Author: Michael Kelley

This is demonstrated up close and hands on at the American Sleep and Breathing Academy annual meeting. Register at http://www.sleep-conference.com. Oral appliance therapy is considered an effective treatment for snoring and obstructive sleep apnea (OSA). The appliance functions by supporting the jaw in a forward position to help maintain an open upper airway. When utilized properly, it is worn at night and fits like a mouth guard used in sports. The success of the appliance, however, depends largely on the quality of the bite registration taken. While many view the process as an uncomplicated procedure, if it is not done using the correct technique with precision it could negatively impact the treatment. The late Dr. Robert Ricketts DDS, NMD who was a well-known and arguably the greatest orthodontist of all time, leader in orthodontic instruction as a professor and a noted researcher in many areas of dentistry including craniofacial growth and development, TMJ, orthodontics and esthetics invented what is known as the the Ricketts Phonetic Bite. The Ricketts Phonetic bite may be used for patients suffering from snoring or obstructive sleep apnea and it determines the position of the mandible that creates the so-called sweet spot for patients using oral appliance therapy. Instructions are as follows: The dentist should instruct the patient to sit upright in the chair. The dentist should instruct the patient to count out loud numbers 55-75. Notice numbers 5, 8, 9 for vertical opening and 66 for maximum anterior posterior positioning. If you do not get the desired AP with the “ss” sound, you can use the second “s” sound, “sh” to acquire the max AP. The “n” sound in 69 will drop their mandible vertically as well and give you their full natural opening. The “n” sound is a straight vertical drop wherever you’re at in speech; using the word “shun” is another method for obtaining the best AP position. The dentist should use a round surfaced instrument as opposed to a flat one (for anterior stabilization during the registration) between teeth #8 and #9 to hold that position of the jaw. Use a fast set bite registration material to capture the bite. You will always want to start with having the patient occlude their teeth a few times in order to make a mental image of their natural occlusion. Having the patient counting those numbers should give you a feel for the most balanced yet natural vertical opening. All three types of basic classes of anterior occlusion must open to disclude the posterior teeth in order to allow a person to speak, and when “ss” sounds must be made, at least 1 to 1.5 mm of clearance must be developed between the upper and lower central incisors. Note that saying “s” will not be sufficient; you will actually have to force the sound to occur using it in a word, as seen during the count in numbers that contain the “ss” sound or like with the word “Mississippi”. David Gergen Demonstrates the Ricketts Phonetic Bite with Dallas Cowboys Super Bowl Champion, Derek Kennard The amount of disclusion depends on the degree of forward movement of the teeth from centric relation to their “ss” position. These movements define the incisal guide angle and represent vertical and horizontal overlaps of the teeth. Thus, the greater the forward movement, the greater the amount of posterior disclusion and the resultant “s” space – or posterior speaking space as found in the number “66” and word “Mississippi”. Once again, repeat these steps a few times to make sure you get the same results. It is important to capture the optimum vertical as it is much harder to adjust after the appliance is fabricated. After using this technique, utilize the Airway Metric System by placing the correct jigs correlating with the sleep bite for reference. Lean the patient back in the chair and see if they can snore. If they cannot, ball game over. I specifically instruct doctors to only use the Ricketts Phonetic Bite with NFL players because of the accuracy and rate of success. For example, Super Bowl Champion Derek Kennard’s AHI went from a 72 to 2 on the first try using this technique. This is demonstrated up close and hands on at the American Sleep and Breathing Academy annual meeting. Register at http://www.sleep-conference.com.

If  you want to get into sleep medicine, or improve the oral appliance section of your dental practice, it takes buy-in from the entire practice. Sure, you can go to the American Sleep and Breathing Academy (ASBA) annual meeting by yourself, but will you be able to transmit the enthusiasm and knowledge that you gain?   I call it the “seminar high” and attaining those heights is better when at least one team member from the clinical or administrative side is along for the trip. Conference tuition and travel expenses for this year’s Sleep and Wellness Conference has been made affordable with the goal being for at least one staff member to attend.   Visit Conference website for more information http://sleep-conference.com   In my work as executive director at Gergen’s Sleep Lab, I have seen all that enthusiasm go to waste because dentists feel overwhelmed at the prospect of adding oral appliances to their practice. It is definitely not the same as traditional restorative dentistry.   Dentists may successfully relay some of what they learn, but they will inevitably forget something. Even if they could describe everything they learned, it’s difficult to communicate the sheer inspiration that happens after a two-day educational event.   Remember, if staff members don’t come to the presentations, they will simply have one thing on their minds; How much extra work is this new oral appliance commitment going to generate? If you can’t explain the tools (software, proper insurance protocols, and treatment), it may only lead to frustration.   Don’t leave staff to scramble and figure out what they need to do. Invite your team members to the ASBA show. Again, we understand that cost can be an issue, and you may hesitate to spend more dollars on tuition and travel expenses. However, if you go to a seminar and pay the tuition, then come back and fail to properly begin the oral appliance business, you will end up losing what you pay in tuition anyway.   The most successful doctors I see are the ones who bring their team members. Once they get home, they are the ones compiling ideas and determining how oral appliances can be implemented. You want everyone on board. If staff members are too busy to go, they are probably too busy to seriously pursue sleep medicine.   Visit Conference website for more information http://sleep-conference.com   Office managers, assistants, and hygienists will be talking to patients about oral appliances and giving those patients the basics. They will be talking about insurance, billing, and treatment and they answer phones and answer questions. Give them the tools they need to succeed. It will be worth the investment.   Angela Kowaleski is executive director of Gergen’s Sleep Lab, with locations in Arizona and Illinois. She has more than 20 years experience in the field of dental sleep medicine.

The National Sleep Foundation announced its annual Sleep Awareness Week for April 23-29, 2017. The nationally recognized week, intended to promote the importance of healthy sleep in America, will also be acknowledged by the American Sleep and Breathing Academy (ASBA) at the upcoming Sleep and Wellness Conference April 21-22, 2017. A multitude of medical conditions that are detrimental to a person’s health have been found to be caused by the effects of what happens before and during sleep. Registration for the Sleep and Wellness Conference, click here. Lack of quality sleep can have a negative effect on mood, productivity at work, relationships, public safety and overall health. The ASBA looks to improve these aspects of everyday life in America by actively focusing on attacking a sleep disorder known as obstructive sleep apnea. This is done specifically by providing education to dentists, physicians and respiratory technicians regarding the treatment of the disorder as well as increasing awareness in communities across the country through free public events hosted by ASBA Diplomates. The public events have been extremely successful resulting in free education to over 10,000 people, over 1,000 patients being tested and hundreds who proceeded with treatment by an ASBA doctor. If you are a treating provider interested in attending the conference, please visit http://sleep-conference.com to learn more.

  There are multiple OSA screening tools available for dentists. A very effective method to use for predictable and accurate screening in the dental setting is Pulse Oximetry. It provides objective data that can be used to make an informed decision about the need for a diagnostic sleep test while also ensuring that patients are at an ideal treatment position before referring them for titration tests. Dr. Stacey C. Laymen a nationally recognized lecturer on Dental Sleep Medicine, will lecture on this important initiative at the upcoming Sleep and Wellness Conference April 21-22, Phoenix, AZ http://sleep-conference.com Overnight Pulse Oximetry in the screening and treatment of Obstructive Sleep Apnea is a very useful and affordable tool.  A patients denial of a problem can prevent the necessary testing and treatment.  Oximetry can help show these patients a problem that does indeed exist in an easy and non threatening way.  It is also used to screen patients prior to sending them back for follow up polysomnography (PSG) or home sleep testing (HST).   Learning Objectives: Using pulse oximetry to screen dental patients in hygiene. Using pulse oximetry to evaluate treatment outcomes prior to follow up sleep testing. Interpreting those overnight pulse oximetry studies. When to refer and when not to. Sequelae of disease in patients within a dental office and how often to screen. For more information about the Sleep and Wellness Conference April 21-22, Phoenix, AZ http://sleep-conference.com Dr. Stacey C. Laymen is a general dentistry practitioner in Glendale, AZ where she treats sleep patients in her practice. Originally from Texas, graduated in the top of her class from Baylor College of Dentistry in Dallas and has completed hundreds of hours in continuing education with a strong focus on cosmetic restorative dentistry and sleep apnea. Dr. Layman is on faculty with Denmat and Dental Sleep Solutions and teaches dentists across the country how to place Lumineers and how to effectively treat sleep apnea using an oral appliance. She is also the Team dentist for Seattle mariners, and the dentist on call for Sonoran Living Live.

You’ve just taken your first course in Dental Sleep Medicine, you cannot wait to go back to your office and provide this life-saving and life-changing service.  However, your team is completely avoiding eye contact with you, avoiding you, or flat out refusing to help?  Why is this?  Why is Dental Sleep Medicine different than incorporating digital dentistry or a new endo technique?  At the recent NADSM Symposium in Clearwater, FL I gave a lecture on exactly this.  If you missed it, the upcoming Sleep and Wellness Conference April 21-22 hosted by the American Sleep and Breathing Academy will be you’re next best option to have these questions answered. http://sleep-conference.com If you ask any general dentist that has successfully integrated DSM into their practice they usually give one reason as to why they are.  Their team!  And that’s what it is… team.  They are not your employees, your “girls,” or your staff, but team.  If you can find a Dental Sleep Medicine Champion to be your point person (whether it be a hygienist or assistant) and get the rest of the team to help support you in screening and treatment then you are well on your way.  You need to start by finding your “Why.”  Why would we spend money to travel and educate ourselves?  Why would we discuss something other than restorative or periodontal needs to our patients?  Why would we want to mess with medical insurance when we treat OSA?  Treat your family, friends or yourself and you will soon discover your “Why” by changing people’s lives. I played a “Family Feud” style game with the “top 8 excuses on the board.”  What are the reasons more practices aren’t treating more patients?  Change was #1.  Yes it is outside of dentistry and it is different but change is coming whether we like it or not.  “Open your mind to the possibilities hidden behind the inconvenience of change.”  Not enough education, not enough time, and my demographic/area also made it on the list.  Some of the biggest hurdles however, are medical insurance and of course, the patients.  With some good verbiage and good systems these can easily be overcome. Don’t let these things stop you, don’t be overcome, don’t give up.  Get your team on board and continue to find your “Why.” Learn more at the Annual Sleep and Wellness Conference April 21-22 in Phoenix, AZ, hosted by the American Sleep and Breathing Academy http://sleep-conference.com

Dr. Dave Singh will present “Non-surgical Upper Airway Remodeling for OSA” at this year’s multi-disciplinary annual Sleep and Wellness Conference, April 21-22 in Phoenix, AZ, hosted by the American Sleep and Breathing Academy [ASBA] 2026 Home Page Sleep Conference Scottsdale This past weekend I had the opportunity of addressing the North American Dental Sleep Medicine Symposium in Clearwater, FL.  I confirmed that it is now known that Obstructive sleep apnea (OSA) is a common disorder, which is characterized by repetitive collapse of the upper airway during sleep. In addition, upper airway narrowing and sleep-induced loss of muscle tone are important factors in the development of OSA. However, there is a growing recognition that craniofacial abnormalities also commonly occur in patients with OSA.  In fact, clinical and epidemiological studies show that OSA is a multifactorial and complex disease with a strong genetic basis. It has been estimated that approximately 40% of the variance in the apnea hypopnea index (AHI) may be explained by familial factors. It is also likely that genetic factors associated with craniofacial structure, body fat distribution and neural control of the upper airway muscles interact to produce the OSA phenotype.  Indeed, it is now thought that there is a continuous interaction between genetic and epigenetic factors in the structural development of the upper airway. In April, I will be presenting at the Sleep and Wellness conference in Phoenix, AZ.  In that presentation, I will be covering the concept that while continuous positive airway pressure (CPAP) and surgical, bimaxillary advancement procedures are thought to represent curative options for OSA, mandibular advancement devices (MADs) are favored by dental professionals for the management of OSA, in conjunction with their medical sleep specialist colleagues.  But, the approach currently taken by most MADs is generally geared towards symptomatic relief with little attention being paid to the underlying etiology of the condition. While MADs are undoubtedly successful in the short- to mid-term in the clinical management of OSA, unwanted long-term side effects of MADs, such as disruption of the occlusion and temporo-mandibular joint pain, have been reported. In contrast, I will present my studies showing that biomimetic oral appliance therapy can reduce the AHI to <5 in some adults diagnosed with mild to moderate OSA (AHI < 29), and sometimes virtually eliminate it completely.  In addition to exploring the efficacy of this exciting, new approach, I intend to conclude my presentation at the ASBA’s Sleep and Wellness conference in Phoenix, AZ with the notion that pediatric epigenetics embraces a firm promise in the prevention of sleep disordered breathing in young children. 2026 Home Page Sleep Conference Scottsdale Dr. G. Dave Singh DDSc PhD DMD is a US citizen who was born, educated and trained in England, UK. He holds three doctorates, including a Degree in Dental Surgery; a Ph.D. in Craniofacial Development, and a D.D.S. in Orthodontics. He was invited to relocate to the Center for Craniofacial Disorders, USA on the basis of being an “outstanding professor”, where he led a NIH-funded program of craniofacial research. Currently, he is a member of: the American Sleep and Breathing Association; the World Sleep Federation; an Academic Fellow of the World Federation of Orthodontists, and Fellow of the International Association for Orthodontics, where he was awarded prizes in 2005, 2013 and 2014. Dr Singh holds several patents in the USA, Canada and Europe as well as international patents. He has published numerous articles and books in the peer-reviewed medical, dental and orthodontic literature, and has lectured in Australia, Asia, Europe, Africa and North America.

Alan Hickey Writes About David Gergen, CEO | ASBA and Their Personal Relationship David Gergen launched Gergens Orthodontic Lab in 1986. He is a serial entrepreneur, and investor in several other companies. I met David Gergen many years ago in Minneapolis. I had heard stories about him and expected to encounter a Paul Bunyon like character. To my surprise, he was only about 5’7”, but I would not want to be in the vicinity if he swung an axe. What he lacks in height, he makes up for with intensity. The discussion that follows delves briefly into aspects of his personality and behavior in order to shed some light into the mindset of one of dental sleep medicine’s truly unique entrepreneurs. David approached me, told me he needed an excellent IT guy, and revealed that the old owner of the academy he was involved with had run off with the money. The academy at the time was a couple of hundred thousand dollars in debt and Gergen was cooperating with authorities to get things back in order. That was the bad news. The good news was that a lot of the debt would eventually go away and Gergen would fund the academy to keep the doors open, which meant no money out of pocket. Better still, the academy had a solid 150 members on the dental side separate from the hundreds on the medical side. Unfortunately, he could not retain the medical side or offer them anything of value at that time, so he wanted my help restoring it in the near future—making the ASBA a multidisciplinary academy serving both medical and dental sleep professionals. I’m presented with opportunities every month, and as challenging as this was, I said yes, because of Gergen’s reputation as a leader, business entrepreneur and an unnatural ability to out-work anybody. I told him when my wife finds out what I’m doing, she will think I’m crazy because it was going to require a lot of gratis work, but ultimately for a good cause. After I agreed to join, Gergen said, “Oh by the way, we have two months to plan a meeting. There are already 25 doctors registered and they have already paid the money. We need to do this so they don’t feel ripped off.” This was the first time I began seeing the true ambition of David Gergen. An ambition to excel is not the only phrase I would use to describe what he does. It’s coupled with a willingness to succeed and an indomitable spirit. Two months later, on the first morning of the conference, the halls of the DoubleTree were filled with attendees. I couldn’t believe my eyes. Now, two years later, the ASBAhas almost 1,000 dental members and receives calls daily from medical doctors wanting to join. I was speaking recently with Dr. Neal Seltzer who told me David has done more to promote public awareness of dental sleep medicine in the past four years than the industry has done the past 25. He described, “Gergen as a “star”. “He’s bringing sleep awareness not only to the public but also to the NFL, congress, attorney general, and senators”. The American Sleep and Breathing Academy is now thriving and legitimate. The 501(c3) has been filed and we are about to reinstate all of the medical members from the past. This year will be the last year the academy will be geared only toward dentistry. Next year (2018) will be the first year that dental and medical will all be at the conference under one roof, because the ASBA will be a true multidisciplinary academy. Final Thoughts There is no doubt that David’s qualities have brought him a great deal of success. His charismatic persona, rebellious spirit, and his easy-going nature play a big part in it. While the professional societies in the space play it safe and keep growing under the cloak of educational respectability, which although are very important don’t get us to where we need to be as an industry. Someone has to have a vision for where we want this industry to be in 5-10 years time. To experience what David wants to share with our community, please join us at our annual Sleep & Wellness conference April 21-22 in Phoenix, AZ. David will host a panel of like-minded professionals and Doctors who all share in the same vision for dental sleep medicine. http://sleep-conference.com Sincerely, Alan Hickey Director/ASBA

WASHINGTON, DC – Rep Tom Price, M.D. (R-Ga) was confirmed 2/10/17 as the next Secretary of Health and Human Services by a Senate vote of 52-47. American Association for Homecare president Tom Ryan released a statement immediately following the confirmation, saying that, “Dr. Price has a strong appreciation of the role that home medical equipment providers play in allowing people to remain in their homes when recuperating from an illness or dealing with long-term health challenges.   “He has been long-time advocate for legislation that would improve Medicare reimbursement practices for home medical equipment,” continued Ryan, “and has led Congressional efforts to make sure that individuals who rely on home medical equipment in rural communities, and other less-densely populated areas, can get the products and services they need.”   Price spoke on day three of last years Medtrade, giving attendees a dose of optimism while demonstrating a clear understanding of the challenges faced by HME providers. Price’s 45-minute talk and Q&A at Medtrade covered a wide range of topics. Here are some brief “excerpts” from his speech.    Competitive bidding: “It just doesn’t make any sense at all. As was mentioned, 39% of DME suppliers have gone out of business since this competitive bidded started. That’s not because they chose to retire…it’s because the federal government got engaged in the process and said, ‘We’ll pick the winners and losers”. CMS: “They are not bad folks, but their charge is different than yours and mine. Your charge is to care for people. Their charge is to make the numbers add up…that hurts you from a professional standpoint, but patients are being compromised right now in their care because of what the government is doing. That is a story that needs to get out there.” Audits: “Three to five years they say is the average [at the ALJ level]. If your appeal process lasts that long, then it is not a fair process…This is ridiculous. I believe we need a timeline. If the federal government can’t get their act together and move through the process, then it is decided in your favor after a finite period of time. For me, that would be six months. You can’t continue to have this going on and on and be over your heads and over your patients’ heads. It simply does not work.” Fee for service medicine: “The nation has kind of bought into this in a superficial way, and there are folks in Washington who are pushing this; that all of health care, for all of us, needs to be run though this massive process of integrated care, value-based purchasing, or whatever the latest buzzword is so that every single incident of care must go through the federal government in some way. This is so they can make those numbers add up and control it. I believe strongly in fee for service medicine—the ability for one free American to identify another free American who has a service or a product that they desire, and to contract independently, outside the realm of government control. This is absolutely vital for quality health care in this country. In fact, I think it’s the only thinking that is going to save quality health care in this country.” Regulation of the medical industry: “It’s not to say that we don’t believe in appropriate regulations and reasonable regulations. It’s not that the government does not have a role in all of this, because they are paying for a lot of it. But at the end of the day, these decisions—clinical care decisions—need to be made between patients, families, doctors, and providers—and nobody else.”   For more information about MedTrade click here.