Category Archives: Oral Appliance Therapy

New Study Shows That CPAP and Oral Appliance Therapy Come Out Even Par, When Used Equal Amount of Time

Gergen's Orthodontic Lab Sleep Herbst
Gergen’s Orthodontic Lab Sleep Herbst

Maria De Lourdes Rabelo Guimarães and Ana Paula Hermont1



Dental practitioners have a key role in the quality of life and prevention of occupational accidents of workers with Obstructive Sleep Apnea Syndrome (OSAS).


The aim of this study was to review the impact of OSAS, the Continuous Positive Airway Pressure (CPAP) therapy, and the evidence regarding the use of oral appliances (OA) on the health and safety of workers.

Materials and Methods:

Searches were conducted in MEDLINE (PubMed), Lilacs and Sci ELO. Articles published from January 1980 to June 2014 were included.


The research retrieved 2188 articles and 99 met the inclusion criteria. An increase in occupational accidents due to reduced vigilance and attention in snorers and patients with OSAS was observed. Such involvements were related to excessive daytime sleepiness and neurocognitive function impairments. The use of OA are less effective when compared with CPAP, but the results related to excessive sleepiness and cognitive performance showed improvements similar to CPAP. Treatments with OA showed greater patient compliance than the CPAP therapy.


OSAS is a prevalent disorder among workers, leads to increased risk of occupational accidents, and has a significant impact on the economy. The CPAP therapy reduces the risk of occupational accidents. The OA can improve the work performance; but there is no scientific evidence associating its use with occupational accidents reduction. Future research should focus on determining the cost-effectiveness of OA as well as its influence and efficacy in preventing occupational accidents.

Keywords: Continuous positive air pressure, obstructive sleep apnea, occupational accidents, oral appliances, review


The Obstructive Sleep Apnea Syndrome (OSAS) is characterized by repeated collapse of the upper airway during sleep, resulting in nocturnal hypoxemia and fragmented sleep. Associated brain dysfunctions can be expressed, such as abnormal daytime sleepiness and lack of concentration, and these are common causes of traffic accidents.[1,2,3,4]

Several studies have associated OSAS with increased risk of traffic accidents[4,5] and the majority of the researches were conducted among professional drivers. Obtaining data on the frequency of sleep-disordered breathing, nocturnal sleep disruption, and excessive sleepiness among the working population is an important public health problem.[6,7] It is noteworthy that the identification and treatment of snoring and OSAS in workers can potentially reduce the number of occupational injuries, absenteeism, improve productivity, health, and wellbeing of these professionals.[8,9,10,11]

Several well-tolerated and effective treatments for OSAS have demonstrated improvements in the quality of life and reduction in the use of health services and vehicle collisions.[12,13,14] Treatments for OSAS can be clinical or surgical, and the clinical treatment options include behavioral measures, and the use of continuous positive airway pressure device (CPAP) or oral appliances (OA).[15]

The OA are a noninvasive treatment option for patients with OSAS and it is considered less uncomfortable than CPAP.[16] The American Academy of Sleep Medicine recommends the OA therapy for patients with mild-to-moderate OSAS and those with severe OSAS who cannot tolerate CPAP and refuse surgery procedures.[17]

The use of CPAP is indicated as firstline treatment for people with high levels of apnea-hypopnea index (AHI) associated with excessive sleepiness[18] ; however, there are indications that OA improves subjective sleepiness and sleep-disordered breathing.[19]

Randomized trials assessing the effectiveness of OA found that it reduced the excessive daytime sleepiness when compared with patients without treatment.[20,21,22,23,24] Moreover, when the results of CPAP and OA were compared, there was no significant difference between both therapies.[25,26,27,28,30]

A randomized clinical trial presented improvements on energy and fatigue levels and vigilance and psychomotor speed among patients treated with OA when compared with placebo.[20] Other studies also found improvements in neurocognitive function using the OA, which did not differ statistically from the improvements achieved by the CPAP therapy.[26,27]

In 2011, a longitudinal study was conducted with patients with mild-to-moderate OSAS who were randomized regarding the treatment for CPAP or OA. The study showed similar improvement from both therapies regarding the AHI and excessive daytime sleepiness; however, the survey sample was not representative.[31] It is worth noticing that changes in the oral appliances design may contribute to different results, once a study comparing devices with different designs showed differences in the improvement of excessive daytime sleepiness.[32]

The CPAP treatment significantly reduces the risk of accidents in OSAS patients.[33,34,35,36,37] Treatment with OA, in addition to being effective to normalize the respiratory disorders, improved work performance of patients with OSAS.[38] However, it still lacks a more comprehensive way to assess the benefit of OA on driving simulation and real driving performance.[14] This article aimed to revise the prevalence and impact of OSA on work performance, occupational impairments, use of health services, and its economic impact. The cost-effectiveness and effects of the CPAP therapy and especially the role of OA concerning those issues were also investigated.


These were the inclusion criteria used in this article: Articles published from January 1980 to June 2014 concerning patients with a diagnosis of OSA, presenting AHI >5, snorers, upper airway resistance syndrome, age ≥18 years; any study design and the languages were restricted to: English, French, and Portuguese.

Exclusion criteria were central sleep apnea, coexisting sleep disorders, regular use of sedatives or narcotics, preexisting lung disease, and psychiatric illness. Searches were conducted on MEDLINE (PubMed), Latin American and Caribbean Literature Data on Health Sciences (LILACS) and Scientific Electronic Library Online (SciELO), in addition to searches from the references of the identified articles.

The search strategy was performed by combining the following descriptors: Apnea, snoring, sleepiness, mandibular advancement devices, oral appliances, continuous positive air pressure, cost, economics, cost-effectiveness, accident, health care utilization, driving, occupational accidents, occupational injury, traffic, commercial vehicle drivers, and work limitation. The analysis was based on critical readings of the articles content. Subsequently, the common contents were identified, grouped, and tabulated to form the thematic analysis and preparation of a critical discourse.


During the search, 2188 articles were identified, but 2095 were excluded once they did not meet the inclusion criteria, totaling 99 articles included.

Impairments in occupational performance

Sleepiness negatively affects cognitive function, therefore it is assumed that patients with OSAS suffer impairments in labor capacity,[9,39,40,41] by presenting lack of concentration and attention, memory impairment, and changes in the ability to perform everyday tasks and learning. Moreover, the reduced capacity for executive functions such as completing tasks, can cause loss of motivation and initiative.[9,42]

The National Sleep Foundations (NSF) in the United States assessed the sleep of workers and found that those at risk for OSAS had a greater chance of having difficulty when performing cognitive tasks, including problems with concentration and organization and also a greater risk of falling asleep at work, decreased productivity, and absenteeism due to sleepiness.[43] Snoring was also highly associated with excessive sleepiness and work performance impairments.[44]

The sleep-disordered breathing was a common finding among Brazilian professional drivers who presented an OSAS prevalence of 38%. Furthermore, the daytime sleep was fragmented and shorter than nocturnal sleep and more drivers presented extreme sleepiness. It is worth noticing that such deficiencies of sleep can negatively affect performance in driving.[45] Another epidemiological study conducted among Brazilian railroad workers suggested age, body mass index (BMI), and alcohol consumption as associated with an increased risk of developing OSAS and it stressed the need for greater attention to this population, once they are more prone to suffer accidents.[46]

In Greece, the prevalence of sleep-disordered breathing among drivers of rail transport was similar to other studies, but the study reported a low prevalence of drowsy drivers (7.1%). However, this data has to be carefully analyzed once it was used a subjective evaluation criterion by Epworth Sleepiness Scale.[47]

Among a group of American officers, sleep disorder was identified as an ordinary problem and that it was significantly associated with increased risk of health problems, work performance, and safety outcomes; OSAS was the most prevalent disorder (33.6%). Excessive sleepiness was found in 28.5% of the police officers and there was an increase in the prevalence of physical and mental health disorders, including diabetes, depression, cardiovascular disease, and increased risk of accidents.[48]

A study carried out among soldiers identified that 88.2% of the sample were diagnosed with sleep disorders. Insomnia coexisting with OSAS was found in 38.2% of the military and they were significantly more likely to meet criteria for depression compared with control subjects and others with only OSAS.[49] Among young soldiers in Korea, it was found that the prevalence of snoring and high risk of OSAS was 13.5% and 8.1%, respectively. It is worth noticing that this is not a low prevalence considering that the individuals were young and not obese.[50]

It was observed that the treatment of OSAS resulted in the reduction of occupational accidents and improved the performance of employees. Therefore, it is advisable to develop strategies for screening effective treatment of OSAS.[51] Nevertheless, it has been difficult to establish the exact effect of untreated OSAS in real driving and traffic accidents. Driving simulators have been used as a cheaper and safer reproducible way to assess the effect of OSAS on different aspects of driving, but despite the benefits provided, the simulator cannot measure all the aspects experienced in a real-life driving situation.[52]

In Canada, useful data from a study of driving in “real life” were evaluated. Over a period of three years patients with mild, moderate, and severe OSAS had an increased rate of traffic accidents when compared with drivers without this condition and had higher rates of road traffic accidents associated with personal injury.[53] Worse performances in driving simulators among subjects with untreated OSAS was also identified by other studies.[54,55,56] Nonetheless, after treatment with CPAP, there was an improvement in the driving performance.[36,54,55] It is known that the CPAP therapy improves driving performance and can potentially reduce the risk of accidents, but the benefits provided by CPAP depend on treatment adherence.[57]

The results of a study conducted in 2011 suggest persistent impairment in driving simulator during long trips in patients with severe OSAS treated with CPAP. These results support the evidence that some neurobehavioral deficits in patients with severe OSA are not fully reversed by treatment. More controlled studies with larger samples are needed to confirm these findings and further researches should investigate the causes of residual driving simulator impairment among patients with OSAS treated with CPAP and its association with increased risk of vehicular accident on highway.[57]

Test driving simulator was also used to investigate whether OSAS patients had worse labor performance than healthy drivers. The benefits provided by OA and CPAP were also analyzed. The results showed a significantly higher number of lapses in attention among OSAS patients. The total number of lapses of attention was significantly decreased after both therapies, with OA and CPAP, with no significant differences between the two types of treatment.[25]

However, a more comprehensive way to assess the benefits of OA on driving simulation tests, and real-life driving performance are needed to adequately assess its potential role concerning the risk of drowsiness at the wheel represented by OSA.[14]

Another important issue that should be discussed concerning the impairments in occupational performance is related to the international driving licensing legislation. A committee established by the European Commission on sleep apnea and driving has been discussing about directives with an approach to patients with moderate or severe sleep apnea, particularly associated with significant sleepiness. Those patients will be prevented from driving, or at least will be prevented from holding a driver’s license, until the condition is successfully treated.[58]

The driving licenses may be issued to applicants or drivers with moderate or severe OSAS who show adequate control of their condition and compliance with appropriate treatment and improvement of sleepiness, if any, confirmed by authorized medical opinion. Applicants or drivers with moderate or severe OSAS under treatment shall be subject to a periodic medical review with a view to establish the level of compliance with the treatment, the continued good vigilance, and evaluate the need for continuing the treatment.[58]

Occupational injury

Many mental functions are reduced in situations of fatigue and sleepiness.[59] It is estimated that 20% of accidents are caused by drivers’ inattention and sleepiness,[60] and the occurrence of drowsiness when driving is a major risk factor for dangerous accidents.[61] Chronic excessive sleepiness and sleep-disordered breathing were common in a sample of drivers of commercial vehicles in Australia. Sixty percent of drivers had OSAS and 16% had OSAS with excessive daytime sleepiness.[62] Drivers with a high risk for OSAS and a work schedule with little chance of rest reported more daytime sleepiness and poor sleep quality in a study conducted among Belgian truckers[63] and Japanese bus drivers.[64]

In Brazil, 16% of professional drivers admitted having fallen asleep at the wheel; however, this number increased to 58% when it was reported by colleagues. It was observed that respiratory disorders and snoring are some causes of fragmentation or reduction of rapid eye movement (REM) sleep, which could support the hypothesis that REM sleep deprivation can lead to common complaints such as mental fatigue, irritability, and sleepiness among professional drivers.[65]

Nowadays, most European countries have traffic laws directed to sleep-disordered breathing.[7] The driver screening methods should contain questions about drowsiness at the wheel, habitual snoring, and sleep apneas, as well as the Epworth Index and BMI.[7] After an assuredly effective and efficient treatment, including regular checkups for control and evaluation of symptoms, patients are allowed to drive. Nevertheless, during the interim period between the diagnosis and therapy, drivers can still be considered able to drive, but with limitations (eg, drive short distances and avoid driving on major highways or at night.[7,66]

In Brazil, due to the high rate of traffic accidents caused by drowsiness, in 2008, a resolution was approved by the National Traffic Department to reduce the number of accidents caused by drowsiness, fatigue, sleep-disordered breathing, and changes in biological rhythms.[59] Evaluation of OSA was included in this resolution as well as the requirement of new medical and psychological examinations for all professional drivers.[59]

Sleep-related accidents comprise 16%-23% of all vehicle accidents.[67] Many of these accidents could be prevented by treating sleep-disordered breathing.[68] However, drivers with symptoms of drowsiness or sleep-disordered breathing may not report accidents due to concerns of losing their jobs, compromising the results of studies on the association between these disorders and accidents.[62]

A study conducted among long distance truck drivers in the United States found that about 20% of drivers presented symptoms of sleep disorders. Drivers who were working with the same company for over a year were more likely to have daytime fatigue, daytime tiredness, restless sleep, hypertension, and increased BMI.[6] Other studies observed a higher prevalence of OSAS in railway workers than in the general population,[46,47] thus necessitating greater attention to this population, due to the greater propensity for accidents.

A research conducted with presumably healthy working men also identified a significant association between the complaint of excessive daytime sleepiness and the incidence of sleep apnea.[69] In Turkey, 241 long-distance drivers were interviewed about symptoms of OSAS, and occupational history. The drivers who had evidence of OSAS underwent polysomnography. Snoring was detected in 56% of all participants and daytime sleepiness was observed in 26.6%. The prevalence of OSAS was 14.1%. There was a significant relationship between the rate of traffic accidents by professionals/year and AHI, lowest saturation, desaturation index, and arousal index. The disease severity was directly proportional to the risk of accidents.[70]

Snoring, which is one of the signals present in OSAS, has been associated with increased risk for accidents and morbidity. A study conducted in Hungary found that snoring is common in the adult population. Through interviews, the study showed that especially loud snoring with breathing pauses was strongly associated with health impairment, higher comorbidity, daytime sleepiness, and a higher frequency of accidents.[71]

A retrospective evaluation of snoring workers due to suggestive symptoms of OSAS found a significantly higher frequency of occupational accidents among these professionals when compared to the general population of snorers. In this study, all subjects underwent overnight polysomnography in a sleep laboratory and, interestingly, the risk of accidents was high among heavy snorers without apnea and patients with OSAS.[8]

A prospective study found that men who reported both snoring and excessive daytime sleepiness were with an increased risk of labor accidents during the 10 years of follow-up.[72] The high risk of traffic accidents among drowsy drivers was mainly determined by the respiratory effort-related arousals (RERA) than by the presence of apneas and hypopneas.[73] The RERAs are secondary to upper airway obstructions during sleep and can occur in the absence of apneas and hypopneas, causing excessive daytime sleepiness.

Studies using the esophageal pressure measure were performed in habitually sleepy drivers and drivers without this condition. Sleepy drivers with apnea had higher accident rates in five years than drivers in the control group. Nevertheless, a high rate of RERA, but not sleep apnea, was still a risk factor among drivers habitually sleepy. These findings confirm the importance of identifying RERA in routine examinations in sleep laboratories.[73]

Just like it occurs with civilians, excessive sleepiness is a risk to the safety of military that operate dangerous vehicles, machinery, or carry firearms. Military with untreated OSA are also at risk for suffering from decreased mental alertness and decreased cognitive function due to drowsiness. Military with mild-to-moderate OSA and upper airway resistance syndrome (UARS) often have abnormal results in the Maintenance of Wakefulness Test and therefore have a pathological tendency to fall asleep. A study conducted in 2009 among military personnel identified that 32% of the sample had UARS and 68% OSA.[74]

Effectiveness and efficacy of CPAP and oral appliances

The physician must diagnose sleep apnea and evaluate the patient’s risk for injuries. The patient should be informed about the risks and an appropriate treatment should be instituted. In addition, the doctor should provide a follow-up plan to determine if the treatment has decreased the patient’s risk for accidents.[75]

Although many investigations have pointed out that treatment of primary snoring and OSAS with CPAP or OA contributes to the reduction of vehicle and labor accidents,[12,33,34,36,76] this review did not find any studies evaluating the effectiveness of OA regarding this outcome.

Like several other medical treatments, the efficacy of CPAP or OA depends on the degree of identification of OSAS and the degree of adherence to the treatment among the diagnosed individuals.[35] Treatment with CPAP reduces the risk of accidents because it is used by the patient.[77] Nonetheless, adherence to CPAP continues to be a major problem when treating OSAS, although more recent data suggest that adherence may have improved in recent years. However, a recent study found that only 5% of professional drivers diagnosed with OSAS showed adequate adherence to CPAP.[35,78]

It is important to include the patients in the treatment decision, offering more than one type of therapy for patients with OSA. Despite the residual apneas with the use of OA, or the highest rate of effectiveness of CPAP in reducing AHI, the similarities between the results of such treatments may be related to the hours of use per night. The OA which are considered to have partial efficacy, when used for prolonged hours may lead to similar outcomes when compared with CPAP.[79]

The ability to pre-select suitable candidates for either treatment is important. Although some predictors of success with OA have been evaluated, further studies are needed to better predict which patient will have a higher level of success with the OA therapy.[79] Less obese patients with mild sleep apnea and certain craniofacial characteristics such as mandibular retrognathia proved to be good candidates for the OA therapy.[80]

When analyzing the economic impact of OSAS, it was highlighted that there was a lack of clarity concerning the epidemiology of accidents in patients correctly treated with CPAP. Furthermore, it was suggested that future studies are needed to evaluate the improvement in the labor activities of OSAS patients before and after treatment, as well as studies evaluating the cost-effectiveness between surgical and clinical treatments.[10]

Most studies regarding the adherence to OA use subjective measures to evaluate the therapy compliance.[81] Nevertheless, a study conducted in 2012 objectively evaluated the use of OA among patients undergoing therapy for OSA by means of a heat-sensitive microsensor, which was attached to the OA. The overall mean rate of OA use was 6.7 ± 1.3 h per day with a regular users’ rate of 82%. Despite not having a statistically significant difference between the self-report and the use of microsensor, the safety and feasibility of using this device to objectively measure the OA’s compliance was highlighted.[82]

Although, according to a systematic review, many studies have demonstrated the effectiveness of OA in reducing daytime sleepiness and improve the neurocognitive function,[19] the Federal Motor Carrier Safety Administration does not recommend the use of the OA in the treatment of OSAS among professional drivers, once there is no scientific evidence associating the reduction of accidents by using these devices and it is difficult to assess the patients’ treatment adherence.[83] Furthermore, an updated version of the Thoracic Society Clinical Practice Guideline recommended the use of CPAP to reduce accidents, but again the OA were not listed due to lack of scientific evidence about the effects of this therapy on the risk of accidents.[84]

The OSAS treatment options may become limited by the conditions of the work environment. The diagnosis of sleep-disordered breathing may affect the deployable strength of the military personnel due to the difficulty they might face concerning the use of CPAP.[74] Military deployed in desert environment are at a risk of inhaling airborne particulate matter that can harm their health. In this condition, the CPAP therapy can facilitate the inhalation of these particles. Therefore, alternatives to solve this problem such as using foam filters have been tested.[85]

Economic impact of OSAS

Obstructive sleep apnea affects the daily lives of millions of people around the world and presents a growing economic impact. The evidence linking OSAS with various public health problems such as obesity, diabetes, depression, cardiovascular disease, and accidents has increased.[10]

It is estimated that in the United States, the total costs attributable to sleep apnea-related accidents is quite high. In 2000, 1400 people died due to vehicular collisions and in 2004 these accidents had a cost of $ 15.9 billion. With regard to the management of accidents, it is estimated that the treatment with CPAP for all drivers who suffer from OSAS would be of $ 3.18 billion. Even taking into account a treatment efficiency of only 70%, there would be a reduction of $ 11.1 billion in collision costs and 980 lives would be saved per year.[13] The literature suggests that treating 500 patients for three years would result in savings more than $ 1,000. 000.[68]

A more recent analysis of OSAs’ treatment showed significantly lower costs of the treatment plan. In addition, it was also observed fewer disability claims; cost reduction for disability and fewer lost days of work.[86] A prospective study compared the effects of OSAS between men and women during 1994-2005. An increased risk of absenteeism in subjects with sleep apnea was observed. In women, the major risk was present five years before diagnosis, whereas in men the major risk was observed one year before the diagnosis of OSAS.[87]

Education campaigns encouraging members of health plans to seek specific treatment for sleep-disordered breathing resulted in substantial savings. Two years after the education campaign started, it was computed savings of U.S. $ 4,900.00.[88]

Dentists can play an important role in accident prevention through the detection of risk factors by screening their patients for OSAS, evaluating oral/jaws anatomical features, and screening for sleep disorders during the anamnesis.[14]

Use of health services and resources

Untreated obstructive sleep apnea predisposes patients to various morbidities and consequently increases the use of health services.[10,12,89,90,91] The risk assessment of OSAS among workers can help to reduce the national health care burden.[51] Evidence suggests that patients with untreated sleep apnea require a greater amount of health resources. Moreover, adherence to treatment in patients with OSAS results in a significant reduction in hospitalizations and medical applications.[92,93]

In 2013 a study comparing the health effects after one month of CPAP and OA therapy identified that despite the CPAP therapy was more effective in reducing the AHI, the therapy with OA had greater adherence, hence both therapies showed similar results.[94]

Cost-effectiveness of OSAS treatment

Concerning CPAP therapy, studies in several countries have evaluated its cost-effectiveness[12,95,96] Some patients have to try more than one treatment option before control of OSAS is reached. Treatment should be individualized and supported by scientific evidence, and the evaluation of cost-effectiveness is also required. Information about the therapy cost is important for the governments, transport, industry, and insurance agencies to plan actions to decrease the economic impact of untreated OSAS.[97]

Data on types of treatment for snoring and OSAS suggested that therapy with OA had lower costs when compared with other treatment modalities.[15] Nonetheless, it has not been evaluated yet the use of OA associated with reduced risk of vehicle and labor accidents. Further studies should evaluate from a social perspective the loss of work productivity, increased absenteeism, insurance, and costs and assess the use of OA in preventing occupational accidents.[10]

The cost-effectiveness of CPAP was compared with the OA therapy and lifestyle advice using a method of quality-adjusted life year (QALY) in a life perspective. On average, CPAP was associated with higher costs than other therapies. However, in another analysis CPAP was more profitable than OA. Therefore, regarding adults who suffer from moderate or severe symptomatic OSA it was concluded that CPAP has better cost-effectiveness when compared with OA and lifestyle advice.[98]

The OA are now widely prescribed for the treatment of OSAS, either as a primary or as an alternative measure to those patients unwilling or unable to tolerate CPAP therapy. Although CPAP has been shown to be more effective than OA[19] and highly cost-effective,[36] there are increasing evidences that OA improve drowsiness, blood pressure, and indices of sleep-disordered breathing.[79] Moreover, many patients who respond to both treatments generally prefer to use OA.[16]

Despite the limited evidence on the cost-effectiveness of OA, through this literature review it can be observed that OA are economically less attractive than CPAP, but remain as a cost-effective treatment for patients who do not want or do not adhere to treatment with CPAP.[99]


This review highlights the fact that OSA is a prevalent disorder among works, leads to increased risk of occupational accidents, greater use of health services, and has a significant impact on the economy.

The CPAP therapy reduces the risk of occupational accidents. Furthermore, it has been shown to be cost-effective, improve the work performance, and reduce health burdens. Regarding OA, despite showing an improvement in work performance, there is no scientific evidence of occupational accidents reduction. Moreover, there is limited evidence of its cost-effectiveness and its effect on reducing the use of health services.

Due to the lack of evidence regarding the use of OA for occupational accidents, future research should focus on determining the cost-effectiveness, influence, and efficacy of these devices in preventing occupational accidents among workers who suffer from OSA.


Source of Support: Nil

Conflict of Interest: None declared.


1. Findley LJ, Weiss JW, Jabour ER. Drivers with untreated sleep apnea. A cause of death and serious injury.Arch Intern Med. 1991;151:1451–2. [PubMed]
2. Strollo PJ, Jr, Rogers RM. Obstructive sleep apnea. N Engl J Med. 1996;334:99–104. [PubMed]
3. Teculescu D. Sleeping disorders and injury prevention of occupational or domestic accidents. Sante Publique. 2007;19:147–52. [PubMed]
4. Ellen RL, Marshall SC, Palayew M, Molnar FJ, Wilson KG, Man-Son-Hing M. Systematic review of motor vehicle crash risk in persons with sleep apnea. J Clin Sleep Med. 2006;2:193–200. [PubMed]
5. Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med. 1999;340:847–51. [PubMed]
6. Stoohs RA, Bingham LA, Itoi A, Guilleminault C, Dement WC. Sleep and sleep-disordered breathing in commercial long-haul truck drivers. Chest. 1995;107:1275–82. [PubMed]
7. de Mello MT, Narciso FV, Tufik S, Paiva T, Spence DW, Bahammam AS, et al. Sleep disorders as a cause of motor vehicle collisions. Int J Prev Med. 2013;4:246–57. [PMC free article] [PubMed]
8. Ulfberg J, Carter N, Edling C. Sleep-disordered breathing and occupational accidents. Scand J Work Environ Health. 2000;26:237–42. [PubMed]
9. Mulgrew AT, Ryan CF, Fleetham JA, Cheema R, Fox N, Koehoorn M, et al. The impact of obstructive sleep apnea and daytime sleepiness on work limitation. Sleep Med. 2007;9:42–53. [PubMed]
10. Leger D, Bayon V, Laaban JP, Philip P. Impact of sleep apnea on economics. Sleep Med Rev.2012;16:455–62. [PubMed]
11. Catarino R, Spratley J, Catarino I, Lunet N, Pais-Clemente M. Sleepiness and sleep-disordered breathing in truck drivers: Risk analysis of road accidents. Sleep Breath. 2014;18:59–68. [PubMed]
12. AlGhanim N, Comondore VR, Fleetham J, Marra CA, Ayas NT. The economic impact of obstructive sleep apnea. Lung. 2008;186:7–12. [PubMed]
13. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM. Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep. 2004;27:453–8. [PubMed]
14. Smolensky MH, Di ML, Ohayon MM, Philip P. Sleep disorders, medical conditions, and road accident risk. Accid Anal Prev. 2011;43:533–48. [PubMed]
15. Schmidt-Nowara W, Lowe A, Wiegand L, Cartwright R, Perez-Guerra F, Menn S. Oral appliances for the treatment of snoring and obstructive sleep apnea: A review. Sleep. 1995;18:501–10. [PubMed]
16. Hoffstein V. Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath.2007;11:1–22. [PMC free article] [PubMed]
17. Kushida CA, Nichols DA, Quan SF, Goodwin JL, White DP, Gottlieb DJ, et al. The Apnea Positive Pressure Long-term Efficacy Study (APPLES): Rationale, design, methods, and procedures. J Clin Sleep Med. 2006;2:288–300. [PubMed]
18. Giles TL, Lasserson TJ, Smith BJ, White J, Wright J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2006;3:CD001106. [PubMed]
19. Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev. 2006;4:CD004435. [PubMed]
20. Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: A randomized controlled trial. J Clin Sleep Med. 2005;1:374–80.[PubMed]
21. Blanco J, Zamarron C, Abeleira Pazos MT, Lamela C, Suarez QD. Prospective evaluation of an oral appliance in the treatment of obstructive sleep apnea syndrome. Sleep Breath. 2005;9:20–5. [PubMed]
22. Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: A randomized, controlled trial. Am J Respir Crit Care Med. 2002;166:743–8. [PubMed]
23. Hans MG, Nelson S, Luks VG, Lorkovich P, Baek SJ. Comparison of two dental devices for treatment of obstructive sleep apnea syndrome (OSAS) Am J Orthod Dentofacial Orthop. 1997;111:562–70. [PubMed]
24. Johnston CD, Gleadhill IC, Cinnamond MJ, Gabbey J, Burden DJ. Mandibular advancement appliances and obstructive sleep apnoea: A randomized clinical trial. Eur J Orthod. 2002;24:251–62. [PubMed]
25. Hoekema A, Stegenga B, Bakker M, Brouwer WH, de Bont LG, Wijkstra PJ, et al. Simulated driving in obstructive sleep apnoea-hypopnoea; effects of oral appliances and continuous positive airway pressure.Sleep Breath. 2007;11:129–38. [PubMed]
26. Barnes M, McEvoy RD, Banks S, Tarquinio N, Murray CG, Vowles N, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med.2004;170:656–64. [PubMed]
27. Engleman HM, McDonald JP, Graham D, Lello GE, Kingshott RN, Coleman EL, et al. Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: Continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med. 2002;166:855–9. [PubMed]
28. Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax.1997;52:362–8. [PMC free article] [PubMed]
29. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996;109:1269–75. [PubMed]
30. Tan YK, L’Estrange PR, Luo YM, Smith C, Grant HR, Simonds AK, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: A randomized cross-over trial. Eur J Orthod. 2002;24:239–49. [PubMed]
31. Aarab G, Lobbezoo F, Heymans MW, Hamburger HL, Naeije M. Long-term follow-up of a randomized controlled trial of oral appliance therapy in obstructive sleep apnea. Respiration. 2011;82:162–8. [PubMed]
32. Ghazal A, Sorichter S, Jonas I, Rose EC. A randomized prospective long-term study of two oral appliances for sleep apnoea treatment. J Sleep Res. 2009;18:321–8. [PubMed]
33. Findley L, Smith C, Hooper J, Dineen M, Suratt PM. Treatment with nasal CPAP decreases automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med. 2000;161:857–9. [PubMed]
34. George CF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP.Thorax. 2001;56:508–12. [PMC free article] [PubMed]
35. Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: Systematic review and meta-analysis. Sleep.2010;33:1373–80. [PMC free article] [PubMed]
36. Antonopoulos CN, Sergentanis TN, Daskalopoulou SS, Petridou ET. Nasal continuous positive airway pressure (nCPAP) treatment for obstructive sleep apnea, road traffic accidents and driving simulator performance: A meta-analysis. Sleep Med Rev. 2011;15:301–10. [PubMed]
37. Komada Y, Nishida Y, Namba K, Abe T, Tsuiki S, Inoue Y. Elevated risk of motor vehicle accident for male drivers with obstructive sleep apnea syndrome in the Tokyo metropolitan area. Tohoku J Exp Med.2009;219:11–6. [PubMed]
38. Arai H, Furuta H, Kosaka K, Kaneda R, Koshino Y, Sano J, et al. Changes in work performances in obstructive sleep apnea patients after dental appliance therapy. Psychiatry Clin Neurosci. 1998;52:224–5.[PubMed]
39. Lavie P. Sleep habits and sleep disturbances in industrial workers in Israel: Main findings and some characteristics of workers complaining of excessive daytime sleepiness. Sleep. 1981;4:147–58. [PubMed]
40. Pack AI, Maislin G, Staley B, Pack FM, Rogers WC, George CF, et al. Impaired performance in commercial drivers: Role of sleep apnea and short sleep duration. Am J Respir Crit Care Med.2006;174:446–54. [PMC free article] [PubMed]
41. Karimi M, Eder DN, Eskandari D, Zou D, Hedner JA, Grote L. Impaired vigilance and increased accident rate in public transport operators is associated with sleep disorders. Accid Anal Prev. 2013;51:208–14. [PubMed]
42. Naismith S, Winter V, Gotsopoulos H, Hickie I, Cistulli P. Neurobehavioral functioning in obstructive sleep apnea: Differential effects of sleep quality, hypoxemia and subjective sleepiness. J Clin Exp Neuropsychol. 2004;26:43–54. [PubMed]
43. Swanson LM, Arnedt JT, Rosekind MR, Belenky G, Balkin TJ, Drake C. Sleep disorders and work performance: Findings from the 2008 National Sleep Foundation Sleep in America poll. J Sleep Res.2011;20:487–94. [PubMed]
44. Ulfberg J, Carter N, Talback M, Edling C. Excessive daytime sleepiness at work and subjective work performance in the general population and among heavy snorers and patients with obstructive sleep apnea.Chest. 1996;110:659–63. [PubMed]
45. Santos EH, de Mello MT, Pradella-Hallinan M, Luchesi L, Pires ML, Tufik S. Sleep and sleepiness among Brazilian shift-working bus drivers. Chronobiol Int. 2004;21:881–8. [PubMed]
46. Koyama RG, Esteves AM, Oliveira e Silva, Lira FS, Bittencourt LR, Tufik S, et al. Prevalence of and risk factors for obstructive sleep apnea syndrome in Brazilian railroad workers. Sleep Med. 2012;13:1028–32. [PubMed]
47. Nena E, Tsara V, Steiropoulos P, Constantinidis T, Katsarou Z, Christaki P, et al. Sleep-disordered breathing and quality of life of railway drivers in Greece. Chest. 2008;134:79–86. [PubMed]
48. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, et al. Sleep disorders, health, and safety in police officers. JAMA. 2011;306:2567–78. [PubMed]
49. Mysliwiec V, Gill J, Lee H, Baxter T, Pierce R, Barr TL, et al. Sleep disorders in US military personnel: A high rate of comorbid insomnia and obstructive sleep apnea. Chest. 2013;144:549–57. [PMC free article][PubMed]
50. Lee YC, Eun YG, Shin SY, Kim SW. Prevalence of snoring and high risk of obstructive sleep apnea syndrome in young male soldiers in Korea. J Korean Med Sci. 2013;28:1373–7. [PMC free article] [PubMed]
51. Sanna A. Obstructive sleep apnoea, motor vehicle accidents, and work performance. Chron Respir Dis.2013;10:29–33. [PubMed]
52. Haja MH, West SD. Obstructive sleep apnoea and driving. Br J Hosp Med (Lond) 2011;72:366–7.[PubMed]
53. Mulgrew AT, Nasvadi G, Butt A, Cheema R, Fox N, Fleetham JA, et al. Risk and severity of motor vehicle crashes in patients with obstructive sleep apnoea/hypopnoea. Thorax. 2008;63:536–41. [PubMed]
54. Findley LJ. Automobile driving in sleep apnea. Prog Clin Biol Res. 1990;345:337–43. [PubMed]
55. Turkington PM, Sircar M, Saralaya D, Elliott MW. Time course of changes in driving simulator performance with and without treatment in patients with sleep apnoea hypopnoea syndrome. Thorax.2004;59:56–9. [PMC free article] [PubMed]
56. Gieteling EW, Bakker MS, Hoekema A, Maurits NM, Brouwer WH, van der Hoeven JH. Impaired driving simulation in patients with Periodic Limb Movement Disorder and patients with Obstructive Sleep Apnea Syndrome. Sleep Med. 2012;13:517–23. [PubMed]
57. Vakulin A, Baulk SD, Catcheside PG, Antic NA, van den Heuvel CJ, Dorrian J, et al. Driving simulator performance remains impaired in patients with severe OSA after CPAP treatment. J Clin Sleep Med.2011;7:246–53. [PMC free article] [PubMed]
58. Li G. Walter McNicholas: Sleep apnea-a disease calling for attention. J Thorac Dis. 2014;6:170–3.[PMC free article] [PubMed]
59. de Mello MT, Bittencourt LR, Cunha RC, Esteves AM, Tufik S. Sleep and transit in Brazil: New legislation. J Clin Sleep Med. 2009;5:164–6. [PMC free article] [PubMed]
60. MacLean AW, Davies DR, Thiele K. The hazards and prevention of driving while sleepy. Sleep Med Rev. 2003;7:507–21. [PubMed]
61. Philip P, Sagaspe P, Lagarde E, Leger D, Ohayon MM, Bioulac B, et al. Sleep disorders and accidental risk in a large group of regular registered highway drivers. Sleep Med. 2010;11:973–9. [PubMed]
62. Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med.2004;170:1014–21. [PubMed]
63. Braeckman L, Verpraet R, Van Risseghem M, Pevernagie D, De Bacquer D. Prevalence and correlates of poor sleep quality and daytime sleepiness in Belgian truck drivers. Chronobiol Int. 2011;28:126–34.[PubMed]
64. Asaoka S, Namba K, Tsuiki S, Komada Y, Inoue Y. Excessive daytime sleepiness among Japanese public transportation drivers engaged in shiftwork. J Occup Environ Med. 2010;52:813–8. [PubMed]
65. Mello MT, Santana MG, Souza LM, Oliveira PC, Ventura ML, Stampi C, et al. Sleep patterns and sleep-related complaints of Brazilian interstate bus drivers. Braz J Med Biol Res. 2000;33:71–7. [PubMed]
66. Rodenstein D. Driving in Europe: The need of a common policy for drivers with obstructive sleep apnoea syndrome. J Sleep Res. 2008;17:281–4. [PubMed]
67. Horne JA, Reyner LA. Sleep related vehicle accidents. BMJ. 1995;310:565–7. [PMC free article][PubMed]
68. Findley LJ, Suratt PM. Serious motor vehicle crashes: The cost of untreated sleep apnoea. Thorax.2001;56:505. [PMC free article] [PubMed]
69. Lavie P. Incidence of sleep apnea in a presumably healthy working population: A significant relationship with excessive daytime sleepiness. Sleep. 1983;6:312–8. [PubMed]
70. Akkoyunlu ME, Altin R, Kart L, Atalay F, Ornek T, Bayram M, et al. Investigation of obstructive sleep apnoea syndrome prevalence among long-distance drivers from Zonguldak, Turkey. Multidiscip Respir Med.2013;8:10. [PMC free article] [PubMed]
71. Torzsa P, Keszei A, Kalabay L, Vamos EP, Zoller R, Mucsi I, et al. Socio-demographic characteristics, health behaviour, co-morbidity and accidents in snorers: A population survey. Sleep Breath. 2011;15:809–18.[PubMed]
72. Lindberg E, Carter N, Gislason T, Janson C. Role of snoring and daytime sleepiness in occupational accidents. Am J Respir Crit Care Med. 2001;164:2031–5. [PubMed]
73. Masa Jimenez JF, Rubio GM, Findley LJ, Riesco Miranda JA, Sojo GA, Disdier VC. Sleepy drivers have a high frequency of traffic accidents related to respiratory effort-related arousals. Arch Bronconeumol.2003;39:153–8. [PubMed]
74. Powers CR, Frey WC. Maintenance of wakefulness test in military personnel with upper airway resistance syndrome and mild to moderate obstructive sleep apnea. Sleep Breath. 2009;13:253–8. [PubMed]
75. George CF. Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med.2007;176:954–6. [PubMed]
76. Krieger J, Meslier N, Lebrun T, Levy P, Phillip-Joet F, Sailly JC, et al. Accidents in obstructive sleep apnea patients treated with nasal continuous positive airway pressure: A prospective study. The Working Group ANTADIR, Paris and CRESGE, Lille, France. Association Nationale de Traitement a Domicile des Insuffisants Respiratoires. Chest. 1997;112:1561–6. [PubMed]
77. Teran SJ, Moreno G, Rodenstein DO. Sleep medicine and transport workers. Medico-social aspects with special reference to sleep apnoea syndrome. Arch Bronconeumol. 2010;46:143–7. [PubMed]
78. Parks P, Durand G, Tsismenakis AJ, Vela-Bueno A, Kales S. Screening for obstructive sleep apnea during commercial driver medical examinations. J Occup Environ Med. 2009;51:275–82. [PubMed]
79. Pliska BT, Almeida F. Effectiveness and outcome of oral appliance therapy. Dent Clin North Am.2012;56:433–44. [PubMed]
80. Hoekema A, Doff MH, de Bont LG, van der Hoeven JH, Wijkstra PJ, Pasma HR, et al. Predictors of obstructive sleep apnea-hypopnea treatment outcome. J Dent Res. 2007;86:1181–6. [PubMed]
81. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: A review. Sleep. 2006;29:244–62. [PubMed]
82. Vanderveken OM, Braem MJ, Dieltjens M, De Backer WA, Van de Heyning PH. Objective measurement of the therapeutic effectiveness of continuous positive airway pressure versus oral appliance therapy for the treatment of obstructive sleep apnea. Am J Respir Crit Care Med. 2013;188:1162. [PubMed]
83. Hiestand D, Phillips B. Obstructive sleep apnea syndrome: Assessing and managing risk in the motor vehicle operator. Curr Opin Pulm Med. 2011;17:412–8. [PubMed]
84. Strohl KP, Brown DB, Collop N, George C, Grunstein R, Han F, et al. An official American Thoracic Society Clinical Practice Guideline: Sleep apnea, sleepiness, and driving risk in noncommercial drivers. An update of a 1994 Statement. Am J Respir Crit Care Med. 2013;187:1259–66. [PubMed]
85. Kristo D, Corcoran T, O’Connell N, Thomas K, Strollo P. The potential for delivery of particulate matter through positive airway pressure devices (CPAP/BPAP) Sleep Breath. 2012;16:193–8. [PubMed]
86. Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med. 2010;52:473–7. [PubMed]
87. Sjosten N, Vahtera J, Salo P, Oksanen T, Saaresranta T, Virtanen M, et al. Increased risk of lost workdays prior to the diagnosis of sleep apnea. Chest. 2009;136:130–6. [PubMed]
88. Potts KJ, Butterfield DT, Sims P, Henderson M, Shames CB. Cost savings associated with an education campaign on the diagnosis and management of sleep-disordered breathing: A retrospective, claims-based US study. Popul Health Manag. 2013;16:7–13. [PubMed]
89. Tarasiuk A, Greenberg-Dotan S, Brin YS, Simon T, Tal A, Reuveni H. Determinants affecting health-care utilization in obstructive sleep apnea syndrome patients. Chest. 2005;128:1310–4. [PubMed]
90. Tarasiuk A, Reuveni H. The economic impact of obstructive sleep apnea. Curr Opin Pulm Med.2013;19:639–644. [PubMed]
91. Kapur V, Blough DK, Sandblom RE, Hert R, de Maine JB, Sullivan SD, et al. The medical cost of undiagnosed sleep apnea. Sleep. 1999;22:749–55. [PubMed]
92. Bahammam A, Delaive K, Ronald J, Manfreda J, Roos L, Kryger MH. Health care utilization in males with obstructive sleep apnea syndrome two years after diagnosis and treatment. Sleep. 1999;22:740–7.[PubMed]
93. Albarrak M, Banno K, Sabbagh AA, Delaive K, Walld R, Manfreda J, et al. Utilization of healthcare resources in obstructive sleep apnea syndrome: A 5-year follow-up study in men using CPAP. Sleep.2005;28:1306–11. [PubMed]
94. Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: A randomized controlled trial. Am J Respir Crit Care Med. 2013;187:879–87. [PubMed]
95. Pelletier-Fleury N, Meslier N, Gagnadoux F, Person C, Rakotonanahary D, Ouksel H, et al. Economic arguments for the immediate management of moderate-to-severe obstructive sleep apnoea syndrome. Eur Respir J. 2004;23:53–60. [PubMed]
96. Tan MC, Ayas NT, Mulgrew A, Cortes L, FitzGerald JM, Fleetham JA, et al. Cost-effectiveness of continuous positive airway pressure therapy in patients with obstructive sleep apnea-hypopnea in British Columbia. Can Respir J. 2008;15:159–65. [PMC free article] [PubMed]
97. Sonnad SS, Moyer CA, Patel S, Helman JI, Garetz SL, Chervin RD. A model to facilitate outcome assessment of obstructive sleep apnea. Int J Technol Assess Health Care. 2003;19:253–60. [PubMed]
98. Weatherly HL, Griffin SC, Mc Daid C, Duree KH, Davies RJ, Stradling JR, et al. An economic analysis of continuous positive airway pressure for the treatment of obstructive sleep apnea-hypopnea syndrome. Int J Technol Assess Health Care. 2009;25:26–34. [PubMed]
99. Sadatsafavi M, Marra CA, Ayas NT, Stradling J, Fleetham J. Cost-effectiveness of oral appliances in the treatment of obstructive sleep apnoea-hypopnoea. Sleep Breath. 2009;13:241–52. [PubMed]

Articles from Indian Journal of Occupational and Environmental Medicine are provided here courtesy ofMedknow Publications
Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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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 Dentists Treat NFL Greats…Do You?


Archie Roberts MD, David Gergen, Isiah Robertson, Dr Harry Sugg
Archie Roberts MD, David Gergen, Isiah Robertson, Dr Harry Sugg






Do you want to be the dentist, in your area, to work with NFL greats?

The Pro Player Health Alliance works exclusively with members of the American Sleep and Breathing Academy. This ensures that the NFL greats will have the highest quality of care. The ASBA members are in a league above the rest. The American Sleep and Breathing Academy offers the highest levels of training. With its monthly study clubs, online webinars, and the world’s largest resource library in sleep medicine, ASBA gives its doctors all the resources they need to become the pillars of sleep practice in their community. The ASBA’s Executive Director, David Gergen, hand selects the dentists in each market that will participate in NFL screenings of former players. This project has been going on, successfully, for five years and has helped to catapult many practitioners sleep practices. For example, Dr. Harry Sugg in Dallas, TX. Harry was doing only 1-2 sleep cases per month until he joined the American Sleep and Breathing Academy. Dr. Sugg’s now treats Tony Dorsett, Michael Irvin, Eric Dickerson,  Derek Kennard, Derek KennardPreston Pearson,  Isiah Robertson and many more NFL greats. Sugg’s sleep practice became so busy he had to hire an associate to exclusively manage it. Harry is just one example of the many ASBA doctors who now have a thriving sleep practice as a result of membership in the American Sleep And Breathing Academy.


Dentists treat NFL Greats
Mark Walczak, Dr Neal Seltzer, David Tyree, Dr Jeffrey Rein and David Gergen at the NFL Legends Lounge, Super Bowl XLVIII









The conference will feature Dr. Rod Willey, the single most successful sleep apnea dentist in the industry. Rod holds the national record for billing 106 cases in a single month. The head of a 3.5 million dollar a year, stand alone, sleep practice, Rod is going to give you a step by step cook book for success.  Five years ago Dr. Willey was not doing Dental sleep medicine. He joined the ASBA and received study club training and the rewards are still paying off. By joining the ASBA, you could be the next Rod Willey. Remember, records are made to be broken.

Dr. Kent Smith, a dental sleep icon, sees the value in joining the American Sleep and Breathing Academy; an academy that is pro dental sleep medicine and pro oral appliance therapy. Dr. Smith has dedicated more than 20 years of his career to researching, analyzing and developing proven techniques in sleep medicine. He has treated more than 6,000 patients with sleep apnea, and his success is not a coincidence. In addition to being a Diplomate of the American Board of Dental Sleep Medicine, Dr. Smith is going to sit for the ASBA Diplomacy exam on April 18th at 8am. Which, of course, he will pass with flying colors since he is one of the foremost leading authorities on dental sleep medicine.

Congressman Marty Russo will be speaking on how oral appliance reimbursement is increasing with the U.S Government while C-PAP reimbursement has been decreased by another 25%. More importantly, he will be discussing what this means for the industry and how dentists will greatly prosper in the coming years.

Dr. Kevin Mueller, Sleep and TMD professor out of Midwestern University in Glendale Arizona, will teach you how to restore a sleep case, how to take a proper sleep bite and, through restorative dentistry, eliminate the need for oral appliances. His revolutionary process and successful outcomes have made Kevin one of the top sleep doctors in the world. This is a rare opportunity for you to learn from a true expert in the industry. His 30 years of experience, personally trained by Robert Rickets and Ed Spiegel, puts Kevin in a world of his own.

Chronic Care Management: what is it? 

For a dentist, it’s an opportunity to bring something to the physicians where they can have residual income and a built in mechanism for oral appliance therapy. The best way to ensure your success in chronic care is to attend the ASBA annual meeting, April 15th and 16th, and become an ASBA member.

What makes the ASBA different?

The ASBA is truly the cream of the crop when it comes to a dental sleep based academy. Our 700+ ASBA members are all being walked thru the process step by step to ensure they are ALL seeing a large number of oral appliance patients per month. How do we ensure this happens? The ASBA has study clubs that meet every other month. This helps to ensure that our members are learning from the most successful sleep dentists in the country. To be a mentor at one of these study clubs, you must have, at least, a 1.5 million dollar per year sleep practice. Having the opportunity to learn from these mentors at these study clubs helps to maximize your success.

ASBA site:

Registration Members $395 non Members $895 :





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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Sleep Herbst Appliance is Better than you Think

A Dentist was recently audited by his state board compliance committee for treating a patient with a Herbst sleep apnea appliance.  It was reported that this particular patient was not given a diagnostic sleep test prior to receiving treatment. A vindictive ex-staff member of this particular practice, who was the former Sleep Apnea Coordinator, turned the doctor into the state board.

In fact the Dentist assumed there had been a home sleep study done and began treatment via the Herbst appliance. In the chart notes, the Dr. had noted sleep bruxism and this particular patient was paying on a cash basis, not using his/her medical insurance.

As it turned out, This is yet another case of why the Herbst appliance is a Dr’s. best friend. The Herbst appliance has been in used in dentistry since 1909, it can be used to treat bruxism, TMJ, snoring and OSA.  If this particular patient had been given a monoblock appliance or OSA mouthpiece whose FDA intended use is exclusively sleep apnea the story would have turned out very differently. The Dr could have been found guilty by the State Board because a monoblock cannot be used to treat nocturnal bruxism and there is no other dental application for the appliance.
Continue reading Sleep Herbst Appliance is Better than you Think

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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3D Printer Fabricates Oral Appliance


Add oral appliances to the list of new uses for the so-called “3-D printer.” The new manufacturing process applied to the familiar item comes courtesy of Australian dental company Oventus and researchers at the Commonwealth Scientific and Industrial Research Organization (CSIRO).


According to reports, the two entities collaborated to come up with a customized mouthpiece to treat sleep apnea. “When Oventus came to CSIRO with this idea, we were really excited. The possibilities of 3D printing are endless and the fact that we can now design and print a completely customized mouthpiece for patients is revolutionary,” said John Barnes, CSIRO’s 3D printing expert.


Reporter Samantha Olson writes that the invention of 3D printing has opened doors for many new inventions and process simplifications, and works by laying down thin layers of a material until it builds into a three-dimensional solid object. The machine bases the process off of a specific digital design, which Oventus CEO Neil Anderson believes was the key to their new 3D treatment.


“The finished product is printed from titanium and coated with a medial grade plastic, which looks much like a retainer,” writes Olson. “It extends from the user’s mouth like a whistle and divides up separate airways in order to channel airflow into the back of the throat. The air will be directed around the obstructive nose and partial throat collapse, to where it can travel down the trachea and avoid the nightly sleep apnea choking.”


“This new device is tailored to an individual’s mouth using a 3D scan and is used only on the top teeth which make it more compact and far more comfortable,” said Anderson in the article.


Soucre: CSIRO

The post 3D Printer Fabricates Oral Appliance appeared first on Sleep Diagnosis and Therapy.

Juggernaut of The Jaw

David Gergen rolled out of bed on September 12, 1981, and had his career “aha” moment. Gergen knew he was going to be an orthodontic technician, and he knew he was going to help people all over the country. Since then, he has built one of America’s most successful dental labs in Phoenix, Arizona, revolutionized the sleep industry through oral appliances and special programs, and was once voted top dental laboratory technician in the country.

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

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

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

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


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

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

What is the Expected Roll out for the Remainder of 2013?

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

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

We got our CE mark and we are beginning our launch in Europe. We received our 510k approval in May. Our game plan now is that we are going to launch in Europe, and then toward the end of summer we’ll be launching in the U.S. By the end of this year, and going into 2014, we plan to be at full scale.

The concept of jaw position as a fundamental piece of sports performance is not new. Dr. Harold Gelb introduced this concept in his early work in the 1970s. The culmination of his work in improved performance was the 2000 Baltimore Ravens who triumphed over the New York Giants to win Super Bowl XXXV.

Every player on the team wore a custom oral appliance that positioned the jaw in Dr. Gelb’s Jaw position called the Gelb 4/7 position. Since that time, professional sportsmen all over the world have been adopting a daytime mouth guard to protect them from injury and improve their performance.

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

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

Improvement on Many Levels

Children undergoing standard orthodontic care have noticed their grades improve, sometimes dramatically. In the past, this would have been attributed to improved self-image or a growth spurt. Today, experts have measured the improved sleep patterns and the increase in airway size that comes from a better jaw position. These patients breathe better at night, and wake up more able to deal with the demands of the day.

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

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

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

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

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

“Pro Player Health Alliance was created to treat the sleep health needs of retired NFL players,” explains Gergen, “while at the same time raising awareness of sleep apnea as a silent killer.”

Dr. Archie Roberts, founder of the NFL HOPE program and retired NFL player, has been one of Gergen’s keynote speakers. Roberts established the much higher incidence of OSA and heart disease in the general population. He asked Gergen to be the sleep apnea director in the program they’re launching at the Mayo Clinic in Scottsdale, Arizona, on August 14, 2013.

Carl Eller, Larry Fitzgerald, Warren Moon, Roy Green, Dave Krieg, Isiah Robertson, Eric Dickerson, Mike Haynes, Tony Dorsett, Matt Blair, Chuck Foreman, and Derrek Kennard were all excellent football players, and some have been inducted into the Hall of Fame. They are all sleep apnea patients who are contributing to the field of sleep medicine and sharing their experiences with the general public.

The results are more diagnostic tests and, hopefully, reversing the trend of undiagnosed sleep apnea. Mike even asked Gergen recently to make an agility guard for his son to help him with his football performance. He also asked Gergen to have his son looked at for pediatric sleep.

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

On the horizon is an upcoming Pro Player Health Alliance event in New York, a presentation with Dr. Brad Eli during sleep symposium at the Super Bowl (scheduled for February 2, 2014 in East Rutherford, NJ), and a seminar in Las Vegas with Dr. Brock Rendeau. “Rendeau is one of North America’s most sought after clinicians, and without a doubt one of the most creative speakers on the topic of functional orthodontic treatment,” says Gergen.

Gergen will remain at the center of these programs. He will be building teams, asking hard questions, and the sleep industry will be better for it.

David Gergen At a Glance

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

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

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

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

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

Three most important tips for success in Dental Sleep Medicine

David Gergen CDT

I try not to think about how long I’ve been involved in the dental industry because I’d like to believe I’m not old enough for the numbers to add up that way, but it has been a long, long time.  I consider myself very lucky because when I started as an Orthodontic Technician I had the opportunity to work with, and learn from, some of the best in the business; true pioneers in orthodontics.  And I again consider myself lucky. Now, almost 30 years after opening my lab, my industry is booming and I’m working with doctors who are pioneers in Dental Sleep Medicine.  Throughout my entire career, I have always managed to surround myself with experts and I know that it has really played a major role in my success and helped me become an expert in my own discipline.

There’s a famous Bob Dylan quote, “Act the way you’d like to be and soon you’ll be the way you’d like to act.” As I speak with dentists who are just getting into sleep apnea treatment, one of the best pieces of advice I can give them is just that.  Find an expert and do what they do, get the education they got, work with the companies they work with.

While I’ll admit that this advice is somewhat self-serving for me and my sleep appliance lab, it doesn’t make it any less true. You might think that the dentists who are having great success in treating sleep apnea would be reluctant to share their secrets with others, but the good guys understand that helping others to do it right helps our industry as a whole.  There are a few things that all the experts do that a new dentist (or an old dentist who’s new to sleep apnea) can do as well.  If you want to put yourself on the path to becoming an expert too, here are my recommendations:

Education is Key

Education is what separates a dentist who treats sleep apnea from a dentist who is a sleep apnea expert.  It seems like there are countless opportunities to take a sleep apnea class, and I haven’t been to a dental convention in the last few years that didn’t have at least one.  In addition, there are a handful of major players in sleep apnea training, and I really like the work that the American Sleep and Breathing Academy is doing for dental sleep medicine.  The reason I recommend the ASBA in lieu of other groups is because they really embrace a multidisciplinary approach.  They are not only educating dentists, they also work with medical doctors, nurses and PAs, sleep technicians, RTs,  sleep diagnostic facilities, and of course, sleep appliance labs like mine.  They have online education available and put on a number of education events throughout the year.  Put their 2014 Dental Division meeting on your schedule May 1st to 3rd, 2014 in Scottsdale AZ, and look into joining at

Testing Your Patients

A big hurdle for a dentist treating OSA is the sleep study.  There are companies that will happily sell a dentist sleep testing equipment at a pretty substantial cost, and without telling them that

Nox T3 by Carefusion medical grade sleep Bruxism monitor
Nox T3

it may cause problems for them when it comes to insurance approving the Oral Appliance.  Working with a local sleep diagnostic lab is always good, but it can be difficult to get the patient back

because the lab my send the patient home with a CPAP machine.   Personally, I really like working with the team at Sleep Services.  They are a national home sleep testing lab and they’ve been in the business almost as long as I have. When I first met with them, I was more than a little skeptical because I’ve had less than stellar experiences with other sleep testing folks in the past, but they really deliver in what they say they’ll do.  They have helped a lot of the dentists I’ve referred to them manage a difficult part of their sleep apnea program, and they can also help with billing medical insurance, which is an invaluable service for many dentists who struggle to do it on their own. Call them at (888) 322-7108 or find them online at

The Appliance

Herbst Appliance by Gergen’s Orthodontics

I’ll be honest and say that I’m just not the right person to give a fair and balanced review of any appliance lab.  I know my team does a great job, and I’ll leave it at that.  However, when it comes

to choosing the right appliance for your patient, I can offer some insight there.  It’s a great thing to see so many sleep appliances becoming FDA/Medicare/Insurance approved and  it speaks volumes about the future of our industry.  I get asked by dentists all the time which appliance is the best one to use.  The answer is, you have to use a variety.  There is no magic appliance that is perfect for everyone, but the Herbst is probably the best place to start. It’s a tough appliance and it doesn’t have any wings, fins or tabs that are at risk of breaking off.  It also allows some lateral movement to minimize TMJ issues, especially in bruxers. See the Herbst and other appliance options on my website or call my team at 866-437-4361.

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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