Author: Michael Kelley

David Gergen Interviews Recent ASBA Hall of Fame Inductee, Neal Seltzer, DMD, FAGD, D’ASBA, D’ABDSM, D’ACSDD An Interview Long Overdue I recently had the privilege to spend some time with Dr. Neal Seltzer, the 2024 recipient of the American Sleep and Breathing Academy Hall of Fame award. This award is given to long standing members of the ASBA who have demonstrated a history of career achievement, a sustained commitment to advancing the profession, and significant contributions to the field, all while conducting themselves with professionalism among their dental and medical peers. Dr Seltzer has been treating patients with oral appliances for over 33 years and estimates he has probably helped treat over 10,000 patients. He is a partner at Long Island Dental Sleep Medicine in New York, one of the longest established oral appliance dental practices in the country.  I wanted to pick his brain and gain insight to his formula for success. David Gergen: How did you first become interested in oral appliance therapy for obstructive sleep apnea? Neal Seltzer: Like many dentists who have incorporated oral appliances into their practices, I first became interested in this field because I was snoring and was searching for a solution for myself.  Back in 1991, I was introduced to the early Snore Guard developed by Dr Thomas Meade, a dentist from Nevada.  He had realized that by mimicking the mandibular advancement we do while performing CPR to open an airway when a person is unconscious, dentists could help maintain a patent airway while we are atonic in our sleep. This was no toy. Tom had collaborated with Dr Wolfgang Schmidt -Nowara, a well-respected physician also from Nevada who was studying the effects of mandibular advancement on the airway. With the support of Dr. Schmidt-Nowara, Tom’s device gained legitimate respect amongst the medical community. I ordered one of Dr Meade’s appliances, and remarkably my snoring was eliminated. My wife was amazed at the result and I thought to myself, this has potential. What I didn’t know was that my relationship with Dr Meade was going to have a monumental effect on my career. Tom Meade was a brilliant businessman and without my knowledge he had been marketing his Snore Guard to sleep physicians around the country via marketing brochures that he would fax to sleep centers. This was way before the advent of emails or the internet as we know it today with google and other search engines. To my amazement, a local sleep physician had received one of Dr Meade’s brochures in which I was listed as “a qualified, experienced, expert” in the use of the Snore Guard and he contacted me to treat one of his patients who was intolerant of CPAP. Bless Tom’s bravado. My one experience (myself as a patient) had endorsed me as the local oral appliance guru.  The patient contacted me, the Snore Guard was ordered, an appointment was made to fit the appliance, and his snoring as well as his apnea was cured.  I was blown away by his gratitude as he claimed I had saved his life. I knew at that moment that I wanted to do this again. I immediately contacted my partner, Dr Jeffrey Rein, and said the practice is going to go in a new direction. We are going to start saving lives! Davide Gergen:  Neal, that is quite a story. To make this story even more remarkable, you know that I am the orthodontic lab technician that Dr. Meade used to help develop the Snore Guard way back in those early days. I was working with many of the dental field’s early Icons like Harold Gelb and Robert M. Ricketts building various splints and functional appliances and Tom Meade reached out to me because of my lab’s reputation for innovation and quality. Hearing your story, it’s so incredible that our careers in sleep medicine were linked by the Snore Guard so long ago.  Those early days were exciting and filled with many progressive thinking people who felt what you felt and saw an opportunity to help people improve their quality of life.  Besides Dr. Meade, who else was influential in your career. Neal Seltzer: You know Dave, 33 years is a long time and during that time I have been fortunate to have met so many passionate people in this field.  Some, I have been closer with than others, but all have played a part in the journey. I certainly will not be able to list all of them here, but a few were very significant in helping move the needle forward.  Dr. Wayne Halstrom, the inventor of the Silencer oral appliance, his son Don, along with Randy Clare had a huge part in helping build my practice in those early days. His appliance the Silencer was a brilliant concept. It not only had the ability to move a mandible anteriorly, but it also had a vertical component that is often neglected in many of today’s appliances. The research on vertical is still controversial to this day but clinically we found that in many situations it did make the difference in obtaining a successful outcome. Another unique concept that Wayne incorporated into the fabrication of the Silencer was the use of a proprietary gothic arch tracer that recorded the envelope of mandibular motion, translated it into the fabrication of the appliance, and insured that the appliance would not create excessive forces on the teeth or TMJ.  Dr Rein and I did countless Silencers.  It was our “go to” appliance for many years and we never saw tooth movement or TMJ issues. As my practice grew and as the field grew, more and more appliance choices became available leading to a myriad of designs.  Be it known, I have probably used or at least tried every appliance ever conceived.  All these designs have incredible people behind them and all of them, including you and your labs Herbst appliance that was, and is, an industry workhorse, had some influence on me and the development of my practice and patient care.  Some have come and gone, and some are still in use as the major appliances we see today.  I’d like to give a shout out and a big thank you to every one of these individuals here but there really are too many to mention in this interview. However, to anyone reading this, if you and I have worked together in any capacity, and you know who you are, I am truly grateful for your help and friendship. David Gergen: Can you share some advice for colleagues and especially young dentists who are hoping to build their sleep practices or get started in this field. Neal Seltzer: Well, as I had mentioned, our dental practice was going to start treating snoring and sleep apnea. We knew what snoring was, but we knew nothing about sleep apnea. We also knew that if we were going to try and get physicians to refer to us, we better start learning about this asap. I cannot emphasize enough that this is the most important component about entering this field…. education about sleep and breathing!  If you are going to enter the medical world, you must be able to understand the medical condition you are treating and to converse with physicians you better know your stuff. Physicians want to refer their patients to a dentist who they can rely on. In the early days it was hard to find places to learn. We went to medical meetings and joined dental study clubs that were being created by dentists who were dabbling in improving the airway. Now, there are great organizations and academies that provide incredible education opportunities for dentists to learn about the airway, sleep and oral appliance therapy.  You know Dave, this is another part of the story that deserves some recognition. It wasn’t always easy for dentists to get their foot in the door with physicians. The organizations that we all take for granted today, that legitimize what we do by offering credentialing and diplomatic status and have enabled us to hold our own with our medical colleagues, were hard fought to develop. I think this is a good place to recognize some individuals who we all owe a debt of gratitude to. The American Academy of Dental Sleep Medicine “AADSM” started out as the Sleep Disorder Dental Society and was conceived on a phone call in 1990 between Robert Rogers, Allan Bernstein, Arthur Strauss, Michael Alvarez, Peter George, Alan Lowe, Gary Johnson, Jeffrey Hall, and Don Rosenbloom. Dr. Rogers’ wife Mary Beth should also be noted here as she was the driving force, as executive director of the organization.  Of course I can’t neglect to include you, Dave, and your endless energy and vision for helping to create the American Sleep and Breathing Academy “ASBA” along with some of the leading Docs in the field both Dental and medical (Edward Spiegel, Steve Carstensen, Bradley Eli, , Todd Swick MD, (list some of our founding members). The AADSM and the ASBA have both helped educate dentists and have been powerful forces in helping our field grow to better help our patients. Since their inceptions, these organizations, have grown and there have been many more passionate individuals involved with their development who have contributed to our field. To all, a big “Thank You!” David Gergen: How can a dentist who wants to treat obstructive sleep apnea find patients? Nael Seltzer: As we just discussed, meeting with local physicians is one way. Introduce yourself as a dentist in the area who is offering this service.  Start slow. Have them send patients who have refused or failed CPAP. Ask for one or two. If you are successful, they will send more. Screen patients in your dental practice. Many dentists are not screening for OSA. The ADA now encourages dentists to do this as part of their medical history questionnaire. It’s amazing how many people undiagnosed with OSA are already in your practice.  Reach out to various social organizations such as senior clubs, veterans’ groups and houses of worship. There are many marketing tools available to reach the public. Print ads, radio, tv, and the internet can all help potential patients find you. David Gergen: As you mentioned already, there are so many oral appliances to choose from. Can you share with us how you choose which appliances you use in your practice. Neal Seltzer: Dave, you are correct. There are so many choices, and the list continues to grow continuously. This is a good thing.  The competition between manufacturers to claim superiority keeps the race to build the best mouse trap moving forward. Over the last 30 years the appliances have evolved from rudimentary boil and bite appliances to sophisticated devices made of superior materials that are smaller, more biocompatible, more durable, more comfortable and provide superior results. The advent of scanners and digital technology have made the fabrication of appliances more accurate. The development of compliance recorders and the future anticipation of other imbedded data recorders are going to rival the information provided by CPAP machines. I believe that with the already great compliance of oral appliances and success stories we see as dentists, the addition of obtaining significant data about a patient’s sleep will truly put oral appliance therapy on par or ahead of CPAP on many levels. In our practice we strive to deliver appliances that are precision made, have impeccable fit, are made of durable materials, maintain their integrity, stay clean, are comfortable, are backed by companies that stand by their products with good warranties and customer service, and yield excellent results. If the patient experience is excellent, the feed back to their physicians will be excellent and that is essential for continued referrals and practice growth. David Gergen: Here’s a tough one. How about getting paid?  How do you deal with the business side of oral appliance therapy. Neal Seltzer: This is a loaded one. So many aspects to this question. I think this comes down to personal choice. Do you want to charge a fee for your work and only accept your full fee? Do want to work with medical insurance?  Do you want to be in network or not?  My advice to anyone just entering into dental sleep medicine is to contact one of the many billing companies that can help you navigate the world of medical billing. There is a lot to learn and once you are educated you can decide how you will structure your practice. David Gergen:  I know you have been involved in teaching your fellow dentists in various aspects of dentistry throughout your career. Early on, you were an assistant clinical professor at NYU college of Dentistry working with special needs patients.  Later, and for many years you were teaching in the private sector, as the Clinical Director of the Equipoise Dental Center, educating dentists about precision attachment removable prosthetics, and of course throughout your career you have written articles and spoken at various dental meetings and study clubs about oral appliance therapy. You and I, along with a few other dentists from the ASBA, had the amazing opportunity to speak in front of a congressional caucus in Washington DC to help educate people in our government about the devastating health effects of OSA, its effects on the transportation industry and daily life, and the remarkable treatment option that dentists can provide with oral appliance therapy. With all these experiences under your belt, what are some things you hope to see for oral appliance therapy and airway health in the future. Neal Seltzer: I think intervening with people at the youngest ages is essential for minimizing the number of patients that will develop OSA. We already know that the health of the pregnant mother can affect the fetus and its developing oral morphology.  We have come to understand the effect of breast feeding on the development of the oral cavity, its effects on tongue position, swallowing and breathing.  Educating dentists and physicians in both dental and medial schools about OSA is very neglected to say the least. If you don’t understand as a clinician how far reaching and devastating the effects of proper breathing and our bodies need for oxygen are, you will miss out on how so many medical conditions are caused or effected by this. Early intervention is key to prevention. So many pediatricians I speak with have very little understanding about this.  As dentists, the use orthodontics can be a life altering aide in the developing airway and, in my opinion, this should be the most important factor in considering and doing orthodontics.  The understanding of the upper airway, and specifically the mouth, needs more dental/medical collaboration. The mouth is one of the entrances to our airway and its effect on breathing cannot be minimized. Our bodies prioritize obtaining oxygen above all else. Before food, before water, air will determine how are developing bodies react to the lack of it. Because of this, all other systems that make up our bodies will adapt to make sure we get that air even at the cost of sacrificing or stressing these systems. I believe its these stresses that lead to or contribute to the breakdown of these systems, many diseases, and ultimately aging. David Gergen: Are there any things that you feel can be improved in our ability to deliver treatment or reach more patients? Dr. Neal Seltzer:  One thing that has bothered me for a long time is the sleep world’s reliance on AHI as the standard of deciding if a patient needs care and if their care has been improved. Research is showing us that other markers and indicators maybe more helpful in reaching better outcomes. Oxidative stress, hypoxemia, and hypoxic burden for example are perhaps a better indicator as well as biomarkers such as c-reactive protein and erythropoietin. Certainly, finding a way to improve insurance coverage for oral appliance therapy would be a giant help in our ability to care for more people. As in so many areas of medicine, the insurance companies fail to understand the power of prevention. Its in their best interest to learn themselves how preventing and treating OSA can improve the overall health of their patients and in the long run save billions of dollars in the cost of treating comorbid illnesses associated with untreated OSA. Lastly, you and I know all too well from our experience in Washington DC, the far-reaching effects of untreated OSA on drowsiness in the transportation industries and day to day life for all of us. So many highway accidents as well as airline, railway, and shipping disasters have been associated with undiagnosed and untreated OSA. For everyday life, poor sleep and breathing effects millions of people at school, work, and in social situations. Public awareness of all this certainly needs to be improved.  Dave, programs like the Pro Player Health Alliance to screen retired NFL players for OSA, that you developed, and I have had the privilege to be involved in, are one example of increasing public awareness. We need more programs like this. William Dement, the father of modern sleep medicine, once noted that as devastating as OSA is, its preventable and treatable. We just need to get the knowledge and treatment to the patients. David Gergen: Those are all important points. We certainly covered a lot of topics today. I’m sure we could go on for hours, but we are limited by time. I want to thank you for sharing your experiences and ideas with me. I appreciate our friendship and all you have done to improve the lives of your patients. Congratulations again on your well-deserved induction into the ASBA Hall of Fame.  Dr. Neal Seltzer Long Island Smile Cosmetic & Restorative Dentistry nsdmd@longislandsmile.com David Gergen Gergen’s Ortho: 602-478-9713 sleep@gergensortho.com

Dr Dave Singh DMD PhD DDSc © 2024 Adjunct Professor, Sleep Medicine, Stanford University, USA Idea/Innovation I am often asked how I came up with the idea of a biomimetic device, such as the DNA appliance, based on the concept of craniofacial epigenetics for the treatment of obstructive sleep apnea. The story begins in 2001 at the Center for Craniofacial Disorders, University of Puerto Rico, USA where a team of dedicated clinicians were developing techniques to treat babies, children and adolescents with a history of craniofacial congenital abnormalities, ranging from cleft lip and palate through to craniosynostoses, including Apert syndrome, etc. At that time, it was decided that these pediatric patients would be treated with a new technique called Distraction Osteogenesis. The UPR Center for Craniofacial Disorders was one of the first centers in the world to investigate this novel technique for midfacial advancement in these types of cases. One of my roles in this team was to undertake quantitative assessment of morphologic changes of the skeletal and soft tissues pre- and post-treatment. At the turn of the century, cone-beam computerized tomography (CBCT) technology was not available, so we used non-ionizing magnetic resonance imaging (MRI) scans and I introduced 3D stereophotogrammetry for surface imaging of these babies. To get a rigorous determination of shape, size and directional changes, I utilized a new series of 3D techniques, including geometric morphometrics for mathematical modeling, which had never been deployed before. These elegant techniques permit determination of changes after correcting for size differences in statistical shape-space, and the results can be pseudo-colored to permit intuitive interpretation of the outcomes by clinicians. At the heart of innovation lies observation. I noticed that nearly all of the cases that were being considered for surgical correction had midfacial hypoplasia prior to treatment. Some of these cases had a genetic mutation such as Apert syndrome where the facial sutures had undergone premature synostosis, and the midface was unable to develop normally because of this. Using the distraction osteogenesis protocol, the craniofacial and plastic surgeons carefully induced a controlled osteotomy. Next, a rigid external distractor was placed, and the patient underwent latency, allowing wound healing to occur. This was then followed by distraction of the callus whereby the orthodontist would manipulate and advance the midface, using the external distractor screws. After approximately 6 weeks, the patients entered the fourth phase, consolidation, to allow the tissues to heal in the new position, after which the distractor was removed. After this procedure, I noticed that not only did the patients have an improved appearance, but their demeanor also improved, and that intrigued me. I went back and analyzed the MRI data. To my surprise, the upper airway had ballooned in all of these cases, and I surmised that these children were therefore sleeping better because of that, which led to daytime improvements in their behavior. Recalling that these children had craniosynostoses, and that the general population does not have this genetic mutation, I wondered if a similar non-surgical technique could be developed for more generalized use to address upper airway issues, specifically obstructive sleep apnea. Current competitors Before launching into a futile effort, I decided to undertake a comprehensive review of as many orthodontic devices that I could find that had historically or were currently being used for maxillary or palatal expansion. These devices included rapid palatal expanders, functional appliances and others that were used by orthodontists and general dentists for these types of purposes. In all, I reviewed nearly 250 appliances, and several of my formal studies were published in the peer-reviewed medical, dental and orthodontic literature. I noticed that these techniques were based on what some might say are ‘outdated’ principles. For example, rapid palatal expanders were used to split the midpalatal suture transversely, induce a midline diastema and then the teeth were moved orthodontically to close the gap. Even more controversial was the idea that palatal expansion could be undertaken in adults where the sutures had undergone “fusion”. In addition, when ‘jumping the bite’ (mandibular advancement using a ‘functional appliance’) for Class II orthodontic correction, there was, and still is, controversy as to whether the mandible simply moves forward, actually grows into the new forward position, or if the clinical outcome is some combination of the two. My approach was to ‘allow the data to speak’. In other words, I based my decision on raw clinical data, initially collected from orthodontists in the US, and also from general dentists that were experienced in orthodontics. I reached the conclusion that while each device or technique had certain characteristics or advantages, I could not find an appliance that addressed all four craniofacial tissues: hard tissues (bone); soft tissues (mostly muscle); dental tissues (teeth), and functional spaces (the upper airway) for non-surgical, craniofacial correction. Background, literature review and mechanisms Before thinking about device design, it was important for me to research and understand the mechanism(s) through which these appliances putatively worked. My experience in molecular biology/molecular genetics came into play. At that time, stem cells were in the news but there were little or no known applications in the dental/orthodontic space. In addition, the human genome was sequenced in 2003, and various pieces of the biologic jigsaw were being put into place. Around that time also, functional genomics was being investigated and the idea that genes undergo environmental interactions or epigenetics to produce the final clinical phenotype was gaining momentum. Add to this mix temporo-spatial patterning, which suggests that certain genes are expressed at certain times during development to form the body plan, which includes 32 teeth; and the stage was set for further innovation, research and development. But what cohesive theory or hypothesis could provide an explanation for the prediction of clinical outcomes? The older theories were steeped in Newtonian physics and Darwinian genetics. Because of this deficiency, I wrote the Spatial Matrix Hypothesis, published in the University of Michigan Craniofacial Growth Series, which appears to have withstood the test of time thus far. The encompassing concept emerged as Biomimetics. Restorative dentists were already using biomimetic dental materials that mimicked the behavior of dental tissues. The next step was to design a biomimetic device that would mimic natural craniofacial growth and development. Intellectual property, device design and clinical protocol Clinical data dictated the design, materials and protocols for the new device. However, to protect the intellectual property, I submitted several US, Canadian and European patents, all of which were eventually issued. One of the first patented components was a unique orthodontic spring design. I had noted that all prior orthodontic springs made point contact with the teeth and acted as finger springs that simply tipped the teeth. My design differed significantly in that it was the first, compressible 3D orthodontic spring with a large surface area. This property was crucial since the nature of the super-elastic, nickel-free wire meant that an intermittent cyclic signal could be imparted to the periodontium through the crown of the tooth to signal stem cells in the periodontium. Next, the appliance had a midline expansive mechanism such as a jack screw or omega loop, unlike preformed templates. This design component permits activation of the midpalatal (and other) suture(s). Moreover, my published clinical studies suggested that concentric collapse of the maxilla occurs in adults diagnosed with obstructive sleep apnea (OSA). This finding had never been reported before and, therefore, a Y-split design with a 3-way screw system was preferential for clinical correction. In addition, occlusal coverage was included to separate the maxilla, which is relatively easy to remodel, from the mandible, which is relatively easy to move. In this way, the mandible could be repositioned simultaneously while the maxilla was being remodeled. Importantly, six degrees of freedom for clinical adjustments were available using this unique approach. My published research findings also revealed the older appliances that splinted the maxilla to the mandible were found to have a headgear effect, resulting in midfacial retrusion; so it was mandatory to separate the upper device from the lower device. Next, the soft tissues were addressed using labial bows to alter the spatial matrix, acting as lip bumpers, and pharyngeal stents were added to restrain the tongue and maintain the patency of the upper airway, where appropriate. Many of these aspects were independently researched, providing novel data. Using these design principles, the four sets of craniofacial tissues were addressed. Apart from the design and materials, it was also important to follow the biologic circadian rhythm. Studies have shown that teeth erupt during the early evening and at nighttime, so there was little advantage in wearing the device during the day. During stage 3 sleep, growth hormone peaks, so it was mandatory to wear the appliance while sleeping to capture this metabolically active phase. In this way, a daytime-nighttime protocol emerged, giving rise to the ‘daytime-nighttime appliance’ or DNA appliance. Clinical tests Scientific endeavors can only be recognized through real world applications. It was necessary to test the appliance clinically for safety and efficacy prior to general release. Regarding safety, all the materials had undergone biocompatibility testing and were deemed safe for clinical use. However, additional refinements were necessary to prevent breakages since patients may have sleep bruxism, resulting in inordinate pressures being placed on various components of the appliance design. Regarding efficacy, I was initially met with a wall of skepticism and outright cynicism from my orthodontic, dental and sleep colleagues! However, several visionary and open-minded general dentists stepped up to face the challenge. The first documented case was a 38-yr old male with a diagnosis of moderate OSA. After 12-15 months of treatment with excellent compliance, his apnea-hypopnea index (AHI) fell to less than 5 events per hour with no device in the patient’s mouth, as confirmed by a Sleep physician. This initial success was followed by a series of approx. 50 studies that confirmed the underlying accuracy of the approach that I pioneered. References available on request! Later on, regulatory approvals were obtained, and veracity of my intuition was validated. In 2023, the DNA appliance became the first palatal expander to be FDA cleared for the treatment of mild, moderate and severe OSA in adults. But the story does not stop there. In the past decade or so, numerous technological advances have been made. The original analog appliances that I invented need to be supplanted by smart, digital devices and wearable technology. This new research direction and initiative has come into play. Let’s talk about it at next year’s ASBA meeting   Source:  Dr Dave Singh DMD PhD DDSc © 2024 Adjunct Professor, Sleep Medicine, Stanford University, USA

Dr. Andrew Valenzuela specializes in pediatric sleep medicine, a discipline that even today he calls an underexplored field that he “stumbled upon” during his pediatric residency. “I happened to have a faculty member who practiced sleep medicine and he thought I’d be a good candidate,” Valenzuela remembers. “I knew I wanted to be in a field that had a lot of overlap with other specialties. I wanted to see complex patients and be able to have that collaboration with other clinicians. Sleep medicine was a blend of multiple specialties.” He is with Banner Health in Phoenix, the capital and the most populous city in Arizona, and the fifth most populous city in the U.S. Despite this, the area has no more than a half-dozen pediatric sleep specialists and his peers report a significant backlog of patients in their health systems. The good news is that clinicians from various disciplines are increasingly recognizing the importance of proper sleep, leading to greater awareness. Today, collaboration in pediatric sleep medicine often involves multiple specialties, including pulmonology, ENT, neurology, and endocrinology. Multidisciplinary Approach When children encounter sleep issues, Valenzuela argues that a multidisciplinary approach is ideal, with treatment tailored to each patient. Some pediatric patients are being seen in dental offices, where parents report symptoms such as teeth grinding, mouth breathing, or morning headaches. A subset of these patients have classic sleep apnea, which is a common issue, while others struggle with insomnia or difficulties in falling or staying asleep. “Many of the patients we see have breathing challenges or anatomical issues,” Valenzuela notes. “We often observe craniofacial abnormalities that disrupt normal airflow.” From the standpoint of job satisfaction, improving a child’s sleep also improves the lives of parents—all amounting to a sense of accomplishment. “I have always appreciated that I sleep well and feel refreshed,” Valenzuela muses. “Then you get these patients who sleep poorly and function poorly. When you fix their sleep, the amount of functional improvement they get is phenomenal and they tend to be very happy. It really is a nice payoff at the end of the day.” Sleepiness in Adults/Hyperactivity in Children In adults, poor sleep typically results in sleepiness, but in children, sleep disorders often have the opposite effect. “When a child doesn’t sleep well,” Valenzuela explains, “they are more likely to exhibit hyperactivity, irritability, and inattentiveness—symptoms that resemble ADHD.” Pediatric sleep apnea has been in the spotlight for decades, and its role in the academic performance of children is increasingly viewed as a problem, detailing the many concerns, and the role of associated professionals in detecting sleep apnea in children. “The American Heart Association says sleep apnea affects 1% to 6% of all children and 30% to 60% of obese adolescents, so it’s more common in youth than people think.” The gold standard for diagnosing sleep apnea is an overnight sleep test conducted in a sleep center using advanced PSG equipment. However, sleeping in an unfamiliar environment can be particularly challenging, especially for children, who often find it more difficult than adults. As Valenzuela points out, “Many of our pediatric patients undergo home sleep tests, which are not only more affordable but also better tolerated.” Recommended Treatments Valenzuela confirms that CPAP therapy can be initiated as early as age 5 or 6. Additionally, dental treatments play a significant role, including the use of oral appliances or mandibular advancement devices that reposition the jaw to open the airway. “The key professionals involved in pediatric sleep treatment are sleep medicine specialists like myself and ENT doctors, who focus on airway-centered approaches such as tissue reduction, removal of tonsils or adenoids, lingual tonsil reduction, and palatal adjustments,” Valenzuela explains. Lastly, the emotional rewards of helping children in pediatric sleep medicine cannot be overstated. “It’s incredibly gratifying when patients start sleeping well and their overall functioning improves,” Valenzuela emphasizes. Bio Dr. Valenzuela completed his residency in Pediatrics at Dell Children’s Medical Center and a Fellowship in Sleep Medicine at Baylor College of Medicine. Dr. Valenzuela is a well-rounded physician specializing in adult & pediatric sleep medicine. He is Board-Certified in Pediatrics and Sleep Medicine. Professional interests include the role of artificial intelligence within sleep medicine, wearables and nearables for sleep tracking and diagnostics. He is especially interested in Narcolepsy and the pharmacologic options for symptomatic treatment. Writer: Greg Thompson

Musings from a Orthodontic Sleep Technician (Artist) A Perfect Fit We love the moment when a mandibular advancement device “just pops right in” to the patient’s mouth, achieving a perfect fit. This seamless fit is not just about comfort; it’s a testament to the precision and quality of the device, as well as the skill of the lab technician working on the case. It’s a very satisfying feeling for both the patient and the dentist. For the patient, it means immediate comfort and ease of use. For the dentist, it reflects their expertise and a satisfied patient. This sense of accomplishment and trust is a key reason why sleep dentists prefer certain devices when treating their patients for sleep apnea. These favored devices provide consistent results, ensuring patients receive the best care, improving their sleep health and overall wellness. When a dental doctor orders an appliance for their patient, they consider several factors to ensure the appliance meets the patient’s needs and treatment goals. – How severe is the patients condition. Mild, moderate, Severe OSA. Is it bruxism or aTMJ disorder, all dictate the type of appliance required. – Comfort and fit: The appliance should be custom-fitted to the patient’s mouth to ensure both comfort and ease of use. Comfort is a crucial factor in achieving patient compliance. – Quality of materials used in the making of the appliance. Durability and biosafety of the materials are essential. – Efficacy and compliance: The appliance must effectively address the patient’s condition, whether it’s maintaining an open airway for sleep apnea patients or preventing teeth grinding for those with bruxism. – Adjustable: Custom oral appliances must be flexible enough to accommodate changes in the patient’s condition or treatment needs over the course of their therapy. – Anatomy: The unique structure of each patient’s teeth, jaw, and oral cavity must be taken into account to ensure proper fit and function. – Maintenance: Oral appliance should be easy to clean and maintain functionality – Patient Considerations: The patient’s lifestyle, comfort preferences, and any specific requests or concerns must be considered to start the correct course of treatment. Orthodontic Technicians – A better choice for your sleep apnea appliance Allow me to explain the difference between a dental technician and a certified orthodontic technician!. The orthodontic technician has been trained in the art of passive retention and not moving teeth, understanding the importance of keeping things in place and keeping everything together without movement.  The dental technician doesn’t have a lot of experience in the art of wire work with passive acrylic that is laying up against the teeth gently. One of the great misnomers in our field “ ball clasps move teeth” An orthodontic technician realizes that wire is round and it has memory so it must be rolled rather than bent on a continuous plane; because if you go off the plane, you create a movement in the wire which also creates pressure in the wire (a spring ). This  pressure, even ever so slightly, will move teeth. That’s why when people say that ball clasps move teeth, I think that is problematic coming from someone who has not been properly trained and certified as an orthodontic technician and/or the appliances the provider has used where this previously happened to their patient were made by a dental technician who is not experienced in wire work. Ball clasps do not move teeth One of the great misnomers in our field “ ball clasps move teeth” Ball clasps do not move teeth, not when they are properly bent.  The properly made wires keep things in place. They maintain things, and they do not move teeth. From my decades of experience, I have told so many people in my life that when I hear about ball clasps moving teeth, it is incorrect, and I reiterate that it’s the lack of training of the non- orthodontic technician who doesn’t know how to bend a proper ball clasp. Improperly bent ball clasps will cause movement of the tooth/teeth. Wiring is Round The wire is a straight piece of wire (metal) with a ball on the end which must be rolled on a continuous plane, not bent or twisted, but rolled. I can’t stress enough the point that a wire is round and it must be rolled. Trained orthodontic technicians know how to add a proper kink, to prevent the wire from naturally wanting to straighten itself out because it has memory.  This is why the certified orthodontic technician is the best choice for making sleep appliances, they have been properly trained in the art of wire work where in most cases the dental technician is not as experienced. The Certified Orthodontic Technician The trained orthodontic technician possesses extensive experience and knowledge in wire work on appliances. They understand that the wires must provide proper retention and comfort for the patient. Ensuring comfort is crucial, as it is closely linked to patient compliance and the overall long-term success of the oral appliance treatment. Understanding the path of draw and undercuts are design qualities that we deal with on a daily basis at Gergen’s Orthodontic Lab. I personally train all technicians with my decades of expertise to ensure they learn the correct methods when making orthodontic and sleep appliances. I come from a long line of dental professionals; as a matter of fact, three generations worth.  My family told me not to get into ortho, but it is my passion and my legacy. Family and friends have often told me, “There’s no money in it and you can’t make money in an Ortho Lab.”  Despite their advice, I believed in myself and loved doing orthodontic technician work.  For that reason, I ignored what I was being told, pushing forward with what I loved doing, launching Gergen‘s orthodontic lab in 1985.   Master of the Mandible With my expertise in combining orthodontic principles, wire bending, and mastering the art of designing and crafting sleep appliances, I am proud to be regularly consulted by doctors from around the world regarding their patient cases. Experience Matters A leading expert in our field, Dr. Jerry Hu, believes that my appliances made his patients feel much more comfortable and therefore, much more compliant to nightly use, which is the key to long term success. In the past, Dr. Hu has seen super rigid appliances, such as control cured PMMA break or fracture and often, patients would complain of the extreme tightness and pressure. Even advanced materials, such as medical-grade 6 material designed by milling software, cannot compare to the art and experience of a certified orthodontic technician in achieving the right level of comfort, retention, and durability for patient cases. When I entered the industry, there were very few labs focused on sleep, and even fewer that integrated orthodontic supplies or had knowledge of their proper use. Experience in this art truly matters. Acrylic Even the type of acrylic used is different with a certified orthodontic lab. With our experience in using cold acrylic, our lab ensures that nothing is pressed.  Our lab doesn’t pack anything like dentures.  We use completely different acrylic and different processing methods.  As a result, experience with cold acrylic is something that non-orthodontic technicians often lack. At Gergen’s Orthodontic Lab, we do not face these issues. I personally ensure that all my technicians receive proper instruction, sharing my decades of knowledge and expertise to provide them with solid training. Many labs lack this type of experience and do not have someone like me personally training their technicians. Without my decades of experience, love, and passion for the work, they are unable to provide the same quality appliances as Gergen’s Orthodontic Lab. Expansion Devices Furthermore, as for the “new” expansion devices for treating airway and sleep apnea, it’s really new. It’s not been around for a very long time. I recently had dinner with Dr. Paul Serano, and we were kind of jokingly, saying we were treating sleep apnea on children in the 80s.using the “occlusal characters Corrector”.  Today we use three-way expanders.  We level the occlusion, and expand the palates concentrically not merely transverse; and if one thinks about it, Dr. Dave Singh of Stanford University has proven to us that this type of treatment on adults also expands and enlarges the adult airway.  The “Y” split 3 way Schwartz type of appliance makes the airway larger. I told Dr. Singh, “Hats off to you; it’s pure genius to perform expansion on adults. I would have never thought of that.” We have extensive experience in this area, which is why certified orthodontic technicians, who are skilled in working with these wires and forces, are the right choice for airway and sleep cases. Gergen’s Orthodontic Lab I have dedicated my entire career to this field, which is why dental doctors trust Gergen’s Orthodontic Lab with their patient cases for airway, orthodontic, and sleep appliances. A notable leader, Dr. Felix Liao, recognizes the necessity of working with our certified orthodontic technicians. Dr. Liao emphasizes the importance of proper training, as using expansion devices incorrectly can be very dangerous. It’s crucial to incorporate stops in an expansion appliance to prevent continuous expansion. Dentists must be adequately trained, and reputable groups such as the American Sleep and Breathing Academy, Vivos, and Dr. Liao’s training programs provide this essential education. Dr. Liao recently reminded me that I was working on these techniques with Orthodontist legend Dr. Robert Ricketts over 30 years ago. “It was then I realized I go back so far, I’m in front of me!”.   David Gergen Gergen’s Ortho Lab 602-478-9713 gxployer@aol.com

On August 1, 2024, in Phoenix, AZ, Dr. Felix Liao, DDS, was announced as a nominee for the Lifetime Achievement Award by the American Sleep and Breathing Academy (ASBA). Successful nominees are inducted into the ASBA Hall of Fame. Click link to visit ASBA Hall of Fame and view the Candidates The ceremony for new inductees will take place Friday April 4th in Houston, TX at the American Sleep and Breathing Academy’s Annual Sleep & Wellness Conference 2025. To be inducted, nominees count on voting from existing ASBA members and Diplomates.  Felix Liao, DDS is counting on you and your vote.  Dr. Liao looks forward to seeing you next April 4-5, 2025, in Houston, Texas at the Annual ASBA Sleep and Wellness Meeting. Cast your vote here. (You must be an ASBA member to vote!) Existing ASBA Member, click here to login Not a member? Click link to join the ASBA **************************************** ASBA is excited to welcome you next April for this special event, where you’ll have the opportunity to see your favorite Hall of Fame  nominee and be part of the induction ceremony. We look forward to your presence! Click Link to Register for the American Sleep and Breathing Academy’s Annual Sleep & Wellness Conference 2025. The Lifetime Achievement Award, along with the corresponding induction into the Hall of Fame, is a prestigious honor reserved for a select few distinguished professionals. The ASBA Hall of Fame was established in 2008 to honor members whose contributions to the field of Dental Sleep Medicine and service to the Academy have been significant, substantial, and long-standing. Inductees have demonstrated a history of career achievement, a sustained commitment to advancing the profession, and significant contributions to the field, all while conducting themselves with professionalism among their dental and medical peers. About Felix Liao, DDS Felix Liao, DDS, is a bestselling author and thought-leader in natural wellness and the mind/mouth/body connection. He is the founder and director of the Whole Health Dental Center in Falls Church, VA, and has served as president of the International Academy of Biological Dentistry and Medicine. A practicing dentist for more than 30 years, Dr. Liao gained acclamation for having identified Impaired Mouth Syndrome as an overlooked source of many medical and dental issues – and for developing an effective intervention framework for redeveloping an impaired mouth into a holistic mouth. He is the author of the bestselling books Six-Foot Tiger, Three-Foot Cage and Early Sirens, and the just released Amazon Best Seller Licensed to Thrive. Dr. Felix Liao offers Airway Mouth Doctor (AMD) Courses. Click here to learn more about Airway Mouth Doctor (AMD) Courses with Dr. Liao You can buy Dr. Felix Liao’s Best-selling books here: Amazon link to: Six-Foot Tiger, Three-Foot Cage: Take Charge of Your Health by Taking Charge of Your Mouth For a more in-depth bio click here Dr. Felix Liao – Curriculum Vitae (C.V.): Click here to learn about Dr. Felix K. Liao & See his Curricula Vitae Click here to connect with Dr. Felix Liao on LinkedIn