinkovich, DDS, ABDSM, is joining the national “Tackle Sleep Apnea” campaign in efforts to spread awareness on sleep apnea, the health dangers and possible treatment options. The Campaign will be holding its fourth event, in a series of events, that will be taking place at LeMay, America’s Car Museum, on September 26. The event will begin at 7 p.m. and is free to the public. The museum is located at 2702 E. “D” St.




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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Puget Sound Sleep Scholar Study Club


Dentists have many choices for training to treat sleep apnea and snoring. Once the basics are understood, however, there are few options to explore the vast amount of learning needed to achieve mastery.  Puget Sound Sleep Scholar Study Club will give participants the opportunity to expand their understanding of sleep disorders and therapeutic options. The emphasis will always be on practical matters and how to achieve positive outcomes for the patients, the practice, and the dentist-physician relationship.

Introducing medical therapy into a dental practice creates many opportunities to design systems and create culture. Establishing best practices for medical procedures will give the dental team confidence and create solid operating systems.  If the dentist intends to seek ABDSM Diplomate status or AADSM Facility Accreditation, work done through the Puget Sound Sleep Scholar Study Club will provide much of the required material.


Meet the Mentors:

Steve Carstensen DDS FAGD, in restorative dental practice since 1983, has been an educator for many years. Since 1996 an invited Visiting Faculty member of the Pankey Institute for Advanced Dental Education, a guest lecturer for the Pride Institute, speaker at study clubs, regional and national dental conferences, and currently a faculty member of SomnoMed Academy. After completing a four year term on the ADA’s Council for the Annual Session, including chairing the 2010 meeting, he created and became Course Director for the Sleep Course at Pankey Institute. Also serves as Sleep Advisor to Spear Education.

Steve achieved Board Certification by the American Board of Dental Sleep Medicine in 2006 and has created good working relationships with every sleep physician in the Seattle area.

Randy Clare,  has been involved in the sleep industry since 1993. Randy has been working with Dentists and  Physicians to provide high quality care for their patients. This has required a broad  range of skills  in sales and marketing that will help build any practice. Randy has an intense interest in the diagnosis and treatment of OSA. He has served as mentor of the Scottsdale Study Club in the past and is looking forward to this new group.



Community Meetings

Puget Sound Sleep Scholar Study Club core curriculum will be realized over four modules of two day community meetings with individual practice assignments between events. Since dentists can clearly not achieve excellence without support, involving team members will be part of each community meeting and will have specialized learning opportunities aimed at their areas of responsibility.

This will not be simply another series of lectures.  Peer to peer learning in community is one of the most powerful tools available in education, and PSSSSC will take full advantage of the wisdom in the room to ensure that each participant is given the chance to maximize value for the time and resources committed to involvement.



  • Day One

Participants will establish the goals of the community and individual members.  Requirements of Diplomate achievement and Facility Accreditation will be discussed so practices can begin to choose whether to adopt these benchmarks. We will also discuss how case presentations are put together for this group; assembling patient data in this manner will prepare the attendee for reports necessary for Diplomate application.

A discussion of the medical model and the legal requirements for treating sleep patients, including HIPAA, ICD and CPT coding by appointments necessary.  Medicare protocols, enrollment, and regulations will be detailed.

  • Day Two

The examination process and record keeping for medical patients is significantly different than for dental patients. These details will be examined and practiced within the community.  We will discuss various ways of keeping records and the pros, cons, and experiences of the members with each.

Reading sleep reports provided by the sleep physicians is a key to understanding treatment choices, strategies, and how to measure outcomes. Members will read and discuss several sleep reports until they can extract the necessary data.





  • Day One

Each attendee will present at least one case for group discussion. This will be the safest possible environment to gain confidence in presentation skills and data gathering.  Positive treatment outcome is not required; emphasis will always be on what the team learned during the case and what the community can learn from the discussion. This module will emphasize patient acquisition, entry into the practice, and appliance choice.

Out of Center Sleep Tests are becoming more common in sleep treatment; several devices will be examined and positives and negatives of each can be discussed.

  • Day Two

Members of Puget Sound Sleep Scholar Community will learn to understand PAP therapy. An experienced respiratory therapist will demonstrate various flow generators, masks, and discuss how patients are treated during that phase of therapy. Compliance issues and strategies to increase patient use rates employed by therapists will be discussed.

An important adjunctive therapy to sleep is Cognitive Behavioral Therapy.  A local physician who spent years as a sleep physician and later became a psychiatrist to help patients with CBT will present the value of having such a practitioner on your sleep team.


  • Day One

Case presentations by each member will generate learning opportunities for the entire community, with an emphasis on dealing with post insertion complications and strategies for dealing with what patients present.  Ongoing case management protocols will be discussed, including understanding when it is appropriate to perform an OCST and when it is best to return the patient to the diagnosing sleep physician.

There will be a unique opportunity to experience polysomnography.  An overnight sleep test will be arranged with a local accredited sleep lab and attendees will observe hooking up of a sleep patient and subsequent titration on a clinical CPAP device.  On the second night, a patient will have an OA that will be similarly titrated.  Two attendees will be given the opportunity to test an OCST and have the scores interpreted by the technician and the community.  This module will satisfy the requirements of the ABDSM Diplomate application.


  • Day Two

Marketing your sleep practice is key to success.  We will explore as a community what has been successful and not successful in each practice.  Members will bring their marketing materials and share their stories. Outcome of this discussion will include specific steps each member team will take and a timeline for implementation.

Nutrition counseling is an area many sleep patients can benefit from but often find difficult to source. It is challenging for a dental office to add this service, but awareness of what is available may help manage the patient treatment.  A registered nutritionist who is used to working with obese patients and aware of sleep breathing issues will guide a discussion of possibilities.



  • Day One

Each member will bring a case for discussion with an emphasis on patients converted from CPAP to OAT and/or using both therapies in combination, hybrid or alternate.

Medical billing will also be discussed this day, with an experienced medical coder leading the group through some of the details associated with billing and gaining network status. 

Pediatric sleep medicine will be presented by a Board Certified sleep physician specializing in this area.

  • Day Two

Sleep Bruxism will be discussed in detail; what is known of the etiology, expression and treatment of this condition so often associated with sleep apnea. TMD and other muscle function disorders will be included. The experience  of community members will be valuable as various treatment strategies are discussed.

The rest of this day will be reserved to wrap up questions in the community about ABDSM Diplomate application and Facility Accreditation requirements, as well as any other topic about best practices that is relevant.



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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Dental sleep medicine economics: A vast bite-wing conspiracy?

by Barry Glassman, DMD

I want to bring some reality to the economics of dental sleep medicine, an area for dentists that is being promoted by many as a new profit center in the dental practice. There is no question that adding this valuable service to your armamentarium has the potential not only to improve the quality of lives of many of your patients, but also provide increased income.

Along with the ability to increase services and income, dental sleep medicine provides many new challenges to the dentist that are often ignored or underestimated. Only if these challenges are recognized and conquered will the dentist be in a position to provide a therapy that could be essential to the patient’s quality of life.

What is dental sleep medicine?

Sleep medicine is a relatively new specialty of medicine. In a 2005 article, Shepard, et al. state that “the history of the development of sleep medicine in the United States is relatively short and most of the individuals involved with its development are still living.” They go on to state: “Until 1975 sleep medicine was deemed ‘experimental’ and medical insurance companies routinely denied reimbursement claims.” In discussing the development of the specialty of sleep medicine, they conclude that “sleep is viewed as a basic biologic process that affects all individuals and has significant impact on the function of all organ systems.”

The International Classification of Sleep Disorders is a 400-page, stand-alone document that was written in 1990 and revised in 2005. Sleep medicine deals with sleep and arousal disorders that include all conditions encountered clinically. It deals with dyssomnias, which are those disorders that involve initiating and maintaining sleep, as well as with parasomnias, which are movements and behaviors that occur during sleep. Obstructive sleep disorders are classified as dyssomnias and represent those disorders resulting from airway obstructions that occur during sleep.

They are relatively common syndromes and by conservative estimates affect 5% of the Western world, but they are often under-recognized despite having substantial morbidity and mortality rates associated with them. Treatment for obstructive sleep disorders ranges from the extremely conservative measures of weight loss and sleep position training to variations of continuous positive airway pressure (CPAP), oral appliance therapy, and surgery. Many patients prefer the concept of oral appliance therapy to either the use of CPAP or surgery. A dentist should then be involved with patient evaluation, insertion, and appliance maintenance as well as managing postappliance insertion complications. Consequently, one might think that oral appliance therapy would be a considerable portion of many dentists’ general practices. But this is not the case.

I started teaching dental sleep medicine courses in 2001. Personal communication with many of those I had taught in the early courses exposed many difficulties that general dentists were facing as they attempted to implement dental sleep medicine into their practices. Ignoring those obstacles may lead to unrealistic expectations.

The carrot of economic success

It isn’t unusual to see an advertisement refer to the potential economic boom that a course will provide for the participant. This lure of increased financial incentive is common to many course advertisements, including periodontics, cosmetic dentistry, and orthodontics.

Silber states that 30% to 50% of the population over 50 snores. This is often interpolated to 40%. So, if 40% of your adult population snores, and you have a practice with 2,000 active adult patients, 800 of your patients snore. If you treat only 25% of them, and you bundle the workup and appliance fee to a moderate charge of $3,000, then your gross income should increase by $600,000 the first year.

Unfortunately, that is an unrealistic computation. The literature ignores the many challenges that face dentistry. Let’s examine some of those challenges.

The physician’s bias

Recent decades have seen the line between dentistry and medicine continually blur, as dentists made significant contributions to the care of patients with chronic daily headache, migraine, and facial pain. There was an early bias among sleep physicians against early attempts at oral appliance therapy. Pantino reports that when he began treating with oral appliances it was not only considered experimental, but with limited data and research and no consideration of coverage from the insurance industry and with limited physician support, he may as well have been “practicing witchcraft.”

The 1995 landmark study by Schmidt-Norwara opened the door to the need for dentistry and medicine to work synergistically and pointed out that as health-care providers, we are challenged to acknowledge the necessity for interdisciplinary communication. This early bias is complicated by the fact that obstructive sleep disorders are indeed a medical disorder. Obstructive disorders are a continuum of disorders that start with snoring.

Therefore, snoring should not be treated without a medical diagnosis, and that diagnosis should be done by a physician. In spite of the tremendous improvements in oral appliance therapy, the fact that oral appliances are usually preferred by patients over the alternatives of CPAP or surgery, and the fact that the Academy of Sleep Medicine has mandated by policy that some patients not only can but in some cases should be treated or given oral appliance therapy, physician bias against oral appliances still exists.

It therefore isn’t enough for dentists to know just the basics of sleep medicine and oral appliances. Dr. Schmidt-Norwara recently suggested that “dentists who offer this service need to become acquainted with the multifactorial nature of sleep medicine to serve their patients better and to facilitate their interaction with other sleep medicine clinicians.” A high level of mutual respect and open communication is required for the medical and dental professions to properly triage and treat patients. In a position paper on practice parameters by Kushida, et al., it is stated that oral appliances should be delivered and followed by qualified dental personnel “who have undertaken serious training in sleep medicine and/or sleep-related breathing disorders with focused emphasis on the proper protocol for diagnosis, treatment, and follow up.”

But there’s more than the science of sleep medicine

In order to be successful in incorporating dental sleep medicine into your practice, understanding the science of sleep medicine and possessing the ability to insert oral appliances is not enough. The art of implementing the science requires a different skill set than was required to develop a general dental practice.

In order to be successful, dentists must have strong communication skills. For the most part, general dentists can work within their own office walls and choose those specialists with whom they would like to work. In sleep medicine, dentists must immediately work to develop relationships of trust and mutual respect with physicians with whom they may have no past relationship and with whom they have had limited contact. Furthermore, because physicians hold the bias discussed earlier in this paper, they will often have to be educated and motivated to refer patients for oral appliance therapy. There is also the matter of “management” and the potential for failure. The dental model of practice doesn’t usually involve “managing” disease; we treat it and cure it. Obstructive disorders can’t be “cured,” a concept I have found not readily accepted by some dentists. Dentists need to develop a new mindset and a new definition of success for the practice of dental sleep medicine. They must learn that success cannot be determined with an explorer or depend totally on the polysomnogram results. They must also realize that some patients will be unable to wear their appliances. Dentists must quell their disappointment and acknowledge that although they have rendered the best possible care, there are factors beyond their control that impact the success of oral appliance therapy. This potential for failure should not dampen their enthusiasm. Fear of failure should not prevent them from helping many other patients. Making this realization and sharing this information with the patient prior to treatment is a total change in the model that dentistry routinely utilizes.

There is also the obstacle of postinsertion management. The oral appliance helps maintain the airway during sleep by creating an external splint, resulting in an increased tonic tone to the relaxing pharyngeal musculature. In order to do this, there is a strain placed on the muscles of mastication, as well as the temporomandibular joint itself. General dentists are not well trained in joint anatomy, physiology, nor in the treatment of joint dysfunction. These common complications will sometimes frustrate the dentist who may not be trained in the ability to diagnose, treat, or manage these adverse effects on the joints or muscles. This frustration has the potential to cause the dentist to stop treating with oral appliances. Training in these areas of treatment is readily available, and will allow the dentist to manage these complications and make wise risk/benefit decisions concerning the continued use of the oral appliance.

The most common adverse effect is occlusal changes. Dentistry has long emphasized the role of occlusion, and it is difficult for the dentist to make an informed risk/benefit decision if that role is considered more important than the resolution of the patient’s obstructive disorder. Ferguson states, “This presents a clinical dilemma when the patient is unconcerned about the occlusal changes and refuses to abandon the appliance citing that the perceived benefit of treatment outweighs the dentist’s concern with the altered occlusion.” Dental malocclusions created by oral appliance therapy may have no or limited effect on the patient’s esthetics or function. It may be more beneficial for the patient to continue to wear his or her appliance despite the occlusal changes. It is counterintuitive for the dentist to do anything that creates a malocclusion, but this may be in our patient’s best interest. This is a difficult concept for dentistry.

A vast bite-wing conspiracy?

Is the promise of economic gain, then, a conspiracy?

The answer is simple. Yes, it is a conspiracy if there is some implication that implementing dental sleep medicine is as simple as finding patients in your office who snore and treating them with oral appliances that you fabricate easily with impressions and bite registrations sent to a lab.

There are real challenges that face dentistry in the field of dental sleep medicine. These challenges include:


  • Becoming a serious student of sleep medicine
  • Educating your medical colleagues about the potential service you can provide their patients who may benefit from oral appliance therapy
  • Understanding the need to manage patients and understanding their role as key players on the treatment team
  • Learning how to communicate with local sleep labs and physicians by keeping them in the loop and referring patients back to them for post-treatment evaluations
  • Establishing reasonable fee structures and understanding the need to process claims through medical insurance in order to get the most coverage for your patients
  • Learning more about the craniomandibular structures you are compromising in order to support a compliant airway
  • Carefully reconsidering some of your occlusal concepts that will prevent your potential bias from keeping patients from treatment for this serious disorder that is associated with substantial morbidity and mortality rates


Ninety percent of OSA remains undiagnosed. Our patient load would be well served if all dentists had a better understanding of sleep disorders. Our profession and our patients would benefit if all dentists were taught the basics of sleep medicine and consequently screened their patients. But more intensive study on many levels and a commitment to consider the model changes discussed are required before the dentist can provide oral appliance therapy and create another income source in his or her office.

So what is a “vast bite-wing” conspiracy? The conspiracy is on the part of those who may gain economically in the short run by having dentists construct snoring appliances for those patients who snore (even if it means without proper diagnosis) or by encouraging dentists to take courses because of the perceived economic gain without recognizing the obstacles to that end. Furthermore, the conspiracy often encourages the front-end purchase of equipment that is not required to perform dental sleep medicine; again, in the long run, this frustrates the general dentist who is not aware of the obstacles that prevent the successful implementation of dental sleep medicine in his/her practice.

Many Level I to V studies have now been completed to demonstrate over and over again the potential of oral appliance therapy to be successful in mild, moderate, and even severe sleep apnea. Certainly, oral appliance therapy has been implemented into many dental practices successfully. Some dentists around the country have actually limited their practices to dental sleep medicine. The obstacles can be overcome. But before they can be overcome, they have to be recognized and acknowledged. Then a plan can be made to overcome each obstacle.

It is essential, then, that the “bite-wing conspiracy” not result in frustration and the dentist deciding not to pursue dental sleep medicine. Those who have accepted the challenges and overcome the obstacles have placed themselves in a position to provide a potentially life-altering and life-saving treatment modality. The diligent dentist has the opportunity to add not only a new stream of income for his practice, but also a new quality of life for his or her patients.

Barry Glassman, DMD, maintains a private practice in Allentown, Pa., which is limited to chronic pain management, temporomandibular joint dysfunction, and dental sleep medicine. He is a Diplomate of the American Academy of Craniofacial Pain, a Fellow of the International College of Craniomandibular Orthopedics, a Fellow of the Academy of Dentistry International, and a Diplomate of the American Academy of Pain Management. He is on staff at the Lehigh Valley Hospital where he serves as a resident instructor of Craniofacial Pain and Dysfunction and Dental Sleep Medicine. He is a Diplomate of the Academy of Dental Sleep Medicine, and is on staff at the Sacred Heart Hospital Sleep Disorder Center. He was recently named medical codirector of the St. Lukes Hospital Headache Center.

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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OSA Increases Cardiovascular Mortality in the Elderly

Untreated severe OSA is associated with an increased risk of cardiovascular mortality in the elderly, and adequate treatment with CPAP may significantly reduce this risk, according to a new study from researchers in Spain titled “Cardiovascular Mortality in Obstructive Sleep Apnea in the Elderly, Role of Long-Term CPAP Treament”.

“Although the link between OSA and cardiovascular mortality is well established in younger patients, evidence on this relationship in the elderly has been conflicting,” said lead author Miguel Ángel Martínez-García, MD, of La Fe University and Polytechnic Hospital in Valencia, Spain. “In our study of 939 elderly patients, severe OSA not treated with CPAP was associated with an increased risk of cardiovascular mortality especially from stroke and heart failure, and CPAP treatment reduced this excess of cardiovascular mortality to levels similar to those seen in patients without OSA.”

To read the article in full, Click Here

(With an impact factor of 11.080, the AJRRCM aims to publish the most innovative science and the highest quality reviews, practice guidelines, and statements in the pulmonary, critical care, and sleep-related fields).

All subjects in this prospective, observational study were 65 years of age or older. Median follow-up was 69 months. Sleep studies were conducted with either full standard polysomnography or respiratory polygraphy following Spanish guidelines. OSA was defined as mild-to-moderate (apnea-hypopnea index [AHI] 15-29) or severe (AHI ≥30). Patients with AHI <15 acted as controls. CPAP use ≥4 hours daily was considered as good adherence to treatment.

Visit the American Thoracic Society webiste

The post OSA Increases Cardiovascular Mortality in the Elderly appeared first on Sleep Diagnosis and Therapy.

Objective Testing Can Determine Whether Sleep Quality Matches Quantity

Compromised health affects Americans in countless ways, not the least of which is sleep deprivation. The price tag in lost productivity can hit a staggering $100 billion annually thanks to medical expenses, sick leave, and property damage. The National Highway Traffic Safety Administration estimates that more than 70,000 injuries each year are related to drowsy drivers.

There are many causes of sleep disruption, and patients rarely exhibit just one. Simply addressing sleep disordered breathing (SDB) may not result in good long term sleep. Other issues can range from an inferior mattress, a disruptive sleep environment, the wrong medication, pain, incorrect positive airway pressure (PAP), and insomnia.

As a result of these staggering numbers and the increasing awareness of sleep disorders, it’s reasonable that sleep should be one of the “vital signs” of health, together with temperature, blood pressure, respiration rate, pulse, pain, and BMI (body mass index).

Adequate sleep has been defined as regularly sleeping 6-8 hours per night. Clinicians now believe that sufficient slumber is a critical factor in health and health-related behaviors across all ages. It is not enough to simply spend these hours in bed. The quality of sleep is just as, if not more important than, the quantity.

Defining Quality Sleep

How is quality of sleep defined? For the sleep specialist, “good” sleep may be defined as sleep that has normal efficiency, organized sleep architecture, and the absence of any sleep disruptions. For the patient, good sleep may mean waking up in the morning feeling refreshed and not feeling sleepy during the day.

How do we currently measure “good sleep?” One way is with an in-lab PSG test, which is often necessary but also expensive. A second way is through home sleep testing (HST), although most of these devices measure parameters that only detect sleep apnea. A third, purely subjective way we measure sleep, is to simply ask patients how they are sleeping. This last approach is akin to asking them whether they feel heavier or lighter instead of having them step on a scale.

In addition, if your patients have never slept well, how do they know they slept well last night versus sleeping a bit better than the night before? This leaves us with the sleep lab but how can we expect a patient to sleep “normally” and collect a representative night of sleep quality when there are so many cables and equipment attached to them, not to mention we are asking them to sleep in a strange environment – with a camera watching them all night – which takes us back to home sleep testing.

Cost Effective and Objective

All of this information points to the need for a simple and objective measure of sleep quality that is cost effective enough to use on patients regularly without being specific to a particular condition, in much the same way a scale will objectively measure weight. What’s needed is a “scale” that objectively measures sleep quality or sleep health.

Enter Robert Thomas, MD, and his colleagues at the Beth Israel Deaconess Medical Center, a teaching school of Harvard Medical School, who have taken a different approach to examining sleep—seeking to objectively measure sleep quality using cardiopulmonary coupling (CPC).

The principle behind this technology is the understanding that stable NREM (non-rapid eye movement) sleep is characterized by a cardiac rhythm known as sinus arrhythmia. During stable sleep, high vagal tone modulating a healthy heart results in characteristic heart rate variability in which the heart slows and speeds up in synchrony with very regular respiration. This is what Thomas calls stable sleep.

But not all heart rate variability is synchronized with normal respiration. Repetitive sleep disruptions, which could be caused by SDB, pain, a noisy sleeping environment, periodic limb movement syndrome (PLMS), restless legs syndrome (RLS), or anxiety, to name a few, can cause the heart rate and breathing rate to vary. This bradytachyarrhythmia is well recognized in polysomnograms.

These recurring disruptions can be seen as infrequently as once every 2 to 3 minutes, or as often as 1 to 3 times every minute, so they are difficult to see in a normal PSG test. How- ever, if we look at the data in terms of frequency we can see these changes occurring over sometimes long periods of time. It’s like being too close and not seeing the forest for the trees. This is unstable sleep.

Thomas also identified that there is little overlap between stable and unstable sleep, so they can be easily displayed and differentiated from each other. This makes interpretation much easier. The concept of stable and unstable sleep is central to CPC.

The result of Roberts’ CPC is a new, low cost, patient centered system call SleepImage that measures stable vs. unstable sleep. This test-anywhere device weighs less than an ounce, sits barely detectable on the patient’s chest, and also records actigraphy, body position, ECG, and snoring. It is fully integrated with a secure website and delivers a simple and easy-to-understand “picture of sleep” that identifies stable and unstable sleep to produce an objective measure of sleep quality.

There are many practical uses for the device, and because of its simplicity, researchers have been able to expand the iden- tification and understanding of sleep beyond conventional sleep diagnostic practices. In the sleep lab, the CPC technology can be used to help identify complex sleep apnea, a disorder that may make conventional CPAPs intolerable for patients.

As a home sleep test, the SleepImage system can be used as a very low cost screener for patients that complain of poor sleep. The SleepImage will quickly and cost effectively validate whether an in-lab PSG or some other course of action is nec- essary and more importantly allow the physician to monitor sleep quality after intervention to ensure that the patient is complying with therapy or if there is another co-morbid condition that is continuing to cause poor sleep quality.

Perhaps the most noteworthy benefit of this technology is its ease of use, requiring little or no instruction to the patient, with automated analysis and easy-to-understand graphic results.

SleepImage is FDA cleared, and affords an objective measure of sleep quality that not only provides a picture of your patient’s sleep, but also assists in tracking sleep trends over time—offering an accurate measure of the effectiveness of a given therapeutic choice. So the next time you ask pa- tients how they slept last night, why not have an objective way to validate the answer?

For more information about SleepImage you can go to

David Baker became involved in sleep when he led the creation of the Sandman PSG system in 1992 and its ongoing development for 8 years, before joining a sleep lab company in Arizona which ran about 8 labs in the South West. In 2005 David was recruited to run the Embla company, a sleep equipment diagnostic company, and SleepTech, a sleep services company with 18 sleep labs throughout the US David led Embla through the purchase of the Sandman system in 2009 and then the sale of Embla to Natus in 2011 and SleepTech to a venture group in 2012. David is now CEO of MyCardio, the exclusive distributor of the CPC technology based in Broomfield Colorado.

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Poster Illuminates Appropriate Intermezzo Dosing Recommendations

Margaret Moline, PhD, recently provided additional clarity about gender-specific dosing for Intermezzo, the Purdue Pharma drug that addresses middle-of-the-night insomnia.

Intermezzo* (zolpidem tartrate) sublingual tablets are currently approved for use as needed for the treatment of insomnia when a middle-of-the-night (MOTN) awakening is followed by difficulty returning to sleep. Many sleep physicians already know that Intermezzo is indicated for the treatment of MOTN insomnia when the patient has at least 4 hours of time in bed remaining.

Gender-specific doses are recommended, but many clinicians may not understand the clinicial support for the efficacy of 1.75 milligrams for women and 3.5 milligrams in men. Margaret Moline, PhD, set about to clear this up with a poster presentation at SLEEP 2012—the 26th Annual Meeting of the Associated Professional Sleep Societies (APSS).

“This is a new set of analyses that we performed on data that were already published,” said Moline, director, Medical Research, Purdue Pharma Inc, Stamford, Conn. “The original analyses were based on the entire patient population, and not broken down by gender.”

In November 2011, when the FDA approved the drug, they stipulated gender-specific dosing, but few clinicians understood the “why” of the government’s decision. “When you are evaluating drugs for approval, it’s important to take into consideration the entire package of efficacy and safety,” said Moline during a discussion of her poster titled “Gender Effects of 1.75 mg and 3.5 mg Zolpidem Tartrate Sublingual Tablets Formulated with a Carbonate-Bicarbonate Buffer on Sleep Onset Following Middle-of-the-Night Awakening and on Next-Day Residual Effects”. “There were two pivotal trials, and this trial we are reporting on for the poster tested two different doses — 1.75 milligrams and 3.5 mg.”

Moline’s analyses specifically investigated the 1.75mg and 3.5mg zolpidem tartrate sublingual tablets (Intermezzo®), formulated with a carbonate-bicarbonate buffer.

Post-hoc analysis was performed to examine response by gender in this double-blind, placebo-controlled 3-way cross-over study in patients with a diagnosis of primary insomnia as defined by the DSM-IV-TR and a history of prolonged MOTN awakenings. Patients had a history of MOTN awakening with difficulty returning to sleep and had to demonstrate polysomnographic (PSG) mean latency to persistent sleep of ≥20 minutes following scheduled awakenings on screening nights.

Treatments consisted of 2 nights of dosing followed by a 5- to 12-day washout. Fifty-eight female and 24 male patients were randomized. Patients were awakened and dosed with 3.5 mg, 1.75 mg or placebo 4 hours after lights out, kept awake for 30 minutes, then returned to bed for 4 hours. Time to return to sleep was assessed by PSG and post-sleep questionnaires. Residual effects were measured by objective/subjective measures.

In both genders, compared to placebo, both the 3.5 mg and 1.75 mg doses of Intermezzo significantly decreased sleep latency based on PSG and post-sleep questionnaires. Following the 1.75 mg dose, 60% and 44% of the females and males, respectively, were asleep within 20 minutes. The rates following the 3.5 mg dose were 80% and 63% in females and males, respectively. Placebo response rates were significantly lower: 26% (females) and 33% (males). Neither dose in either gender showed significant residual effects compared to placebo based on the assessments performed during the study.

These data demonstrated that Intermezzo was effective in reducing time to return to sleep in MOTN insomnia without producing residual effects. Further, the effects of 1.75 mg in females and 3.5 mg in males were comparable. This gender-specific related dosing is consistent with previously reported differences in zolpidem pharmacokinetics.

PSG and patient-reported measures indicate that Intermezzo  doses of 1.75 mg and 3.5 mg significantly shortened time to return to sleep and improved total sleep time in MOTN insomnia, and that the effects of 1.75 mg in females and 3.5 mg in males were comparable.

Minimal residual sedative or other adverse effects were observed with Intermezzo versus placebo, and there were no differences between females and males on any parameter.

* Intermezzo is contraindicated in patients with known hypersensitivity to zolpidem. Observed reactions with zolpidem include anaphylaxis and angioedema.

Co-administration with Intermezzo and other CNS depressants increases the risk of CNS depression. Intermezzo should not be taken with alcohol. The use of Intermezzo with other sedative-hypnotics (including other zolpidem products) at bedtime or the middle of the night is not recommended.

The risk of next-day driving impairment (and psychomotor impairment) is increased if Intermezzo is taken with less than 4 hours of bedtime remaining; if higher than recommended dose is taken; if co-administered with other CNS depressants; or co-administered with other drugs that increase the blood levels of zolpidem. A small negative effect on SDLP (standard deviation of lateral position, a measure of driving impairment) may remain in some patients 4 hours after the 1.75 mg dose in women, and after the 3.5 mg dose in men, such that a potential negative effect on driving cannot be completely excluded.

The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated.

Cases of angioedema involving the tongue, glottis, or larynx have been reported in patients after taking the first or subsequent doses of zolpidem. Some patients have had additional symptoms such as dyspnea, throat closing, or nausea and vomiting that suggest anaphylaxis. Some patients have required medical therapy in the emergency department. Angioedema and additional symptoms suggesting anaphylaxis may be fatal. Patients who develop angioedema or anaphylaxis should not be re-challenged.

Abnormal thinking and behavior changes have been reported in patients treated with a sedative-hypnotic, including zolpidem. Complex behaviors, including driving or eating while not fully awake, with amnesia for the event, as well as visual and auditory hallucinations and abnormal behaviors such as decreased inhibition, bizarre behavior, agitation, and depersonalization may occur. Although behaviors such as “sleep-driving” have occurred with zolpidem alone at therapeutic doses, the co-administration of zolpidem with alcohol and other CNS depressants increases the risk of such behaviors, as does the use of zolpidem at doses exceeding the maximum recommended dose. Discontinuation of Intermezzo should be strongly considered for patients reporting a “sleep-driving” episode.

In primarily depressed patients, worsening of depression, including suicidal thoughts and actions (including completed suicides) have been reported with the use of sedative-hypnotics. Intentional over dosage is more common in this group of patients; therefore, protective measures may be required and prescribe the least amount of Intermezzo that is feasible.

Because persons with a history of addiction to or abuse of drugs or alcohol are at increased risk for misuse, abuse, and addiction of zolpidem, they should be monitored carefully when receiving Intermezzo. Zolpidem tartrate is a Schedule IV controlled substance. Post-marketing reports of abuse, dependence, and withdrawal resulting from use of oral zolpidem tartrate have been received. Zolpidem has produced withdrawal signs and symptoms following a rapid dose decrease or abrupt discontinuation.

The most commonly reported adverse reactions in all treatment groups were headache, nausea, and fatigue.

For additional information, please read the Intermezzo Full Prescribing Information available at

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