Advancements in the Field of Dental Sleep Medicine

Transcription

1 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

2 X Type of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other Details of Potential Conflict

3 Topics Early interventions: Rapid Maxillary Expansion Making Progress: New Standards of Care & Collaborative Efforts Improved Outcomes: Innovation & New Technology Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

4 Early Interventions in Pediatric OSA: Rapid Maxillary Expansion (RME) Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

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

6 ADHD or Sleep Deprivation Treat the Sleep Problem, Treat the ADHD? Primary Symptoms of ADHD: Hyperactivity Inattention Impulsivity Distractibility Difficulty waking Primary Symptoms of Sleep Deprivation: Hyperactivity Inattention Impulsivity Oppositional behavior Difficulty waking the morning

7 Pediatric OSA Interventions Current Treatment Standards May Not Be Ideal 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: /fneur 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,

8 Rapid Maxillary Expansion (RME) How Dentistry & Orthodontics Can Help 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 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 ,

9 RME: The Basics What is it? 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. Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

10 Courtesy of Dear Doctor, Inc. 2012

11 RME: Indications & Mechanics of Treatment 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. Photo Courtesy of OrthoLemay.com

12 RME: Details & Side Effects 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. Photo Courtesy of SlyvainChamberland.com

13 RME: Early Age is Key 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 Photo courtesy of Oxford Journals Oxford University Press

14 Rapid Maxillary Expansion Before & After Courtesy of Dear Doctor, Inc. 2012

15 Rapid Maxillary Expansion 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 Banabilh SM. Orthodontic view in the diagnoses of obstructive sleep apnea. Journal of Orthodontic Science. 2017;6(3): doi: /jos.jos_135_16.

16 Rapid Maxillary Expansion 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 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: /fneur

17 Making Progress: New Standards of Care & Collaboration Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

18 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 Markets & Markets Survey: The global OA market is expected to register a CAGR (compound annual growth rate) of 15.7% from Shelton, T. The Price of Good Night s Sleep Insight into the Oral Appliance Market. Frost & Sullivan Industry Focus. January Sleep Apnea Oral Appliances Market by Product - Global Forecasts to Markets & Markets. May 2018

19 Shelton, T. The Price of Good Night s Sleep Insight into the Oral Appliance Market. Frost & Sullivan Industry Focus. January 2015

20 Clincal Practice Guidelines on Oral Appliance Therapy 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 Ramar, et. al. Clinical Practice Guideline for the Treatment of OSA & Snoring with OAT: An update for Journal of Clinical Sleep Medicine, Vol. 11, No7, 2015.

21 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. House of Delegates adopts official policy statement at ADA 2017 America s Dental Meeting October 23,

22 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 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.

23 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 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.

24 It Takes Two Underlying THEME so far Physician & Dentist collaboration with a multi-disciplinary approach to screening, treating & managing SDB Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

25 Collaboration among providers: Physicians & Dentists Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

26 Further Collaboration is Needed Challenges for Physicians 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 Roy, S. Oral Appliance Therapy Awareness and Perceptions Survey. Sleep Review. January 5,

27 Further Collaboration is Needed 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 Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

28 Further Collaboration is Needed 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 Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

29 Further Collaboration is Needed 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 Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

30 A Patient Centered Approach Opportunities for Multi-Disciplinary Team 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 Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

31 A Patient Centered Approach Opportunities for Multi-Disciplinary Team Collaboration & multi-disciplinary approach will always yield the best outcomes and keep the PATIENT s best interest as the priority Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

32 Confidence in a Referral Dentists with Proper Qualifications: 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 Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

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

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

35 Improved Outcomes: Innovation & New Technology Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

36 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 Courtesy of Prosomnus ( Panthera Dental ( and Oventus (

37 Oventus O 2 Vent TM 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 Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

38 Appliance Selection MATTERS! ASK dentists which appliances they use & why it can make a difference! Daniel Burton DDS, D.ABDSM - MASM Annual Meeting 10/6/18

39 Oventus Airway Technology + PEEP delivering low resistance inhalation and controlled exhalation Soft Palate Collapses and a switch to device breathing occurs Increased nasal resistance 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 O 2 ExVent and Oventus Airway 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: /j.chest

40 Technology & Innovation: Predictive Polysomnography MATRx A Single-night, attended polysomnographic test 1. Accurately selects patients who will respond to OAT and 2. Identifies an efficacious protrusive position for each responder Prospectively selecting patients for oral appliance therapy results in more efficient delivery of treatment and improved outcomes 1 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): Courtesy of Zephyr Sleep Technologies Continuing Education Series: MATRx In-Lab Titrations Studies Selecting the Right Patients for Oral Appliance Therapy. 2018

41 MATRx PSG Configuration Components Temporary Dental Trays & Remote-controlled Mandibular Positioner Trays with Impressions Courtesy of Zephyr Sleep Technologies Continuing Education Series: MATRx In-Lab Titrations Studies Selecting the Right Patients for Oral Appliance Therapy. 2018

42 MATRx Workflow 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 Courtesy of Zephyr Sleep Technologies Continuing Education Series: MATRx In-Lab Titrations Studies Selecting the Right Patients for Oral Appliance Therapy. 2018

43 MATRx Similar to PAP Titration 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 Courtesy of Zephyr Sleep Technologies Continuing Education Series: MATRx In-Lab Titrations Studies Selecting the Right Patients for Oral Appliance Therapy. 2018

44 MATRx High Predictive Accuracy 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):

45 MATRx Why sleep labs should consider 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-totherapy, and minimizes risk of over-titration and related side-effects Predicting target protrusion & OA responders drastically improves OAT success rate Courtesy of Zephyr Sleep Technologies Continuing Education Series: MATRx In-Lab Titrations Studies Selecting the Right Patients for Oral Appliance Therapy. 2018

46 OA Compliance Monitoring: A Game Changer DentiTrac TM 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 microrecorder's long lifespan. Photos courtesy of Braebon Medical

47 DentiTrac TM With the DentiTrac TM base station and a web-enabled PC, compliance data is easily extracted from the micro-recorder and sent to the cloud. Photos courtesy of Braebon Medical

48 THANK YOU Daniel Burton DDS, D.ABDSM Michigan Sleep Network, PC