Every time you turn on the TV or open the newspaper there is some kind of story about sleep apnea. This is not totally surprising given the magnitude of the untreated patient population. Stanford has reported that only 1% of the total OSA patient population is currently receiving care. The increase in profile of the condition is leading to an increase in diagnostic procedures however patients under care numbers are still not where they need to be.

Enter David Gergen President of ProPlayer Health Alliance and lifelong football fan. David was inspired by a conversation he had with ex NFL quarterback and Cardiologist Archie Roberts MD. Dr Roberts completed research on apnea rates among retired NFL players that indicated that Apnea risk in retired NFL players is exceeds that of the general public (http://1.usa.gov/10cRgsG). David reached out to his friend Derek Kennard as his first contact to test the concept that retired NFL players need better options so that they can sustain sleep treatment.

David found that there was a fundamental problem facing almost all of the retired NFL players that he met. The first issue is that retirement has not affected all players equally some have done very well and are able to navigate the health system easily. Others need help getting diagnosed and then get treated. The unexpected discovery was that almost all of the players that David approached wanted to help raise awareness with their peers but also with the general public. This lead to the “AHA” moment that inspired the launch of ProPlayer Health Alliance. ProPlayer was founded to provide sleep care for retired NFL players and also raise awareness in the general public through public events that invite patients treated and untreated to share their stories and if necessary learn about alternative treatments for OSA. Retired players across the country have embraced this new initiative.

Recently there have been events in Dallas,Tacoma, Minneapolis, San Jose, Phoenix and coming up in May there will be an event in San Diego with Dr Bradley Eli. It is the David Gergen’s intention, that sleep care providers, physicians, dentists and DME providers, host these events in order that patients immediately recognize their need and meet someone with the advanced training and certification to communicate treatment options. The recent ProPlayer Health Alliance event in Phoenix saw a new level of engagement by the NFL player community. Syndicated sports writer, producer and talk show host Larry Fitzgerald Sr was a presenter at the event and his son Arizona Cardinal Larry Fitzgerald attended the event, sponsored by Dr Gary Core. Sleep Apnea runs in families as Derek points out in his video above. If you have a family member with OSA or you are concerned yourself please join us at one of our public events.

The following slide presentation was created to outline the excitement and OSA community awareness that a ProPlayer Health Alliance event can create. ProPlayer was founded to provide treatement for retired Football players and to raise awareness in the community of the dangers that untreated obstructive sleep apnea presents. I have been advised by David Gergen president of ProPlayer Health Alliance the retired NBA players association has made some overtures. I expect that the ProPlayer concept will change the way people learn about their sleep disorders and connect with medical and dental practitioners.

John Viviano DDS, discusses the findings of this previously published study in ‘Respiration 2011 2: 20′ Aarab G, Lobbezoo F, et al.

Airway Orthotics vs. nCPAP; which is better? Previous randomized controlled trials investigating this have found nasal continuous positive airway pressure (nCPAP) to be superior to Airway Orthotic therapy (AO).  However, in most of these studies, only nCPAP was titrated objectively but not the AO. In order to establish an unbiased comparison between these treatment modalities, the AO should be titrated objectively as well.

The purpose of the cited study was to compare the treatment effects of a “titrated AO” with those of “nCPAP” and an “intraoral placebo device”.  Sixty-four mild to moderate patients with OSA were randomly assigned to three groups: AO, nCPAP and placebo device. From all patients, two in-lab sleep study recordings were obtained; one before treatment and one after approximately 6 months of treatment.

The results demonstrated that the change in the apnea-hypopnea index (AHI) between the baseline and therapy evaluations differed significantly between the three groups. However, no statistical difference was found between the AO and nCPAP therapy, whereas the changes in AHI in these groups were significantly larger than those in the placebo group.

The authors concluded no clinically relevant difference between AOs and nCPAP in the treatment of mild to moderate OSA when both are titrated objectively. A number of very good, user-friendly ambulatory sleep screeners are available for Dentists to use. Consider it something like driving with your eyes open!

Every professional who treats sleep apnea wants to recommend the most effective therapy for each individual patient.  If only we had a tool to predict such a positive match!

Study after study shows that CPAP, applied effectively, will resolve all forms of sleep disordered breathing.  Unfortunately many studies also show that CPAP is not well accepted by patients, thus alternative therapies have been pursued almost since obstructive sleep apnea was described.

As dentists seek to form collaborative care relationships with diagnosing physicians, it is necessary to back up claims of effectiveness of the dental appliance therapy we provide.

Two recent articles can help support dental interventions:

Efficacy of An Adjustable Oral Appliance and Comparison to Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Syndrome
Aaron B. Holley, Christopher J. Lettieri and Anita A. Shah
Chest; June 2, 2011; DOI 10.1378/chest.10-2851

Full Article Available Here

The comparison of CPAP and OA in treatment of patients with OSA: A systematic review and meta-analysis
Wenyang Li1, MD, Lin Xiao2, PHD, Jing Hu1*, PHD
RESPIRATORY CARE . Published on January, 2013  DOI: 10.4187/respcare.02245

Full Article Available Here

Each of these well written papers show that many measurements of sleep-related diagnostics such as Epworth, SQALI, and oximetry are equally treated with either CPAP or OAT.  Patient preference continues to be for OAT while AHI reduction is best accomplished by CPAP, especially as the diagnosed AHI rises above 30. This was summarized well recently:

Eur Respir J. 2012 May;39(5):1241-7. doi: 10.1183/09031936.00144711. Epub 2011 Nov 10.

Non-CPAP therapies in obstructive sleep apnoea: mandibular advancement device therapy.
Marklund M, Verbraecken J, Randerath W 

Read Abstract

How can the interested dentist use this information?  Your sleep physicians may understand that dentists have something to offer their patients, but are not as sure about effectiveness.

Dentists mostly treat disease with procedures:  we surgically remove decay and restore the void with various materials. We mechanically reduce infection and rely on the body to heal tissue lesions. We can do this for years without much concern for scientific basis of why we do what we do.

Physicians tend to pay much more attention to research and publications than dentists do. This fact means that as dentists seek to gain a legitimate role in the treatment of medical patients, we must provide properly researched data to support our therapeutic option.

Of course, there are research savvy dentists and CPAP-blinded physicians. Focusing on improving the health of our community depends -on all parties growing together.

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Steve Carstensen, DDS
Bellevue, WA

Stimulating Awareness and Early Intervention of Breathing Issues in Children and How it Effects Behavior, Brain Development, and Facial Development

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Airway Centric™ Dentistry trumps everything else in dentistry. The airway and proper or ideal breathing is hierarchically the most important function for humans to thrive. Ideal health and facial development is dependent on correct oral posture and silent nasal breathing, as opposed to mouth breathing and snoring.

“We are seeing our children’s faces narrowing and their jaws retruding, which is closing airways, not conducive to ideal healthy breathing and restorative sleep. This leads to children having more learning disabilities, Attention Deficit Hyper-activity Disorder (ADHD), diabetes, and obesity are on the rise, and Obstructive Sleep Apnea (OSA) is reaching epidemic proportions,” said Dr. Michael Gelb, DDS MS.

So what is truly the cause of these issues? SDB is observed as early as 6, 18, and 30 months. Food allergy, inflammation and epigenetic factors lead to enlarged tonsils and adenoids and narrow, retruded jaws. Our faces are starting to look like the bulldog. The upper and lower jaws are pushed in, nostrils are pinched, noses congested, and teeth are crooked.

Parents need to know that this preventable. By establishing normal nasal breathing and tongue posture in the first few years of life the stage is set for ideal growth and development. This can be achieved by breastfeeding to reduce SDB and encourage palatal expansion as well as ideal lip and facial tone. Parents need to understand the value of the airway related to the nose and jaws and be made aware of the signs that their child might be heading down the wrong road.

Airway Centric™ Dentistry requires a partnership between parent, teacher, dentist, ENT, pulmonologist, lactation consultant, OBGYN, myofunctional therapist, sleep specialist and physical therapist. Dr. Gelb’s philosophy and new approach to dentistry allows the dentist (or physician) to transform lives by reducing sleep fragmentation, increasing oxygen saturation, improving heart rate variability and treating apnea, hypopnea, upper airway resistance syndrome (UARS), and snoring. Airway Centric™ Dentistry enables the dentist to achieve a higher level of health and wellness with their patients. This new approach will help the patient to have a better night’s sleep, with fewer awakenings and renewed energy and focus in the morning and throughout the day.

Disturbed Breathing or Sleep-disordered breathing (SDB) is a general term for breathing difficulties that occur during sleep. Its hallmarks are snoring and sleep apnea. SDB reportedly peaks from two to six years of age, but also occurs in younger children and infants. By integrating Airway Centric™ Dentistry into his practice, Dr. Gelb has been successful in treating infants to adults with SDB and the issues it causes.

“It is my life’s passion to make our community and nation know how the airway impacts child brain development, social and emotional skills, peer relationships, hyperactivity, and behavior,” said Dr. Gelb.

For additional information regarding Airway Centric™ Dentistry and this new paradigm in dentistry, please visit http://www.gelbcenter.com and http://www.aapmd.org.

About The Gelb Rejuvenation Center The Gelb Rejuvenation Center, located in New York and White Plains, NY, offers integrated treatment for head, neck, and jaw pain and dysfunction including headache, snoring, and sleep apnea. The professional pain team, led by Dr. Michael Gelb, integrates physical therapy, nutrition, biofeedback, applied kinesiology, and cranial therapy in their treatment regimen—and focuses on beauty, health, and wellness. For patients with sleep disorders, The Gelb Rejuvenation Center offers two affordable, patient-friendly, at-home sleep test systems, which aid in patient screening, clinical assessment, and treatment to restore peace and quiet to their bedrooms

Dentists and patients have been told for years ‘why’ they grind their teeth at night.  I’ve heard from occlusion specialists that it has to be because of imperfections in the bite, from myofacial pain specialists that it’s because of dis-coordination of the function due to inflammation in the muscles, from behavioral specialists it’s because of stress, and from neurologists claiming it is from brain dysfunction. Nutritionists, massage therapists, acupuncturists, psychiatrists, and kinesiologists all claim to have the answers.  There seem to be as many theories for ‘why’ as there are theorists and just as many solutions.

Research in this area often leads to confusion but the deepest research yields a firm understanding that there is no firm understanding of sleep bruxism.  The best resource I have found,  ‘Bruxism – Theory and Practice’ edited by Daniel Paesani (Quintessence, 2010) concludes many of its 25 chapters and 524 pages by noting that ‘more research is needed’ or ‘multiple explanations are likely’ for what it presents.

What does the practitioner do with this body of data?  I think we should treat our patients according to the best research we have available all the while sharing that we don’t know everything we wish we knew.  Those patients who claim that ‘stress’ is causing their sleep bruxism and those who are sure that it’s “because everyone in their family does it” could both be right.  There’s no reason for you to assert any other theory (and try to be ‘right’) because you can’t say with any more certainty than they can.

Treat the symptoms in the least invasive way possible.  Keep in mind that many of your sleep bruxism patients may be suffering with sleep disordered breathing and before you make that ‘nightguard’ – whatever design that means to you – be sure to screen for the medical condition.  You may just help the patient discover that there is more to what she/he is feeling than just sensitive teeth.

Dentists like you make thousands of choices during your career. From dental school days to how you shape your retirement plan, you get to decide how you want to do things.  While these days the new graduate may not have as many career paths as one might have a few decades ago,  the mix of services the involved dentist gets to pick from is ever expanding.

Dental Sleep Medicine is the closest thing to practicing medicine any non-oral surgeon dentist will get.  More and more dentists every day are taking up the challenge of helping their patients breathe better during sleep.  Membership in the American Academy of Dental Sleep Medicine has grown by double digits each year, the calendar is crowded with courses in how to make oral appliances, dentists are finding the rewards that come with this area of practice stimulating and whole office teams are being reshaped to learn new skills.

So is this right for you?  I’m going to assume that since you have found your way to Sleep Scholar, you are at least interested in this field.  Perhaps you have begun making appliances after some basic education.  Maybe you seek that first opportunity for helping a person live longer.  It’s possible you are intimidated by the breadth of knowledge required and want assurance that you know enough to help.

Over the years of my practice, I have been the extremely fortunate recipient of hundreds of hours of expert instruction, well-founded advice, and individual coaching by dentists and others I’m happy to have had as mentors along the way. A passion for passing along the wisdom learned  has created chances to meet with other individual dentists, study clubs, dental institutes, regional and national dental meetings to share what I’ve assimilated.

Sleep Scholar is a new venture for me to offer what I’ve learned, engage with interested parties, and facilitate improvement in the practice of dental sleep medicine.  While I’ve had years of experience and read more articles than I could count, the fact I am most sure of is that I don’t come close to ‘knowing everything’ and the second point I will always make is that almost everyone knows something I don’t, with many people knowing much that I look forward to hearing about.  Still, I’ve found it quite valuable over the years to gather up a group of interested people and create an environment where we learn from each other.  I can claim some skills in helping folks accept what they do know, share it with others, and in the process gain confidence to put that knowledge to action, gaining wisdom along the way.

Perhaps you will find the upcoming essays helpful.  I pledge to stay committed to present clinically oriented information that is based on the ever-growing body of published evidence.  We can’t practice medicine without applying what we know to the individual patient sitting with us, so the artistry lies in taking that evidence and distilling it down to choosing an action for one person.  Therein lies the beauty of being a doctor – evidence supports how we choose to apply our skills.

Shall we learn together?