Advancements in the Field of Dental Sleep Medicine Fall... · Rapid Maxillary Expansion (RME) Rapid Maxillary Expansion (RME) has been proven to be a highly successful treatment option

Advancements in the Field

of

Dental Sleep Medicine An update for sleep specialists &

technologists

Daniel Burton, DDS, D.ABDSM Dentist / Owner at Michigan Sleep Network, PC

MASM Annual Meeting October 6, 2018

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• Early interventions: Rapid Maxillary Expansion

• Making Progress: New Standards of Care &

Collaborative Efforts

• Improved Outcomes: Innovation & New Technology

Topics

SOURCES

Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

Early Interventions in Pediatric

OSA:

Rapid Maxillary Expansion (RME)

SOURCES


What We Know So Far

• Mouth breathing, and snoring can start at birth and is a sign of a child needing help

• Habitual snoring is seen in 8-10% of children

• Difficulty in breathing can lead to neurological changes as early as 1 Year

• Changes produced by snoring, apnea, flow limitation and resisted breathing in an

infant can lead to monumental function issues at ages between 4-7 with

neurobehavioral and neurocognitive consequences

• OSA diagnosed in 1% to 6% of all children (significantly underdiagnosed)

1. Huang Y-S and Guilleminault C (2013) Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front. Neur. 3:184. doi: 10.3389/fneur.2012.00184

2.. Bonuk K, Freeman K, Chervin R, Xu L, Sleep Disordered Breathing in a Population -Based Court: Behavioral Effects at 4 and 7 years. Pediatrics. 2012; 129 (4): e857-865

3. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130:e714.

Treat the Sleep Problem, Treat the ADHD?

ADHD or Sleep Deprivation

Primary Symptoms of ADHD: Primary Symptoms of Sleep Deprivation:

Hyperactivity Hyperactivity

Inattention Inattention

Impulsivity Impulsivity

Distractibility Oppositional behavior

Difficulty waking Difficulty waking the morning

Current Treatment Standards May Not Be Ideal

Pediatric OSA Interventions

Tonsil and Adenoid Removal

• Not curative of OSA in anywhere from 40-70% of children after long term follow up

• 3D imaging showed abnormal oral-facial development in these children

Nasal CPAP Therapy

• Significant craniofacial changes in longer term use

• Reduces maxillary and mandibular prominence and/or by altering the relationship

between the dental arches

1. Huang Y-S and Guilleminault C (2013) Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front. Neur. 3:184. doi: 0.3389/fneur.2012.00184

2. Tsuda, Hiroko et al. Craniofacial Changes After 2 Years of Nasal Continuous Positive Airway Pressure Use in Patients With Obstructive Sleep Apnea CHEST , Volume 138 ,

Issue 4 , 870 - 874

How Dentistry & Orthodontics Can Help

Rapid Maxillary Expansion (RME)

Rapid Maxillary Expansion (RME) has been proven

to be a highly successful treatment option for OSA

in Pediatrics.

OSA children with isolated maxillary narrowing

initially and followed up into adulthood present with

stable, long-term results post RME treatment for

pediatric OSA.

Conclusion: PEDIATRIC OSA in the non-obese

child is a disorder of oral-facial growth

SOURCES

Paola Pirelli, Maurizio Saponara, Christian Guilleminault; Rapid Maxillary Expansion in Children with Obstructive Sleep Apnea Syndrome, Sleep, Volume 27, Issue 4, 1 June

2004, Pages 761–766, https://doi.org/10.1093/sleep/27.4.761

https://doi.org/10.1093/sleep/27.4.761

SOURCES

What is it?

RME: The Basics

Children who have been

diagnosed with OSA may be

referred to an orthodontist for

treatment with rapid maxillary

expansion (RME).

This treatment involves placing

an expandable brace on the roof

of the mouth that increases the

width of the maxilla. The

orthodontist directing this

treatment typically has had

specialty training in managing

pediatric airways.


SOURCES

Courtesy of Dear Doctor, Inc. 2012

Indications & Mechanics of Treatment

RME:

• Rapid maxillary expansion is recommended for children who have been diagnosed

with obstructive sleep apnea.

• This treatment is best designed for children who are earlier in their growth and

development. Ideally, children in early grade school (ages 4 to 10)

• Gradually widens the hard palate and increases nasal patency as hard palate is

floor of nasal passage resulting in larger airway and reduction in collapse

• Later, growth plate of the maxilla fuses and when growth ends, this zone becomes

calcified and further pressure applied will not lead to continued expansion.

SOURCES

Photo Courtesy of OrthoLemay.com

Details & Side Effects

RME:

• Hardware often referred to as butterfly brace w/

adjustable component at center roof of mouth –

child usually tolerates well and often forgets

about brace which is hidden and hardly visible

outside of mouth

• Child can experience mild initial pain; does not

significantly impact eating or speech

• Aims at enlarging the maxillary dental arch and

palate to establish balance between the widths

of the jaws and indicated when the upper jaw is

too narrow compared to the lower jaw.

SOURCES

Photo Courtesy of SlyvainChamberland.com

Early Age is Key

RME:

• This procedure can done at an early age because jaw width problems visible

early and will not be fixed with time - a second phase of treatment will be

necessary when all the permanent teeth have erupted to complete the corrections

of malocclusion.

• Ideally, expansion is performed at an early mixed dentition. Some children may

require cosmetic orthodontics to improve alignment and spacing. There may be a

risk in children who were born with a cleft lip/palate

SOURCES

Photo courtesy of Oxford Journals – Oxford University Press

Before & After

Rapid Maxillary Expansion

SOURCES

Courtesy of Dear Doctor, Inc. 2012

Relevance Today


• 49% of students with medically diagnosed sleep disorder have already been

placed in special education before their diagnosis

• Early treatment can change the path of a child’s quality of life and health: Early

diagnosis & intervention is CRUCIAL in preventing long-term neurological &

neurobehavioral changes d/t snoring, apnea & resisted breathing (10% of kids)

• A few generations back…malocclusions a very small part of the population.

Today…. a very small part of the pediatric population that does NOT have some

form of malocclusion! Direct correlation with increase in ADHD

SOURCES

Banabilh SM. Orthodontic view in the diagnoses of obstructive sleep apnea. Journal of Orthodontic Science. 2017;6(3):81-85.

doi:10.4103/jos.JOS_135_16.

A Multi-Disciplinary Approach


• Recognition & screening of symptoms by dentist & PCP

• Dx & coordination of appropriate Tx by sleep specialist & ENT

• Involvement of Orthodontist, ENT, Sleep Physician in Tx & management

COMBO THERAPY PROVES OPTIMAL

Tonsil/Adenoid removal w/ Palatal Expansion and Craniofacial Development

(Orofacial Myofunctional Therapy) for at least 6 months to teach tongue posture and

nose breathing to avoid palate from vaulting results in best long-term outcomes

SOURCES

Huang Y-S and Guilleminault C (2013) Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front.

Neur. 3:184. doi: 10.3389/fneur.2012.00184

Making Progress:

New Standards of Care & Collaboration

SOURCES


Landscape of Dental Sleep

Medicine A larger role for Oral Appliance Therapy (OAT)

The field of dental sleep medicine is evolving and growing due to factors:

• Pt demand for alternative therapies & increased awareness of OSA

• Although CPAP remains gold standard, compliance remains a key issue

• Technology of OA and training of dentists driving improved outcomes

• Physicians gaining confidence increase in referrals for OAT

• Medical insurance benefits being utilized by dentists

Sullivan & Frost: Oral appliances on track to be part of OSA treatment

(combo or stand-alone) for every 1 in 5 cases by 2020. 1

Markets & Markets Survey: The global OA market is expected to register

a CAGR (compound annual growth rate) of 15.7% from 2018 – 2023 2

1. Shelton, T. – The Price of Good Night’s Sleep – Insight into the Oral Appliance Market. Frost & Sullivan Industry Focus. January 2015

2. Sleep Apnea Oral Appliances Market by Product - Global Forecasts to 2023. Markets & Markets. May 2018

SOURCES

Shelton, T. – The Price of Good Night’s Sleep – Insight into the Oral Appliance Market. Frost & Sullivan Industry Focus. January 2015

SOURCES

Clincal Practice Guidelines on

Oral Appliance Therapy

Ramar, et. al. Clinical Practice Guideline for the Treatment of OSA & Snoring with OAT: An update for 2015. Journal of Clinical Sleep Medicine,

Vol. 11, No7, 2015.

Summary

• Physicians prescribe oral appliance rather than no treatment for primary

snoring

• When physician prescribes for OSA, a qualified dentist should use custom,

titratable appliance

• Physicians should prescribe oral appliance rather than no treatment at all

for OSA patients intolerant to CPAP OR PREFER ALTERNATIVE TX

• A qualified dentist should provide oversight through follow up to survey for

side effects

• Sleep physicians should conduct follow-up sleep testing to improve or

confirm tx efficacy for patients fitted with OA

• Physicians and Dentists should instruct pt to return for periodic office visits

SOURCES

House of Delegates adopts official policy statement at ADA 2017 – America’s Dental Meeting October 23, 2017. www.ADA.org

ADA Adopts New Policy

The Dentist’s Role in OSA

In 2017, the ADA issued a policy statement which outlines the role of dentists in

treating SRBD. Key components include:

• Assessing a patient’s risk for SRBD as part of a comprehensive medical

and dental history and referring affected patients to appropriate physicians;

• Evaluating the appropriateness of OAT as prescribed by a physician and

providing OAT for mild and moderate sleep apnea when a patient does not

tolerate a continuous positive airway pressure (CPAP) device;

• Recognizing and managing OAT side effects;

• Continually updating dental sleep medicine knowledge and training;

• Communicating patients’ treatment progress with the referring physician

and other healthcare providers.

SOURCES

Dental Sleep Medicine Standards of

Care Screening, Treating & Managing Adults w/ Sleep

Disordered Breathing (2018)

• All dentists should screen for SRBD during normal dental check-ups –

physicians must diagnose

• OA may be a first-line therapy or may be used when previous treatment efforts

(PAP non-compliance) have fallen short of maximum efficacy.

• Dentists are expected to perform comprehensive examination to assess if OA

is appropriate, discuss potential side effects, and establish baseline symptoms

• Initiation of OAT should follow qualified sleep study indicating OSA and include

physician medical necessity & written order and dentist consent for Tx

• Custom-fabricated, adjustable dual-arched appliances should be considered

and constructed from digital or analog impressions and protrusive bite record

SOURCES

Levine M, Bennett K, Cantwell M, Postol K, Schwartz D. Dental sleep medicine standards for screening, treating, and managing adults with

sleep-related breathing disorders. J. Dent Sleep Med. 2018;5(3):61-68.

Levine M, Bennett K, Cantwell M, Postol K, Schwartz D. Dental sleep medicine standards for screening, treating, and managing adults with

sleep-related breathing disorders. J. Dent Sleep Med. 2018;5(3):61-68.

Dental Sleep Medicine Standards of

Care

CONT…

• OA delivery & calibration may include a series of appointments and should

focus on comfort, fit, instructions on wear/use, minimizing side effects, gradual

advancement in protrusion to improve symptoms

• Obtaining objective results of Tx progress through HSAT or PSG are optimal;

Unattended Titration HSAT ordered by dentist has conflicting viewpoints

• Ongoing follow up and management is key and involves referral back to

physician, dental exam at 6 months x 2 then annual, management & reporting

of side effects, adherence to Tx, and evaluation of condition of appliance

SOURCES

Underlying THEME so far… Physician & Dentist collaboration

with a multi-disciplinary approach to screening, treating &

managing SDB

It Takes Two…

SOURCES


Collaboration among providers:

Physicians & Dentists

SOURCES


Challenges for Physicians

Further Collaboration is Needed

• Believe they can convince/teach patient to be CPAP adherent

• Cost of OA / Insurance

• Efficacy of OA

• OA recording compliance (adherence)

• Side Effects

• Lack of correspondence on treatment results & referral back to MD

• Lack of trust with local dentists

SOURCES

Roy, S. Oral Appliance Therapy Awareness and Perceptions Survey. Sleep Review. January 5, 2016.

http://www.sleepreviewmag.com/2016/01/oral-appliance-therapy-awareness-perceptions-survey/

What Dentists Can Do


Dental Sleep Community must understand these concerns and

demonstrate professional competency, patient centered care, work

with insurance, and recognize they are only part of managing this

medical condition

SOURCES


Challenges for Dentists


• Lack of previous standards of care

• Shady marketing models & cutting corners by a few ruins it for the rest

• Lack of response from sleep centers & sleep physicians (dentists feel

they are unimportant when in fact they are screening/referring patients)

• LONG wait times for PSG/HSAT when patients are suffering

• Physicians dismissing a large body of evidence that OA can be effective

• CPAP compliance not honestly being addressed beyond the 90 day

compliance requirement for insurance

SOURCES


What Physicians Can Do


Medical Sleep Community should consider working with an

experienced dentist, review current evidence & innovation within

sleep dentistry field, and accommodate referrals as dentists are

screening/treating more patients than ever before

SOURCES


Opportunities for Multi-Disciplinary Team

A Patient Centered Approach

• Complex cases requiring combo therapy, proven very effective

• Patients with known PAP intolerance – experienced dentists to help educate

medical staff on OA so they can better educate pt on OAT (treatment plan,

appliance options, insurance)

• Craniofacial & dental/orthodontics involvement in optimal tx for pediatric OSA

through RME

• Predictive polysomnography (MATRx) – a true collaborative approach

• Dentists screen and reveal significant risk for possible SRBD – a referral to

sleep spc for medical evaluation is clinically important

SOURCES


Opportunities for Multi-Disciplinary Team

A Patient Centered Approach

Collaboration & multi-disciplinary approach will always yield the

best outcomes and keep the PATIENT’s best interest as the priority

SOURCES


Dentists with Proper Qualifications:

Confidence in a Referral

• Have training & education specific to dental sleep medicine which may include

TMJ & craniofacial development and pain

• Follow scope of practice defined by state

• Follow standards any published standards of care

• Comply with billing practices of insurers, federal & state programs

• Are familiar with guidelines & research in the field of DSM

• Rely on qualified sleep study, medical necessity, and written order from

MD/DO/PA/NP to provide OAT

• May have obtained board certification in dental sleep medicine

SOURCES


Professional Societies

• American Academy of Dental Sleep Medicine

• American Board of Dental Sleep Medicine

• Academy of Clinical Sleep Disorders Disciplines

• American Sleep and Breath Academy

• American Board of Craniofacial & Dental Sleep Medicine

SOURCES


Board Certified Dental Sleep

Specialists

More dentists are achieving board certifications in dental sleep

medicine from these professional societies.

Are there any in your neighborhood?

SOURCES


Improved Outcomes:

Innovation & New Technology

SOURCES


Technology & Innovation

New OA designs delivering better results

The oral appliance market is becoming increasingly competitive as more labs &

manufacturers strive to develop more effective appliances

Prosomnus appliances - series of upper & lower arch

combinations to achieve advancement, replacing the need for

any moving parts

Panthera D-SAD – smallest device on the market and only

one made entirely by CAD/CAM technology

Oventus – O2 vent bypassing nasal obstruction, pharyngeal

collapse and residual events; now OAT can be tolerated by

patients with moderate-high nasal resistance

SOURCES

Courtesy of Prosomnus (www.prosomnus.com), Panthera Dental (www.pantherasleep.com), and Oventus (www.oventus.com.au)

Oventus

O2VentTM Airway Management Technology bypasses the multiple levels of

obstruction including the nose, soft palate & tongue where MAD alone may not

A titratable oral and oro-nasal PEEP valve is being developed to deliver

constant pressure on exhalation increasing stabilization of the airway CPAP

PAP Connection also in development – device should reduce need for higher

PAP pressures and eliminate full mask for pt with nasal obstruction

SOURCES


Appliance Selection MATTERS!

ASK dentists which appliances they use & why –

it can make a difference!

SOURCES


Oventus Airway Technology + PEEP delivering low

resistance inhalation and controlled exhalation

Neg pressure

swings reduced

due to air being

delivered

through device

airway and

oropharyngeal

airway,

supported by

PEEP

Low resistance

inhalation and

PEEP targeted

to the

oropharynx via

O2 ExVent and

Oventus Airway

Increased nasal

resistance

Soft Palate

Collapses and

a switch to

device

breathing

occurs

SOURCES

Genta PR, Sands SA, Butler JP, Loring SH, Katz ES, Demko BG, Kezirian EJ, White DP, Wellman. Airflow Shape Is Associated With the

Pharyngeal Structure Causing OSA. CHEST DOI: 10.1016/j.chest.2017.06.017

Technology & Innovation:

Predictive Polysomnography

Prospectively selecting patients for oral appliance therapy results in more

efficient delivery of treatment and improved outcomes1

1. Kastoer, C. et.al. Use of Remote Controlled Mandibular Positioner as Predictive Screening Tool for OMAD..A Systematic Review. J Clin Sleep Med 2016;

12(10): 1411-1421 2. Courtesy of Zephyr Sleep Technologies – Continuing Education Series: MATRx In-Lab Titrations Studies – Selecting the Right Patients for Oral Appliance

Therapy. 2018

1. Accurately selects patients who will respond to OAT and

2. Identifies an efficacious protrusive position for each responder

MATRx A Single-night, attended polysomnographic test

SOURCES

MATRx

PSG

Configuration

Temporary Dental Trays &

Remote-controlled Mandibular Positioner

Trays with Impressions

Components

SOURCES

Courtesy of Zephyr Sleep Technologies – Continuing Education Series: MATRx In-Lab Titrations Studies – Selecting the Right Patients for Oral

Appliance Therapy. 2018

MATRx

Mandible is protruded by mouse click by RST, while the patient sleeps

Study is started at the patient’s lower limit (habitual bite) and titration is performed

within the range provided by the dentist

Mandible is advanced in 0.2mm steps in response to respiratory events

If possible, patient is studied in supine and lateral, REM and NREM

Workflow

SOURCES



Instead of cmwp

mm protrusion

Patient Profile

42 year old female

Pre-study AHI = 41.4

BMI = 32.3

Tray Fitting

Lower Limit (Resting

Position) = 10.0mm

Upper Limit (Maximum

Protrusion) = 17.0mm

MATRx – Similar to PAP

Titration

SOURCES



MATRx

High Predictive Accuracy

SOURCES

Remmers J, Charkhandeh S, Grosse J, Topor Z, Brant R, Santosham P, Bruehlmann S. Remotely controlled mandibular protrusion during sleep

predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. SLEEP 2013; 36(10): 1517-25.

MATRx

Why sleep labs should consider

Predicting target protrusion & OA responders drastically

improves OAT success rate

Appropriate for patients who are asking about OAT, who are non-compliant or

unable/refuse to use PAP

Utilize a network of experienced dental sleep specialists (fabricate temporary

trays, set bite position)

Informs physician on decisions of managing patient and having knowledge in

advance who will respond to OAT and their target protrusion

Increases physician confidence in the efficacy of oral appliances

Improves efficiency of appliance fitting at target by dentist, decreases time-to-

therapy, and minimizes risk of over-titration and related side-effects

SOURCES



OA Compliance Monitoring:

A Game Changer

DentiTracTM by Braebon Medical

is the first compliance chip that is

inserted into OA and measures

wearing times

Measuring a wide range of

metrics, from temperature to

three dimensional rotation

Enables sophisticated

algorithms to determine

accurate wearing times. This

power comes without

compromising the micro-

recorder's long lifespan.

SOURCES

Photos courtesy of Braebon Medical https://www.braebon.com

DentiTracTM

With the DentiTracTM base station and a web-enabled PC, compliance

data is easily extracted from the micro-recorder and sent to the cloud.

SOURCES

Photos courtesy of Braebon Medical https://www.braebon.com

THANK YOU

Daniel Burton DDS, D.ABDSM Michigan Sleep Network, PC [email protected]

Documents

Advancements in the Field of Dental Sleep Medicine Fall... · Rapid Maxillary Expansion (RME) Rapid Maxillary Expansion (RME) has been proven to be a highly successful treatment option