Author: Michael Kelley

Las Vegas, April 2024, Dr. Neal Seltzer DMD, was inducted into the American Sleep and Breathing Academy “ASBA” Hall of Fame, a great honor bestowed only to very few distinguished sleep 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. Dr Seltzer received his Doctor of Dental Medicine degree from the Tufts University School of Dental Medicine in 1982. He continued his education with a residency program in New York City at Bird S. Coler Memorial Hospital. After this, he continued his academic affiliation as an assistant clinical professor at New York University College of Dentistry. An expert in removable prosthetics, Dr. Seltzer is currently the clinical director of the Equipoise Dental Center in Bergenfield, New Jersey. This is a world famous teaching facility that trains dentists and laboratory technicians the Equipoise philosophy of prosthetic design. He lectures throughout the U.S. and internationally and is published in many dental journals. Seltzer is a member of several professional organizations, including the American Dental Association, New York State Dental Association, and Nassau County Dental Society. He is also a Fellow of the Academy of General Dentistry and the American Academy of Sleep Medicine. He has visited the U.S. Congress as a part of a panel of experts to appear before members of congress as well as other representatives from government agencies and the military to address “The National Crisis of Undiagnosed Dangers of Airway and Sleep Problems.” He is one of the very first Diplomates of the American Sleep and Breathing Academy and currently services on both the ASBA’s education and membership committees. (Photo: David Gergen, Neal Seltzer, Alan Hickey) Source: American Sleep and Breathing Academy (602) 478-9713 info@myasba.com

Andrew Valenzuela, MD, FAAP, is a specialist in pediatric sleep medicine, a field that has historically been underrecognized. Thankfully, more clinicians across various disciplines are beginning to understand the importance of quality sleep, leading to increased awareness. Today, collaboration in pediatric sleep medicine spans multiple specialties, including pulmonology, ENT, neurology, but most importantly pediaticans. He is affiliated with Banner Health in Phoenix, Arizona’s capital and most populous city, and the fifth largest in the U.S. Despite its size, the region has only about half a dozen pediatric sleep specialists, leading to a significant patient backlog. When children do run into sleep problems, Valenzuela contends that the multidisciplinary approach is ideal, with treatment depending on the patient. Some patients have classic sleep apnea, a frequent problem, while others have insomnia or difficulties staying asleep or falling asleep. “A lot of the patients we see have breathing challenges or anatomical problems,” Valenzuela says. “We see some craniofacial abnormalities and these are disruptive to normal airflow”. With adults, poor sleep can lead to sleepiness, but pediatric sleep disorders often lead to the opposite. “If a child doesn’t sleep well,” Valenzuela points out, “they tend to have more hyperactivity, irritability, and inattentiveness—more of an ADHD picture.” The gold standard for diagnosing sleep apnea is a sleep test and ideally these patients would spend the night in a lab. That’s tough enough for adults, so Valenzuela reveals: “A lot of our pediatric patients get home sleep tests which are much cheaper and more well tolerated.” Valenzuela confirms that CPAP can be started at age 5 or 6. Of course, the dental approach is another big category of treatment that includes oral appliances and/or mandibular advancement devices that pull the jaw forward and open the airway. “The main people involved in sleep treatment for kids are going to be sleep medicine professionals like me, and ENTs for airway-focused approaches such as tissue reduction, tonsils/adenoids, lingual tonsils, and palatal adjustments as well,” Valenzuela adds. Finally, the emotional payoff of helping children can’t be underestimated in any discussion of pediatric sleep medicine. “It really is a nice payoff at the end of the day when patients are sleeping and functioning well again,” Valenzuela enthuses. (Dr. Valenzuela currently serves on the American Sleep and Breathing Academy Diplomate Credentialing Board) 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.     Source: Greg Thompson, ASBA

The most important motif when it comes to treatment of obstructive sleep apnea in the field of dental sleep medicine is that qualified dentists need to address this condition as a serious medical problem and not something considered merely, dental. With that stated, it is essential that patients are seen as individuals coming with the potential of having multiple systemic illnesses, complex medical history and medical records & treatment history; therefore, it is critical that dentists look “beyond the teeth/mouth.” Not only are there many co-morbidities to obstructive sleep apnea, but there are many factors, such as syndromes, prior injuries, trauma, mental health, phenotypic variances, chronic/ acute pain history, TMJ/TMD/orofacial issues, and even financial aspects that dentists need to address to attain a successful outcome in treatment. Several treatment options require patients’ commitment both in time and adherence to protocol. Furthermore, dentists need to be thoroughly active and take part of the physical adjustments, fitting, refining, and finishing of the cases at each and every appointment rather than relying on delegating. Complications, liability, experience, education, and knowledge all play an important aspect for the success of any case; thus, it is paramount all qualified dental sleep providers be prepared and planned for all the variables. The oath in the healthcare profession is to do no harm and to provide the best quality care possible. As each patient presents with their own unique medical history, tolerance to treatment duration, level of invasiveness, expectations, and financial capabilities, the foundation of any successful case lies in carefully considering these factors. This article will break down these topics into sections for the practitioner to review and consider.  If there is any lack of education, experience, or knowledge, the author highly recommends pursuing continuing education through either of the two major dental sleep academies (AADSM and ASBA), attending academy conventions, or participating in mini-residencies at universities, medical or dental schools or the dental sleep academies. This article will begin with a discussion on the preliminary considerations (medical history/record, expectations, and financial aspects) then, the following treatment options will be discussed: 1) CPAP intolerant and Straight Forward Customized Oral Appliance Cases 2) Complex cases using Oral Appliance (such as TMD/orofacial pain patient) 3) Non Responder to Oral Appliance but using Minimally invasive bone remodeling appliances / orthotropics with myofunctional therapy and other adjuncts- Chirodontics, Rochabado Physical Therapy, etc.  4) More invasive options that involve surgery (in the dental field), MARPE, MSE II, SARPE, DOME 5) Referral for MMA or Inspire, and other options PRELIMINARY CONSIDERATIONS TO PREPARE PATIENTS FOR TREATMENT PROCESS AND MANAGEMENT OF THEIR CASE Patient intake The important first step in every new case is to create a solid initial foundation by completing a thorough review and discussion of the patient’s medical history and records. This means not only current systemic illnesses and both prescription and OTC medications, but also prior and current treatments and scheduled future treatment plans, will be documented and reviewed. It is crucial that the provider understand the current conditions and to be able to rank and discuss patients goals and expectations before any new treatment is initiated. Syntax and the sequence & plan of treatment have everything to do with attaining long term successful outcomes. For example, urgent and acute conditions, pain and/or biopsies, ASA III issues, etc should all be addressed before any appliance therapy, expansion, and/or surgeries.  Outlining the treatment choices and steps from the very beginning of records collection and analysis will save time and help curtail risks for failure mid-treatment. Another example for patients wanting expansion for sleep apnea treatment, is to first assess if the patient presents with TMD and orofacial pain issues or postural and cranial problems (cranial distortions and descending/ascending disorders). Not knowing where the plan of treatment is going and for what reasons can be disastrous to the whole case and outcome.  Neuromuscular issues, jaw/orofacial head/neck pain, and asymmetries when addressed and corrected can definitely help the expansion process and even improve the time frame needed and predictability. Next, proper referrals should be addressed early on in the case, too. If ENTs, pulmonologists, cardiologists, and oral surgeons are to be needed in the treatment process, proper referrals and scheduling should be made. During the preliminary work up, it is also important to discuss commitment, adherence to protocol/ compliance, time frame and financial aspects of the case. Expectations need to be realistic and the patient needs to be informed of the entire process. Follow ups, the finishing of the case, and attaching costs for the different treatment options should be explained before initiation of any treatment. If medical insurance is involved, it is absolutely necessary that pre-authorizations, verification of benefits which include deductibles, co-pay/co-insurance and all out of pocket costs have all been reviewed and accepted by the patient before treatment begins. Explaining at times, peer-to-peer calls, GAP exceptions, and more clinical paperwork from letters of medical necessity to referral/ prescriptions are needed to successfully bill medical insurance. Finally, understanding all rules and regulations of Medicare/ PDAC and also coordination of benefits all should be well communicated to the patient during the preliminary collection of data. TREATMENT PLAN OPTIONS AND CONSIDERATIONS FOR PATIENT CARE AND CASE MANAGEMENT: 1)    CPAP Intolerant and Straight Forward Oral Appliance Cases This first category of a dental sleep medicine case may be the most straightforward, but careful attention needs to be given to each step of the process. If the patient has been properly diagnosed by a board certified sleep physician and has been referred to the dental provider due to CPAP intolerance or failure, a thorough analysis of the patient’s occlusion, prior dental/restorative work, and TMJ with functional analysis with border movement measurements should be completed. The options for doing non-customized oral appliance therapy should be discussed in the beginning as well and acknowledgement that there are non-responders to customized oral appliances exist in the population. Utilizing equipment such as cone beam/ CT scanning, acoustic reflection, and performing a clinical dental sleep medicine examination should all be done to establish a baseline and recorded metrics for both soft and hard tissue anatomy. The results of the sleep test should be discussed with the patient. RDI/ REI which include RERAs and ODI/oxygen saturation levels, heart rate variability, sleep staging percentage, snoring decibels, positional issues and details of the medical necessity from the sleep physician regarding the results of the sleep study should be reviewed with the patient. Goals in terms of efficacy of the oral appliance, the follow up and titrations/calibrations that may be necessary, should all be explained to the patient so they can prepare for all variables to appropriately complete the case and have long term success. Addressing the patient’s dental history, anatomical limitations, and level of comfort are all connected to long term compliance and success. For example, if a patient is very retrognathic as in Class II Division II cases, the anterior-posterior dimension may be very sensitive and correlated to tolerance and compliance of the oral appliance. Over protrusion in these patients can create a myriad of side effects and even TMD, hypertonic muscles, and extreme orofacial pain. 3D measurements and considerations are a essential, and there really is no excuse in modern times to avoid using equipment that provide thorough analysis for this critical part of the treatment process. As in the example of a mid-face deficient patient with a class III skeletal profile and occlusion, only looking at the anterior-posterior dimension is insufficient and often lead to failed treatment. Evaluating multiple dimensions such as lateral (asymmetries), vertical, pitch/diagonal, roll, and yaw dimensions are necessary as all patients who present are three dimensional and not one or two. Providing instructions and offering videos/links to jaw exercises are important part of the management of oral appliance therapy in dental sleep medicine. Furthermore, providing a morning occlusal guide (MOG) / AM aligner to aid the patient to attain Centric Occlusion “CO” Habitual bite, is also highly recommended. Bite Continuing this discussion to the steps to attain the initial bite position or “start position” of the oral appliance, it is important there are many philosophies, schools/camps of thought, and options on this topic. Some (but not all) of the various bites to consider are : Silibant Phonemes/Phonetics (Ricketts), Neuromuscular, George Gauge, Andra Gauge, Swallow, Moses, Apnea/MAD Fit, pharyngometer, Gelb 4/7, and Apnea Guard to name a few. It is very important that the practitioner understand the airway bite method they use and to thoroughly follow the steps on the chosen method. Several of the dynamic bites include kinetics and reflex testing. Some may be subjective and some measured using equipment. For example, in the neuromuscular bite method, Ultra Low Frequency (ULF) TENsing using a Myomonitor (J5) or a MicroTENs unit would be necessary to first establish an antidromic effect on the hypertonic muscles of mastication and head/neck muscles so that they can truly be at rest (without action potentials) when the bite is taken. Then, further neuromuscular equipment such as the Myotronics K7 or the BioPak (Bioresearch) equipment is used with EMGs, electrosonography, and jaw tracing mechanisms to record and find the ideal airway bite for the oral appliance. It is of paramount importance that proper training and the following of instructions is met when using and selecting whichever bite method for the oral appliance. Delivery After the oral appliance is delivered, it is also important to automatically schedule chair time with the patient within the first two weeks to see how the patient is doing nightly with compliance and comfort. It is important that in order for the oral appliance treatment to be effective, especially long term, the patient has to be compliant and have any side effects be mitigated. Early follow up appointments can include adjustments for tight areas to titration/ calibration for improved comfort. Patients should also be given options for future dental restorative work from new crowns to bridges and implants, and in this day and age of digital records and scanning, there should be no reason to plan well ahead so that new restorations can be made to fit the existing oral appliance. This includes implant retained dentures, overdentures and partials. It is also important to review proper cleaning and maintenance of the oral appliance as well. Understanding biogunk, bacteria, and inflammation, the dental team needs to convey the importance of proper cleaning and maintenance of the appliance. For certain flex/ soft liner material, it is also important to note the avoidance of liquids that contain alcohol—only use non-alcoholic cleaners. Using Medicare guidelines and rules, after 90 days, there should be post titration/calibration sleep study(ies) done. The post op sleep test results are important to show efficacy and the need for titration/calibration.  After final position is validated a board certified sleep physician needs to interpret and finalize the outcome of the oral appliance case. 2) Complex cases using Oral Appliance (such as TMD/orofacial pain patient) Patients who present with complex medical/ systemic issues or orofacial pain and TMJ must be allocated differently for sequencing of treatment, time frame, follow through, and expectations compared to the first category of dental sleep medicine patients mentioned above.  Again, any acute pain or urgent systemic concerns all should be stabilized before the provider proceeds with dental sleep medicine treatment. Working inter-disciplinary with all the healthcare providers taking care of the patient should be planned for. Any surgeries, medical or dental related, should coordinated well in advance. It is important to recognize that medical concerns extend beyond the realm of Western medicine. Patients may come in having undergone naturopathic treatments or using homeopathic remedies and therapies. They may present with certain allergies and conditions; for example, some patients may require an appliance without any metal, and some may even require the provider to send in materials used for allergy testing. Several new screening tools such as thermal scanning or even brain scans, such as those done at Amen Clinics throughout the US, should also be discussed when there are mental, behavioral (i.e. insomnia-cognitive), and list of medications should be factored in with any dental sleep medicine treatment. Pain Patients with acute or even chronic pain who are going through therapy must forward all documentation and clinical notes from all providers so that the dental sleep medicine provider can ascertain syntax and proper treatment planning and order. For example, the patient can be already under the care of an A-O Chiropractor, SOT Chiropractor, Rochabado Physical Therapist, or Chirodontist and certain manual releases and treatment are needed to stabilize the patient. If any oral appliances are made without coordination with these healthcare providers, then treatment failure, rephase, or lack of stabilization can occur. Also, it is worthy to note that combining myofunctional therapy exercises to patients using oral appliance therapy will only help the overall outcome of the treatment case. Patients with TMD and orofacial pain issues should have those issues evaluated and addressed for daytime issues. Oral appliance therapy for sleep apnea is focused for improved and quality sleep at night. However, TMD and pain patients often need daytime appliances. Some examples are daytime Gelb appliances, Neuromuscular daytime orthotics (removable, if fixed then careful attention for a second appliance will be needed once phase 2 is completed for fixed orthotics), and Farrah type appliances for TMJ. It is important for the provider to understand the protocol and the equipment, bite techniques used for these appliances prior to OSA treatment using customized oral appliance therapy. Follow through and time frame expectations should be discussed prior to treatment as well. Generally, with multiple factors or systemic issues, the length of time and treatment process all should take longer periods to complete or achieve. 3) Non Responder to Oral Appliance but using Minimally invasive bone remodeling appliances / orthotropics with myofunctional therapy and other adjuncts- Chirodontics, Rochabado Physical Therapy, etc. In the literature, it is known there are non-responders to oral appliance therapy. When they are also CPAP intolerant, then what are the treatment options remaining? It is important for these patients to have a candid discussion of invasiveness, time frame, compliance to protocol, expectations and even costs/financial considerations for the remaining treatment options. In this category, we will review only the minimally invasive options such as osseo- bone remodeling options with orthodontics and orthotropic options for the pediatric field, and all of them should be paired with myofunctional therapy and adjunctive procedures, such as tongue tie/ ankyloglossia releases.  Generally, these cases require the patient to commit from a year to two during phase 1 and 2 of treatment, and sometimes, finishing these cases can take additional year(s). Therefore, long term compliance and expectations must be agreed upon from the very beginning. Some examples of treatment types in this arena are: 3-way Schwartz, Homeoblock (as well as unilateral), DNA, mRNA, mmRNA, ALF, Hyrax palatal expanders (only transverse), Fixed Osseo-Remodeling Appliance, and for pediatrics, Myobrace, VIVOS, Removable Oseeo-Remodeling Appliance and Healthy Start-Orthotain. These cases all begin with a proper and thorough collection of records. Adequate CT scans with enough Field of View (FOV) size is critical. A board certified oral radiologist should review the entire CT scan and give a full diagnostic report. The dental sleep medicine provider should review the report and go over the report with the patient as well as schedule for any adjunctive care recommended. For example, a discussion with parents of pediatric patients for tonsil and adenoid issues should be discussed as well as tongue tie releases and myofunctional therapy. Patients presenting with cranial strains and orofacial pain including TMJ issues need to be given options for cranial squamous suture releases, manual releases and leveling. Patients with SI or lower back issues, SOT issues or even asymmetries in length of legs need to consider foot orthotics and leveling before expansion begins. Complete and thorough pre-treatment records collection is absolutely essential. This means proper radiographs, measurements, clinical exams, photos (in front of symmetrographs), and treatment history should all be evaluated and kept. Again, tongue tie release, nutrition, exercise and mental health issues should all be addressed at the beginning of records collection. The rate of expansion matter with all expansion cases. It is important that expansion is done at a biomimetic rate that is unique to the patient’s own anatomy and physiology. Going beyond these forces and rate of expansion by turning barrels too rapidly, for example, can cause potential unwarranted side effects. Furthermore, these are dynamic treatment modalities, and therefore, proper adjustments and wire bending, barrel turning, etc. all have to be done with proper protocol and frequency.  If forces are used too dramatically, or too much, too soon, the complications can include: a)     Relapse b)    Inflammation c)     Dehiscence d)    Root resorption e)     Teeth flaring out of bone f)     Pain g)    Worsening periodontal prognosis h)    Worsening of the finishing of the case It is also very important that patients understand the expansion is only one phase of the treatment. After expansion, finishing of the cases can be done with traditional orthodontics, such as controlled arch orthodontics, or clear aligners, such as Invisalign or Candid Pro, or even restorative options with veneers and crowns. These all need to be properly planned and adequately set up in advance to minimize patient management issues and failure of expectations. 4) More invasive options that involve surgery (in the dental field), MARPE, MSE II, SARPE, DOME Patients who are CPAP intolerant, non-responders to oral appliance therapy, and either have anatomical limitations or conditions, or patients with urgent need for sleep apnea treatment (i.e. a extremely morbidly obese patient with oxygen desaturations and severe RDI/REI results) should be given these more invasive treatment options. Patients who have major skeletal issues with crossbites and arches that make it difficult for less invasive expansion appliances should consider these options. With surgical intervention, from splitting the palatal suture to surgically assisted rapid palatal expansion, these treatment options do have good success rates in the evidence based literature, but with any invasive procedures, the risks of permanent complications are greater, and post-operative healing times, and pain tolerance will be variable from patient to patient. Generally, due to these being surgical cases, the time frame to complete these cases are shortened compared to the less invasive options. But, the pros, cons, risks, benefits and alternatives must thoroughly be explained to the patient prior to initiating treatment. Also, an oral surgeon, periodontist, and/or ENT are generally involved in the process. Myofunctional therapy exercises, nutrition, exercise and mental health should also be discussed for long term management and success of this category of cases as well. 5) Referral for MMA or Inspire, and other options If all the above cases are not possible, then MMA surgery is an option to consider, which in the literature, has a 95% success rate. Unlike other surgeries with lower success rates such as UPPP (40% at best and not long term due to relapse), or pillars, or genioglossus advancement procedures, the MMA option tends to have more long term success rates. This option needs to weigh in the risks, potential irreversible damages, and complications that can arise. Healing time and patients tolerance of pain and their ability to eat/function for months immediately following surgery need to be all weighed in. Another option would be Inspire, and for central sleep apnea (phrenic nerve stimulation—by Zoll Itamar), should also be discussed. Each of these options have criteria that need to be met before they will allow the patient to proceed with treatment. For example, with Inspire, the patient’s BMI and upper airway collapsibility need to be ascertained with DICE. Patients with concentric upper airway collapse will not qualify for Inspire.  Furthermore, some patients end up with more fragmented sleep as the hypoglossal nerve is stimulated, the shock actually wakes the patient during sleep and can do so multiple times. If that is an issue, often the ENT’s would ask the patients just to leave the implants in and turn them off, as risks of secondary infection for another surgery to remove the implant would not be worth the risks. Conclusion Proper management of the sleep apnea patient becomes easier and more predictable when adequate planning, preparation, equipment, and education/knowledge are being executed for the patient. It is only fair the provider offers all options and discuss the pros, cons, risks and benefits, including costs and time frame expectations and compliance expectations with the patient. It is the oath in healthcare to do no harm and to provide the best possible care to our patients. Jerry Hu, DDS, DASBA, DABDSM, DACSDD

Dr. Rodolfo Martinez Ferrate, M.D., has been installed as the new President of the American Sleep and Breathing Academy (ASBA), succeeding Dr. Jon Caulfield DDS. He is Board Certified in three distinct medical specialties; Family Medicine, ABFM, Bariatric Medicine, ABBM/ABOM and Board Certified Sleep Medicine ABSM. He has private practices in Glendale, AZ and SLC, UT and is licensed in multiple States and Countries. Dr. Ferrate has been diagnosing and treating patients with sleep disorders for over 20 years. During this time, he has prescribed thousands of oral appliances and is a strong ally of dental professionals. “I have great confidence in the dental profession and their efforts to address sleep problems among patients. My goal is to help more patients by enhancing clinical and practical education and training. I believe that dentists are our best allies in this endeavor. They have the unique ability to examine the mouth and airway, making them ideal clinical partners in addressing sleep medicine issues.” said Ferrate. Professional Interests Dr. Ferrate is deeply interested in medical weight loss and preventative medicine, with a focus on hormones and nutrition. From the start of his medical career, he has pursued his passion for identifying the best, most specific, yet natural treatments in wellness, rejuvenation, sleep disorders, and weight loss. He actively participates in various academies, including the AASM. In the field of sleep medicine, his goal is to collaborate with top experts to shape the future of sleep disorder treatments and performance, promoting cooperation between dentists and physicians. Together, they aim to utilize all available therapies and develop innovative protocols, tools, and medical devices to enhance sleep disorder treatment. Protocols  Dr. Ferrate has been involved in numerous successful practice models throughout his career. Whether in pediatric or adult sleep medicine, he excels at developing protocols that optimize outcomes for both patients and practitioners through efficient processes and care. On a broader scale, he aims to help the Academy integrate more dental and medical practitioners to treat sleep disorders more widely. Along with his ASBA board colleagues, they plan to establish protocols that will give consistent guidance to dentists to be successful in this field and improve their patients’ lives. The ASBA is developing white papers to help both dental and medical members better understand the various elements involved in dental sleep medicine. These elements include building a referral network, bite registration, scanners, HST diagnostic devices, PSG, PAP, OAT, billing, and telemedicine. The goal is to create a comprehensive guide that ASBA doctors can follow to achieve success in their practice, build a fulfilling career in dental sleep medicine, and ultimately save lives. The goal extends beyond oral appliance therapy. Dr. Ferrate aims for dentists to become more well-rounded clinicians with comprehensive knowledge of a wide range of sleep medicine-related topics. Whether it’s positional therapy, hypersomnia, insomnia, or TMJ disorders, ASBA members and advanced Diplomate practitioners must continuously learn and improve in these areas. Research His current research focuses on a collaboration with the Mayo Clinic in Rochester, MN, the top ranked hospital in the U.S., David Gergen of Gergen’s Orthdontic Laboratory and the current dental director of the NFLPA and the NFLPA Professional Athletes Foundation (PAF). This important research aims to diagnose and treat sleep disorders in former NFL players, with a particular emphasis on the outcomes of Oral Appliance Therapy “OAT”. Once the results are published, it should be a significant addition to the list of published research validating OAT. It all begins with the patient Dr. Ferrate firmly believes that everything starts with the patient and prioritizing what is best for them. He believes in ensuring that patients receive the most appropriate care, whether it be OAT, PAP, or another treatment. His goal is to advocate for this philosophy across the Academy and the entire field. On a personal note… I hope you like Coffee!   Speaking   Source: ASBA

By Jerry Hu, DDS, DASBA, DABDSM, DACSDD Intro Current consensus in the medical community on duration of quality sleep needed for a typical adult needs to be at a minimum of at least 7 hours at 7 nights per week. (ref 1.)  With CPAP usage, the bar set for “compliance” comes notably short of the consensus recommendation. It is generally accepted compliance for CPAP at greater than 4 hours with at least 70% of the nights. (ref. 2). Moreover, after 6 months of usage, the adherence of CPAP users goes down to 50% and even further to 17% after 5 years.  When CPAP is not being used, then those times can be potentially life threatening, as zero or no treatment is being utilized. In hypertensive OSA patients, studies show that minimum of 5.6 hours of CPAP usage is needed to sustain a long-term reduction in blood pressure. Therefore, it is important for clinicians to weigh in the mean disease alleviation (MDA), apnea burden/load and consideration of the Sarah Index (ref. 3) when determining what treatment option is best for suited the OSA patient. Furthermore, recent crossover studies show that with retrospective analysis, most patients preferred oral appliance therapy over CPAP for higher adherence and effectiveness in treatment outcomes. (ref. 4). A 2018 study done by Hu J. et al (ref. 5), has shown with oral appliance therapy with the Braebon compliance chip tracker, the mean usage for oral appliances was at 7.4 +/- 1.4 hours per night at 87.9% compliance, which shows far better success in outcomes regarding overall effectiveness of oral appliance therapy over CPAP treatment. Discussion In June of 2021, PHILIPS recalled a considerable number of their CPAP due to carcinogens and in April of 2024, the FDA consent in Decree against Philps Respironics following the recall of their machines (ref. 6). On January 29, 2024, FDA made a Class I recall, the most serious type of recall, against ResMed, Ltd. for their machines that cause magnetic interference with certain medical devices. Citing the seriousness of the issue, the FDA noted that certain implants and medical devices can malfunction causing serious harm, including death (ref. 7). Also, 2024 research at Columbia University by Peker. Y, et al (ref. 8) shows CPAP increasing angiopoietin 2 pro-inflammatory response. The study shows the greater the CPAP pressure level, the greater the release of proinflammatory, lung distension- responsive angiopoietin-2 while reducing cardioprotective angiogenic factor VEGF, which would counteract the expected cardiovascular benefits using CPAP for OSA treatment. This means that patients should be informed before given CPAP treatment, if and when they use pressures above 7 on machine, they are increasing the risk of a cardiovascular event, due to the pressure causing increase in angiopoietin-2, and that would counteract any prior conclusions that claim CPAP lowers cardiovascular risk. Patients also need to understand the importance of properly cleaning and maintaining their CPAP machines. There has been cases of patients getting Legionnaires disease and infections from their CPAP when not cleaned appropriately (ref. 9). The biogunk in the water from CPAP and sputum when not cleaned appropriately shows Legionella pneumophila serotype 1 ST37, and that is a serious infection. Therefore, sleep centers need to forewarn the consequences of CPAP cleaning maintenance before they dispense a potentially hazardous treatment option. Aerophagia and GERD with CPAP usage have also been published in the literature. A 2008 study showed that there is a relationship between GERD related LES patho-physiology and development of aerophagia in OSA patients using CPAP (ref. 10). Again, the risks and potentially negative consequences need to be told to all patients considering CPAP treatment prior to use. It is the duty of healthcare professionals to do no harm and stand by their oath. CPAP treatment-emergent central sleep apnea also need to be disclosed to the patient before CPAP is dispensed. It is estimated that around 10% of all CPAP initial titrations result in the increase of central sleep apnea (ref. 11).  There are also Mayo clinic studies that show with mask leakage, the chances of increasing CSA become notable during use of CPAP. There are also some general considerations with CPAP machines the healthcare provider should consider before dispensing. The portability of the machine, as it would be difficult to take them to camping, hiking, and on certain work related activities. For shift workers, such as airline pilots and commercial truck drivers, the ease and use of oral appliances versus CPAP machines is considerably more practical. Regarding bed partners, the noises, etc. that comes from CPAP machines might worsen sleep quality and even cause more fragmented sleep in both the patient and bed partner. In terms of overall effectiveness, one can see that due to compliance/ adherence to oral appliance therapy, the MDA of patients using OAT over CPAP is shown in the literature. This does not mean that OAT is bullet proof.  The Sutherland study in 2019 (ref. 3) does show that for mild to moderate OSA, the non-responders to OAT can be up as high as 50 %. Non-responding means the AHI/RDI/REI reduction was not significant, but it is possible the pool of patients used in those studies did not have all the bite positions measured in three dimensions (3D).  It would not be reasonable and fair to make conclusions and judgements on oral appliance therapy responders based only on one bite method with titrations or calibrations done only in one dimension, such as anterior-posterior (AP). If no lateral, vertical, pitch, roll, and yaw are considered, then it is unfair to label the patient as a non-responder if those different bite positions were never considered. If patients have deviated septum, prior car accidents, asymmetries, cranial distortions, side bends, etc. only evaluating one dimension and titrating only in one dimension does not give the proper thorough analysis the patient deserves before being labeled a “non responder” to oral appliance therapy. Also, certain appliances harvest or retain more biogunk than others. Therefore, like CPAP potential risks for infection, the materials of the oral appliance used all matter. Materials such as nylon with more porosity, will trap bacteria and plaque, and that is noteworthy as well when discussing oral appliance selection and types for treatment. When patients are true non-responders to OAT for OSA and they’re also CPAP intolerant or failed CPAP, then, other non-invasive to completely invasive treatment options are available. Myofunctional therapy in combination with any treatment with OSA have been shown in the literature to aid in reduction of AHI/RDI/REI (ref. 12). With tongue release (ankyloglossia), myofunctional therapy can go hand in hand with any treatment including oral appliance therapy.  The following are also available options (and in no particular order of non-invasive to invasive)—craniofacial epigenetic/ pneumopedics, osseo-growth guidance, MSE II- Won Moon, MARPE/DOME (ref. 14 and 15) , SARPE, INSPIRE,  Phrenic Nerve for CSA- ZOLL Itamar, MMA, and tracheostomy. Other options such as UPPP, etc. can be considered but it is important to look at success rates, relapse rates, and potential side effects from dehiscence, to bone loss, to root resorption. Studies have also shown playing the didgeridoo or double winded instruments such as an English Horn or Oboe, can benefit reduction of AHI/RDI/REI (ref. 13). Randomized controlled studies were done showing the effectiveness with sleep apnea treatment with playing these musical instruments. Combining these treatment adjuncts can be beneficial to the overall outcome for the OSA patient, as well as proper nutrition, exercise and breathing (Buteyko breathing, ref. 16). Conclusion When considering compliance, comfort, portability, practicality, and patients’ preferences, the customized oral appliance therapy exceeds the effectiveness and MDA versus CPAP for treatment of OSA.  Healthcare professionals have an oath and duty to do no harm, but also need to obtain full informed consent from patients after reviewing pros, cons, risks, benefits and all alternatives. When certain treatment modalities fail, it is also the duty of the clinician to offer other treatment methods, adjunctive choices, and to follow through with long term analysis. 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