February 2012 99 Cda Journal, Vol 40, Nº 2

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departments

101 The Associate Editor/Dental School Debt: Getting all of your Swimming to the Surface or Drowning 107 Impressions

115 CDA Presents insurance through 183 Classifieds

194 Advertiser Index the most trusted 198 Dr. Bob/Salt: There’s Na-thing Like It 107 features source? 126 Dental Sleep Medicine An introduction to the issue. Michael S. Simmons, DMD

C 131 Somnology 101: A Primer on Sleep Disorders, Their Impact on Society, and a Role for Dentistry M Good call. This manuscript introduces sleep and sleep disorders, focuses on those sleep disorders within the domain of dentistry, and addresses Y contributions the dental community can make toward specific sleep problems. CM Michael S. Simmons, DMD MY Protect your business: Protect your life: CY 141 Medical Consequences and Associations with Untreated Sleep-related Breathing Disorders and Outcomes of Treatments CMY TDIC Optimum bundle • Life/Health/Disability This article reviews the scientific literature that links sleep-related breathing disorders to various medical conditions including K • Professional Liability • Long-Term Care hypertension, coronary artery disease, cardiac arrhythmias, stroke, diabetes mellitus, obesity, and depression. Daniel Norman, MD; Paul B. Haberman, MD; and Edwin M. Valladares, MS • Building and Business • Business Overhead Personal Property Expense 151 Past, Present, and Future Use of Oral Appliance Therapies in Sleep-related Breathing Disorders • Workers’ Compensation Discussion of the ability of removable oral appliances utilized during sleep to create and maintain a patent airway has seen the • Home and Auto creation of a new area of interest in dentistry termed dental sleep medicine. • Employment Practices Robert R. Rogers, DMD, DABDSM

Liability 159 Neurology of Sleep and Sleep-Related Breathing Disorders and their relationships to Sleep Bruxism The purpose of this article is to provide the basic science of sleep physiology and how it relates to disorders that are pertinent to dentistry. Concepts are presented that explain airway dynamics and how the jaw and tongue influence airway obstruction. Jerald H. Simmons, MD

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february 2012 99 cda journal, vol 40, nº 2

CDA Journal Volume 40, Number 2 Journal february 2012

Courtney Grant communications Reader Guide: coordinator Upcoming Topics Letters to the Editor march: CDA Research Kerry K. Carney, DDS Crystan Ritter april: Oral Health Literacy [email protected] Journal of the California administrative may: Pathology Dental Association assistant Subscriptions Manuscript Submissions The subscription rate is published by the Advertising Patty Reyes, CDE $18 for all active members California Dental Corey Gerhard assistant editor of the association. The Association advertising manager [email protected] subscription rate for 1201 K St., 14th Floor 916-554-5333 others is as follows: Sacramento, CA 95814 Jenaé Gruchow Author guidelines Non-CDA members and 800.232.7645 traffic/project are available at institutional: $40 cda.org coordinator cda.org/publications/ Non-ADA member journal_of_the_california_ dentists: $75 Management Production dental_association/ Foreign: $80 Kerry K. Carney, DDS Matt Mullin submit_a_manuscript Single copies: $10 editor-in-chief cover design Subscriptions may This [email protected] Classified Advertising commence at any time. Randi Taylor Jenaé Gruchow Please contact: Ruchi K. Sahota, DDS, CDE graphic design traffic/project Crystan Ritter associate editor coordinator administrative is why Kathie Nute, Western Type [email protected] assistant Brian K. Shue, DDS preproduction 916-554-5332 [email protected] associate editor 916-554-5318 California Dental Display Advertising Peter A. DuBois Association Corey Gerhard Permission and Reprints we’re executive director Daniel G. Davidson, DMD advertising manager Jeanne Marie Tokunaga president [email protected] publications manager Jennifer George [email protected] 916-554-5304 JeanneMarie.Tokunaga@ vice president, cda.org marketing and Lindsey A. Robinson, DDS 916-554-5330 here. communications president-elect [email protected] Alicia Malaby Journal of the California Dental Association (issn When you give to the communications James D. Stephens, DDS 1043-2256) is published monthly by the California Dental CDA Foundation, you help director vice president Association, 1201 K St., 16th Floor, Sacramento, CA 95814, [email protected] 916-554-5330. Periodicals postage paid at Sacramento, fund local clinics, support Jeanne Marie Tokunaga Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, dentists who serve in rural publications manager Walter G. Weber, DDS secretary Sacramento, CA 95853. [email protected] areas, and give countless Jack F. Conley, DDS The Journal of the California Dental Association is published editor emeritus under the supervision of CDA’s editorial staff. Neither the kids healthy, happy smiles. Clelan G. Ehrler, DDS editorial staff, the editor, nor the association are responsible Editorial treasurer for any expression of opinion or statement of fact, all of Michael S. Simmons, DMD [email protected] cdafoundation.org which are published solely on the authority of the author guest editor whose name is indicated. The association reserves the Alan L. Felsenfeld, DDS right to illustrate, reduce, revise, or reject any manuscript Robert E. Horseman, DDS speaker of the house submitted. Articles are considered for publication on contributing editor [email protected] condition that they are contributed solely to the Journal.

100 february 2012 Assoc. Editor cda journal, vol 40, n 2 º

Dental School Debt: Swimming to the Surface or Drowning

ruchi k. sahota, dds

t is the 25th day of the month. His rent, $2,500, is due in five days. Add Despite the sticker price, another $1,000 for his car and professional insurance policies. The bill the number of dental school applicants for his malpractice and disability Iinsurance for $300, due at the end of the continues to rise each year. month, is on his desk. And then there are his student loans. He had to borrow more than $200,000 to pay for school. Every 30th of the month, his staffing costs and competitive salaries for able to buy a car or home. She was left with monthly loan payment is $2,200. He has to high-quality educators are needed to train a sense of utter hopelessness.3 pay this every month for the next 15 years. high-quality clinicians. We also teach them to calculate the He needs to earn $6,000 every month Despite the sticker price, the number realistic necessary amount they need to just to pay these bills. He has a good as- of dental school applicants continues to borrow. “Home life ceases to be free and sociateship but the economy is still bad. rise each year. It is more competitive to beautiful as soon as it is founded on bor- His days have been cut. One day, he wants gain admission. It takes hard work, lots of rowing and debt,” remarked Henrik Ibsen. to start or buy a practice. They say he will heart, and complete dedication. Once in We teach that it is prudent to borrow only need at least another $500,000 — all up school, we regularly visit the financial-aid what is needed. We urge students to look front. That’s just to open the doors. That’s office. A simple ballpoint pen and our sig- into student loan consolidation, gradu- another $5,000 a month — on top of the nature provide a fresh, crisp check. Those ated repayment programs, and service- $6,000 he already has to pay every month. checks silently add up. And then gradua- connected repayment programs. And that doesn’t include the office rent tion finally comes. We are eager to get on Interest rates are at the heart of the and staff salaries. with life. But it is then one job interview issue — inciting the actual, final, and How will he ever get there? after another. The bad economy becomes significant repayment dollar value, said Every month, this is a very familiar personal. Our hearts drop. What did we Dr. Michael Meru, former American fear for many new graduates struggling to get ourselves into? The grace period for Student Dental Association president. make a living and to pay their bills. the loan repayment is ending. The 30th of Meru pointed out the sizable disparity In California schools, there are some the month is now inescapable. between potential student loan interest students with nearly $600,000 in loans. Through the ADA-sponsored Smart- rates (roughly 6.5 to 9 percent) and a 30- In 2010, the American Dental Education Start SUCCESS program seminars at Cali- year fixed home loan interest rates (cur- Association reported that more than 90 fornia’s dental schools, I speak to students rently in the 4 percent range). “We need to percent of all graduating seniors reported about debt load. We teach them the finan- lobby for better interest rates because the some sort of loan to finish their education cial principles of student loans. We warn real cost of attendance and thus cost of and that more than 44 percent of dental about the ramifications of compounded in- education is not incurred during school. students in private schools accrued more terest, “It is like a snowball down a snowy The staggering blow often comes once we than $200,000 of debt.1 Public dental hill, getting bigger and bigger as it goes realize the final repayment amount, after schools are no different. In 2009, ADEA … Compounding the interest on … your the interest rate has piled up.” reported that 20 percent of dental stu- debts will increase the total amount that Facing the magnitude of this debt is dents in public dental schools have more you owe, impacting your financial picture.” daunting. Dentists, dental school admin- than $250,000 of debt.2 A physician in Ohio reported watching her istrators, and current dental students on As with all graduate studies, the cost debt more than double from $250,000 to studentdoctor.net share options on how to of a dental education continues to rise. $555,000 dollars. Unable to pay her loan manage this debt. Facing a $420,000 debt Facility costs, technology improvements, back, her credit rating sank, leaving her un- continues on 104

february 2012 101 Stories. Everybody has one. Some people have a career. The lucky ones have a calling, a passion for dentistry that likely began in an illuminating moment. For some, it was the first time they set foot in a dental office, or the magic of seeing a tooth that came back to life. But whatever your story, the reasons to join CDA are clear— advocacy, protection, education, support and being part of an organization dedicated to improving the oral health of all Californians. Join. Renew. Share. cda.org/member

Craig Crispin, DDS

He nearly lost a tooth, but gained a profession. When Craig Crispin was 6, his older brother tied his hands behind his back and took him prisoner. What happened next changed the rest of his life. As he walked up some steps, he tripped and landed on his front teeth. He didn’t knock them out, but it wasn’t good. His parents took him to a dentist, who advised that since the Progress. root hadn’t formed, they should wait and see. Maybe the tooth would heal. Almost It’s what happens when a year later, his tooth turned white again. It was magic. And Crispin was hooked. 25,000 dentists work together.

journal_double_feb1.indd 2-3 1/18/12 2:46 PM Stories. Everybody has one. Some people have a career. The lucky ones have a calling, a passion for dentistry that likely began in an illuminating moment. For some, it was the first time they set foot in a dental office, or the magic of seeing a tooth that came back to life. But whatever your story, the reasons to join CDA are clear— advocacy, protection, education, support and being part of an organization dedicated to improving the oral health of all Californians. Join. Renew. Share. cda.org/member

Craig Crispin, DDS

journal_double_feb1.indd 2-3 1/18/12 2:46 PM feb. 12 assoc. editor cda journal, vol 40, nº 2

editor, continued from 101 and scarce job prospects in California — our Foundation program can help only of Delegates as well as the ADA House of one student forum entry on this website one dentist a year. State governments, Delegates to help us find sustainable solu- considers “moving to a higher income state.” private foundations, and even communi- tions. The marketplace has changed. New In the past, we may have been able to ties without a dentist can consider this dentists struggle to make a living. set up a practice where we wanted to live. solution for their community. It is in the self-interest of those In light of this down economy, scarce job In 2002, an article in the Journal of the ahead of us in the profession to look prospects and the pressures of high debt, California Dental Association concluded at the big picture of how debt affects practicality forces other options. that larger debt correlated with delayed the profession. “The bow may steer the One option many consider is moving practice ownership. Over a 10-year period, canoe, but if the rudder is impaired, the to a practice location where starting a as educational debt increased, the dura- course becomes unpredictable.” We must practice is less constrained by competition tion from graduation to the onset of start- paddle together in this journey to reach and the economy. As a temporary measure ing or acquiring a practice also increased.4 our destination. in one’s life, some may save money and Almost 10 years later, the economy ride out the economy for three to five has dipped and the ratio of dentists to references 1. Education Association, 2010 graduating class survey. years. This will provide less debt pres- available positions seems to have also 2. American Dental Education Association, 2009 senior survey. sures and greater freedom to then move increased. It seems more difficult to have 3. Pilon M, The Student Loan Effect. Wall Street Journal, Feb. anywhere without that pressure. a five-day-a-week “job” within the first five 18, 2010. blogs.wsj.com/juggle/2010/02/18/the-student-loan- effect/. Accessed Dec. 13, 2011. The magnitude of this debt may have years of graduation. An online Wall Street 4. Chambers D, Budenz AW, et al, Debt and practice profiles of other far-reaching implications. The best Journal article, “The Student Loan Effect,” beginning dental practitioners. J Calif Dent Assoc 30(12):909- and the brightest may not consider the in late 2010 reported that many medical 14, December 2002. 5. Kuhnehenn J, et al, Obama Announces Help for Student Loan Bor- cost for this education worth the money. and law school graduates are straining to rowers. http://abcnews.go.com/m/index?sid=77, Oct. 26, 2011. After finishing school, the pressure to find jobs because of the high saturation pay this debt and make a living may limit in desirable locations. The article further additional resource nces.ed.gov/pubs2008/2008179rev. those who may consider a career serving reports that these new professionals the underserved or teaching. are delaying marriage and children after Ten years ago, the California Dental graduations.3 Association Foundation started a pro- Debt pressure can influence practice The Journal of the California Dental gram to provide grants to new dentists decisions. When there is an overarching Association welcomes letters. to repay dental school loans in exchange monthly bill to pay, will there be decisions We reserve the right to edit all communi- for serving in an underserved area. driven by money? There may be some very cations and require that all letters be signed. Currently, each grant provides $35,000 real ethical decisions and challenges facing Letters should discuss an item published in the over three years if the educational loans this generation. As it is aggregated, can Journal within the past two months or mat- amount to $105,000 or more. This pro- this debt cause our profession to encroach ters of general interest to our readership. Let- gram allows new dentists whose passion boundaries we would rather not enter? ters must be no more than 500 words and cite is public health to pursue their goal by The national debt is nearly $15 trillion. no more than five references. No illustrations reducing the pressure of debt. National student loan debt has exceeded will be accepted. Letters may be submitted via Each recipient has provided an national credit card debt. As the payment e-mail to the Journal editor-in-chief at kerry. average of about $1.5 million dollars in for our school debt comes every 30th of [email protected]. By sending the letter to the services over their grant term. Once all the month, the national debt numbers Journal, the author certifies that neither of the current 11 recipients complete become personal. Our nation and our the letter nor one with substantially similar their grant terms, the program will have generation are drowning in debt.5 content under the writer’s authorship has been helped provide approximately $16.5 mil- There have been studies looking at published or is being considered for publica- lion in oral health services. the root cause of debt in dental education elsewhere, and the author acknowledges All of the CDA Foundation’s grant tion. There are articles and commentaries and agrees that the letter and all rights of the recipients have chosen to continue to that describe the struggle. But this is not author with regard to the letter become the serve those underserved populations. But enough. Let us call upon the CDA House property of the California Dental Association.

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Muda Ethics by david w. chambers, phd “Muda” is a Japanese word for an activity that is wasteful or unproductive. The West became familiar with it through the quality movement. Here is how the concept of “muda” relates to ethics in oral health care: Reduced waste promotes quality, which leads to reduced cost. Because health care is a limited resource, reducing cost means that more people can have better oral health. It is unethical to raise costs unnecessarily or to avoid taking reasonable steps to reduce cost. At least that is what most of us think about cable TV monopolies, insurance companies, and government services. Waste is any activity that does not add Matt Mullin value. Would patients pay to sit in the waiting room? Would they pay for a full-mouth X-ray series having just had one before moving to a new town? Would they pay

continues on 109

On Being Happy Although recent studies have shown that people are born with a genetically determined “happiness set point,” Michael Prazich, DDS, a certified life coach who works with health care professionals, has said that happiness can be learned, even by the perennially unhappy. Over the years, Prazich has noticed certain traits that happy dentists exhibit and that, with a little effort, self- identifying unhappy dentists can use to achieve happiness. In a recent issue of Northwest Dentistry, Prazich listed the following traits that the happiest people tend to have: n They are comfortable expressing gratitude; n They make physical exercise a weekly or even a daily habit; n They are often first to offer aid to friends or fellow professionals; n They devote a great amount of time to family and friends; n They have interests and passions outside their profession; n They maintain poise and strength when coping with challenges; and n They are more sociable, energetic, charitable, and cooperative than unhappy people.

february 2012 107 feb. 12 impressions cda journal, vol 40, nº 2

Gum and Hard Candy Can Help In addition to a comprehensive cavity- Prevent Caries prevention program that includes the use of A multidisciplinary expert panel has fluoride, the scientific panel recommended actually recommended gum and hard that clinicians consider applying a mixture of candy in preventing caries in high-risk cholrhexidine-thymol varnish to the teeth of patients. That is, provided of course, the high-risk adults and the elderly every three gum is sugar-free and the lozenges con- months to reduce cavities developing in the tain xylitol or polyol combinations, and root of the tooth. The panel encouraged are combined with varnishes. clinicians to consider advising parents and The panel, convened by the American caregivers of healthy children older than age Dental Association’s Council on Scientific 5 who are at higher risk for cavities to chew Affairs, said in its report that these non- sugar-free polyol gum after meals for 10 to fluoride options could provide an extra 20 minutes to prevent cavities. benefit to prevent cavities in patients at The panel’s recommendations are based high risk for developing cavities when on a review of evidence from 71 published used in addition to products such as articles that described 50 randomized con- toothpaste, dental sealants, varnishes that trolled trials and 15 nonrandomized stud- contain fluoride, as well as community ies to assess the effectiveness of various water fluoridation, and good eating habits. nonfluoride agents in preventing cavities. The ADA recommended that clinicians To see the full report, which is available determine a patient’s risk for developing on the ADA’s Center for Evidence-Based cavities by conducting a caries risk assess- Dentistry website, go to ebd.ada.org/con- ment, which includes completing a caries tentdocs/clinical_recommendations_non_ risk assessment form that can be used as a fluoride_caries_preventive_agents_full_ communications tool with their patients. report.pdf.

Healthy Plate Menu Updated Healthy Eating Plate, which provides guidance via visuals for healthy repasts, has been launched by Harvard Health Publications, in partnership with Harvard School of Public Health nutrition experts. Similar to the U.S. government’s version of MyPlate, Healthy Eating Plate is straightforward and “addresses important deficiencies in the MyPlate icon,” according to a news release. “Unfortunately, like the earlier U.S. Department of Agriculture Pyramids, MyPlate mixes science with the influence of powerful agricultural interests, which is not the recipe for healthy eating,” said Walter C. Willett, MD, DrPH, professor of Epidemiology and Nutrition and chair of the Department of Nutrition at HSPH. “The Healthy Eating Plate is based on the best available scientific evidence and provides consumers with the information they need to make choices that can profoundly affect our health and well being.” The Healthy Eating Plate is based on the latest scientific evidence showing that a plant-based diet rich in vegetables, whole grains, healthy fats, and healthy proteins lowers the risk of weight gain and chronic Whole disease. In the United States, two in three adults and one in three grains Vegetables children are overweight or obese. Healthy Eating Plate emphasizes an active lifestyle, a critical factor in controlling one’s weight. “We want people to use this as a model for their own healthy plate or that Healthy protein of their children every time they sit down to a meal — either at home or at a Fruits restaurant,” said Eric Rimm, associate professor of Epidemiology and Nutrition at HSPH and a member of the 2010 U.S. Dietary Guidelines Advisory Committee.

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Dental X-rays Can Predict Risk for Bone Fractures By using dental X-rays to investigate the bone structure in the lower jaw, it’s now possible to see who’s at risk of future fractures, according to researchers at Sahlgrenska Academy. “We’ve seen that sparse bone structure in the lower jaw in midlife is directly linked to the risk of fractures in other parts of the body, later in life,” said Lauren Lissner, PhD, a researcher at the Institute of Medicine at the Sahlgrenska Academy. The study, which recently was published in the journal, Bone, draws on data from 1968 with the Prospective Population Study of Women in Gothenburg, included 731 women, who have been examined on several occasions since 1968, when they were 38-60 years old. X-ray images of their jawbone were analyzed in 1968 and 1980, and the results related to the incidence of subsequent fractures. For the first 12 years, according to a news release, fractures were self- reported during follow-up examinations. It is only since the 1980s that it has been possible to use medical registers to identify fractures. A total of 222 fractures were identified during the whole observation period. The study shows that the bone structure of the jaw was sparse in around 20 percent of the women aged 38-54 when the first examination was carried out, and that these women were at significantly greater risk of fractures.

muda ethics, continued from 107 for fixing joint pain from a crown that was things around unnecessarily and waiting too high? Would dentists pay themselves are also examples of waste. Patient sched- what they pay a hygienist or assistant when uling inefficiencies is the obvious example, doing work that can be delegated? but staff members can also be affected. The muda concept begins by envision- Reducing unproductive motion is one area ing an office that runs smoothly, giving where dentistry has driven down muda. every patient exactly what is required the But overprocessing, doing work to stan- first time in the most efficient manner dards above what is required, is a type of possible. Everything that falls short of waste that professionals tend to embrace. that ideal is waste; it adds to cost without It is understandable that experts will want contributing value. Some offices work to use all of their talent, but it is uncertain continuously to reduce waste; others are that treating one patient to the acme of content to accept some level of waste. A care is better than treating two to a profes- few team members even celebrate their sionally acceptable level. The squandering skill at fixing problems and would dread of talent is a final kind of waste. the prospect of losing that opportunity. The Nub: This is muda by design. And anybody who 1. Ethics is a pattern, not an event. We sees an opportunity to increase their per- are judged by the overall impact of our lives, sonal influence or profit from inefficiency not specific acts that we select for evaluation. will be a closet critic of quality. 2. Oral health care resources are lim- The experts tell us there are eight ited: it is unethical to waste them. categories of waste. Defects are an obvious 3. It is better to design systems that example. Somebody has to pay for redos or minimize waste than to become famous for work that is not as serviceable as what for fixing symptoms. could have been done instead. Overpro- David W. Chambers, PhD, is a professor duction is a second type. In the dental of dental education, Arthur A. Dugoni School office, this includes overtreatment and per- of Dentistry, San Francisco, and editor of the forming work before it is needed. Moving Journal of the American College of Dentists.

february 2012 109 Everyone knows you can do a Now, let’s keep your first years in the composite in your sleep. profession from keeping you up nights.

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Emerging Evidence Base in Third-Molar wrote Dennis regarding indications for Management third-molar removal, including findings For several generations now, dental in the American Association of Oral treatment of third molars has been based and Maxillofacial Surgeons’ Third Molar on clinical impressions rather than on Clinical Trials that show an association of published scientific data, said Matthew third molars and periodontal disease. Dennis, DDS, in an issue of the Journal of Dennis said that the trials suggest the Michigan Dental Association. But, as he that the inaccessible third-molar anatomy noted, “questions about third-molar man- can harbor periodontal pathogens in up agement are beginning to be answered.” to four-fifth of patients with third-molar Impacted third molars, because of symptoms. “A large review of population the lateness of their emergence, should and clinical studies with more than 8,000 always be evaluated for removal or ob- subjects showed that patients with third servation. Most impactions involve arch molars had a worsened periodontal status length that is less than total tooth mass, on other teeth in the quadrant over those resulting in inadequate space for eruption patients without third molars.” Other to occur. conditions that may have greater inci- The average age for eruption of third dences associated with third-molar impac- molars is 20, but some eruptions can tions are pericoronitis and caries. occur as late as 25. Predicting eruption is, Dennis explained how dentists can Dennis said, an inexact science, requiring deal with impacted teeth that may be radiographic as well as clinical evaluation. coming in under prostheses, including “Even when symptom-free, two-thirds fixed-dental restoratives. “Partially erupt- of young adult subjects were found (by ed teeth almost always cause problems the clinical trials) to have periodontal with an overlying prosthesis and must be pathology in their third-molar regions,” removed prior to denture fabrication.”

Parents of Autistic Children Have New Oral Health Resource The National Museum of Dentistry has created “Healthy Smiles for Autism,” an oral health resource for parents of autistic children. The guide helps parents teach children with autism spectrum disorder how to brush and floss with the assistance of step-by-step instruction, social stories, and visual sequencing cards that can be used wherever brushing happens. This guide is free and downloadable at healthysmilesforautism.org. The guide also provides information to help parents prepare their children for a first dental visit. “We want to be able to give parents readily usable tools to help their children to develop a good oral hygiene regimen,” said Jonathan Landers, National Museum of Dentistry executive director. “We’ve combined best practices for autism education, such as visual sequencing cards and rewards systems, with proven personal oral hygiene techniques to help make the process a little bit easier.” Dental care is the leading unmet health care need among children with special needs, and across all income levels, children with special needs are almost twice as likely to have an unmet oral heath care need than their peers without special needs, according to the National Maternal and Child Oral Health Resource Center

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Leukocyte- and Platelet-Rich Fibrin an Excellent Option for Heart Patients For those cardiac patients on anticoagulant medications and who need a tooth extraction, it is important for the treating clinician to have a protocol that will help prevent major bleeding following dental extractions without suspending anticoagulant therapy. In an issue of the Journal of Oral Implantology, a study evaluated the use of leukocyte- and platelet-rich fibrin biomaterial, which is commonly used in dentistry to improve tissue regeneration and healing. It was tested as a safe filling and hemostatic material after dental extractions in 50 heart patients undergoing oral anticoagulant therapy, according to a news release. The heart patients in the study had mechanical valve substitutions and were placed on anticoagulant oral therapy with warfarin. It is not recommended to suspend the anticoagulant and replace with heparin prior to minor surgery, although this substitution may control the risk of postoperative bleeding. Using a platelet-rich plasma placed in postextraction tooth sockets is way of controlling bleeding without suspending the anticoagulant. While this method has shown some success, barriers to daily use exist: The platelet concentrates take a long time to prepare and it is expensive. An alternative biomaterial that is simple and inexpensive to prepare, platelet-rich fibrin has proven useful in daily dental practice as filling material for regeneration in order to place implants.

New Contract Restricts Tobacco Use in quit. “This is significant progress,” said Professional Baseball the coalition. “We continue to support a A new Major League Baseball con- complete prohibition on tobacco use at tract limits tobacco use in ballparks; and games and on camera.” the coalition initiated by the American “In light of the serious health risks Dental Association, nine major health from smokeless tobacco — it causes organizations, as well as more than 200 oral cancer and has been linked to heart local, state and national supporters disease and pancreatic cancer — play- couldn’t be happier. ers should be encouraged to quit and Managers, coaches, and players no be given support to help them do so,” longer may carry tobacco containers or according to the letter signed by of- packages in their uniforms at games or any ficials of the Campaign for Tobacco-Free time fans are in the ballpark, according to Kids, American Academy of Pediatrics, the contract agreement announced follow- American Cancer Society, American ing the 2011 baseball season. Additionally, Dental Association, American Heart they are prohibited from using smokeless Association, American Lung Association, tobacco during interviews that are tele- American Medical Association, Legacy, vised, at autograph signings, and any other Oral Health America, and the Robert occasions where they are in contact with Wood Johnson Foundation. fans or at team-sponsored appearances. The 10 initial member organizations The restrictions take effect in 2012. offered to collaborate with the players The agreement, according to a news association “toward a smokeless tobacco release, enhances tobacco education pro- prohibition that would be in the best grams for players and creates a new Major interests of baseball, the players and the League Baseball Players Association millions of young people who watch their center on cessation to help these athletes idols,” according to a news release.

february 2012 113 feb. 12 impressions cda journal, vol 40, nº 2

More Plans Needed for Treating ated difficult conditions. Another paper Cleft-Lip Palate Patients During discussed an emerging trend of a higher Chaotic Times incidence of craniofacial anomalies after An issue of Cleft Palate-Craniofacial a disaster. A third article suggested that Journal recently called for the need to guidance is needed for domestic and establish standards for continuing care for global crisis-relief programs. children with craniofacial anomalies during The review also discovered that com- times of natural or man-made upheaval. munications with patients were found to The number of new In general, medical care for cleft lip be lacking following Hurricane Katrina. or palate is offered in carefully planned Hospital staff was unable to contact cleft cases showed an phases with comprehensive care provided many patients’ families to inform them by a team of professionals. However, when when and where they could expect medi- increase in greater a crisis occurs, such as a natural disaster cal care for craniofacial anomalies. Be- or political unrest, this standard of care is fore this disruption, the mail had served New Orleans about disrupted. For example, when Hurricane as the primary means of communica- Katrina struck New Orleans in 2005, Chil- tion. Mobile phone numbers and e-mail nine months after dren’s Hospital housed one of the two cra- addresses now are collected as part of niofacial teams in the city. Lessons learned routine patient information. Hurricane Katrina. during the hurricane’s aftermath have led In another article, the number of new to new policies for the hospital, according cleft cases showed an increase in greater to a news release. When evacuating its New Orleans about nine months after facility became necessary, the hospital set Hurricane Katrina. Researchers found that up a temporary location at a Baton Rouge the increase, particularly among African- clinic 80 miles away and a satellite clinic Americans, could be attributed to higher in Lafayette, about two hours away. The levels of teratogenic agents or elevated hospital has continued to work with these stress levels following the hurricane, ac- locations as satellite sites in case future cording to a news release. evacuations are required. Hurricane Katrina and other cata- One of the articles in the issue ad- strophic events in recent years have shown dressed craniofacial care in locations a need for guidance in crisis-relief pro- where disaster and unrest have cre- grams. No such standards currently exist for cleft and craniofacial care. As presented upcoming meetings in another article in this issue, principles 2012 set forth by the American Cleft Pal- ate–Craniofacial Association may provide March 29– such guidance. The authors recommended CSPD/WSPD Annual Meeting, Portland, Ore., [email protected] April 1 using this document as a template for international clinical care programs. This April 22–28 United States Dental Tennis Association’s 45th Annual Spring Meeting, would provide standards for examining the Kiawah Island, S.C., dentaltennis.org or 800-445-2524 conduct of relief programs and ensuring April 26–28 World Federation for Laser Dentistry, 13th Annual World Congress, that medical teams are effective, ethical, Barcelona, Spain, wfldbcn2012.com and culturally sensitive. The article, “Flood, Disaster, and Tur- May 3–5 CDA Presents the Art and Science of Dentistry, Anaheim, 800-CDA-SMILE moil: Social Issues in Cleft and Craniofa- (232-7645), cdapresents.com cial Care and Crisis Relief,” was published in the Cleft Palate-Craniofacial Journal Oct. 18–23 ADA 153rd Annual Session, San Francisco, ada.org (volume 48, no. 6, November 2011). To have an event included on this list of nonprofit association continuing education meetings, please send the information to Upcoming Meetings, CDA Journal, 1201 K St., 16th Floor, Sacramento, CA 95814 or fax the information to 916-554-5962.

114 february 2012 Presents_ANA2012_savedate_REV1.pdf 1 8/18/11 3:00 PM

PRESENTS

The Art and Science of Dentistry

Save the date!

CM Anaheim, MY California

CMY

K Thursday- Saturday May 3-5, 2012

cdapresents.com CDA Presents Headlining Speakers

Lee Ann Brady, DMD Terence E. Donovan, DDS

Restorative Dentistry/Occlusion Dental Materials Anterior Esthetic Techniques and Materials Restoration of the Worn Dentition Thursday morning lecture Friday lecture Occlusion in Everyday Dentistry Update in Contemporary Restorative Dental Materials Thursday afternoon lecture Saturday lecture Fabricating Exquisite Anterior Provisionals Friday workshop Robert C. Fazio, DMD

Dennis G. Brave, DDS Kenneth A. Koch, DMD Periodontics Antibiotics and Dentistry Endodontics Friday morning lecture Changing Paradigms in Endodontic Therapy Medicine, Dentistry and Drugs Thursday lecture Friday afternoon lecture Changing Paradigms in Endodontic Therapy Workshop Periodontitis and Peri-Implantitis: The Good, the Bad Friday workshop and the Ugly Saturday lecture

Gerard J. Chiche, DDS Henry A. Gremillion, DDS

Cosmetic Occlusion Smile Design, Occlusal and Esthetic Techniques Saturday lecture The Dynamics and Function of the Masticatory System: The Multiple (Inter)Faces of Occlusion Friday lecture Karen Davis, RDH, BSDH

Gerard Kugel, DMD, MS, PhD Dental Hygiene America’s Sweet Tooth Obsession and Its Impact on Oral and Esthetic Dentistry Systemic Health Saturday morning lecture The Do’s And Don’ts of Porcelain Laminate Veneers Thursday workshop Creating the Ultimate Doctor-Patient Hygiene Exam Saturday afternoon lecture Esthetic Dentistry: Materials and Techniques Update Friday lecture Special Event Exhibit Hall

CDA Presents will feature more than 550 Grand Opening exhibiting companies showcasing the latest in Thursday, 9:30 a.m. dental technology, products and services. Stay New Exhibit Hall Days and Hours ahead of the curve by exploring the innovative new products being launched in the exhibit hall. Thursday, May 3, 9:30 a.m.–5:30 p.m. Friday, May 4, 9:30 a.m.–5:30 p.m. Thursday–Saturday, Saturday, May 5, 9:30 a.m.–4:30 p.m. May 3–5, 2012

Visit cdapresents.com to maximize Family Hours your tradeshow experience. Daily, 9:30 a.m.– noon The Spot

This contemporary lounge in the exhibit hall features a Cool Product display, Net Café and charging station, a C.E. Pavilion, and an educational theater that is the venue for the Smart Dentist Series of free, one-hour lectures. Thursday

9:30–10:30 a.m. Nutrition (C.E.: none) Juli Kagan, RDH, MEd 11 a.m.–noon Establishing an Office Policy Handbook (C.E.: 20% – 1.0) Robyn Thomason Noon–1 p.m. Handling Refund Requests From Insurance Plans (C.E.: 20% – 1.0) Patti Cheesebrough 1–2 p.m. Nutrition (C.E.: none) Juli Kagan, RDH, MEd Friday

9:30–10:30 a.m. Yogernomics (C.E.: 20% – 1.0) Juli Kagan, RDH, MEd 11 a.m.–noon Patient and Parent Communication (C.E.: 20% – 1.0) Katie Fornelli Noon–1 p.m. Managing Patient Conflicts (C.E.: 20% – 1.0) Brooke Kozak 1–2 p.m. Yogernomics (C.E.: 20% – 1.0) Juli Kagan, RDH, MEd 4–5:30 p.m. Wine Seminar (Ticket Required)

Saturday

9:30–10:30 a.m. Staff Building (C.E.: 20% – 1.0) Art Wiederman, CPA Join us for interactive wine activities and trivia. You’ll learn to distinguish the various scents and 11 a.m.–12:30 p.m. Making the Best Decisions for flavors in wine by tasting both white and red Your Practice (C.E.: 20% – 1.5) William Van Dyk, DDS varietals and about pairings with both cheese and chocolate. Plus, you’ll have the opportunity to put Check the On-Site Show Guide for updated program your knowledge to the test and win prizes! information. Hotel Information

Save time and money and Reservation Acknowledgments reach all the CDA hotels with Will be sent to you directly from CDA’s Housing Bureau. one phone call. Mail CDA Housing Bureau 800 W. Katella Ave. Our ability to offer you the best conference dates and competi- P.O. Box 4270 tive hotel rates is directly tied to the number of rooms that are Anaheim, CA 92803 reserved under our block in the Anaheim Resort .™ Reserve early to get the hotel of your choice. A limited number of rooms is available at these preferred rates, so call CDA’s Housing Bureau Deposit/Cancellation Policy as soon as possible. Every effort will be made to accommodate Reservations will only be accepted with a credit card or check your first hotel choice. If your requested hotel is not available, payment. All credit cards will be charged a one-night room and CDA’s Housing Bureau will confirm comparable accommodations tax deposit. Check must be made payable to requested hotel. for you. Hotel reservations must be made by April 6, 2012. Reservations must be canceled before 5 p.m. Pacific Time on Friday, March 9, 2012, to receive a full refund. Reservations Phone canceled after 5 p.m. Pacific Time on March 9, but before 5 714.765.8868 p.m. Pacific Time on Friday, April 6, 2012, will be charged a Office hours are 8:30 a.m. – 5 p.m., Pacific Time. $35 processing fee per room. Cancellations received after 5 p.m. Pacific Time on April 6, 2012, will forfeit Fax their entire deposit. 714.776.2688 Be sure to include a return fax number or email address in Online/New Reservations case of questions or problems with the fax transmission. Making reservations is easier than ever. Just log onto Make reservations as soon as possible through CDA’s Housing cdapresents.com, and you can make your hotel reservation. Bureau, by April 6, 2012. After this date, reservations will be The online service has been upgraded to be more convenient made on a space-available basis. Do not mail or fax forms to and flexible in making and changing reservations. You may CDA headquarters because this will delay your request. phone, fax, complete the online housing form, or write to make your reservations. Be sure to have a copy of the housing Changes, Cancellations, Refunds form and your credit card information on hand if you call, or All changes, cancellations and refund requests must be made complete the housing form and mail or fax to CDA’s Housing in writing directly with CDA’s Housing Bureau. This can be Bureau. Please do not do both! done by mail, fax or email ([email protected]). An acknowledgment of your request will be sent to you once it has been completed. Refund and cancellation requests must be received prior to March 9, 2012, for full refund of hotel deposit. Reservations canceled after 5 p.m., Pacific Time April 6, 2012, will forfeit their deposit. Hotel Reservation Form

Reservation Deadline: April 6, 2012 (After this date, reservations will be made on a space-available basis.)

ONLINE: MAIL TO: PHONE: FAX: Book online anytime: CDA Housing Bureau 714.765.8868 cdapresents.com 800 W. Katella Ave. Office hours are: 714.776.2688 P.O. Box 4270 8:30 a.m.– 5 p.m., PT Anaheim, CA 92803 Name

Address

City State ZIP

Phone Fax Email

Name of person making the reservation Please indicate how your hotel selection was made: Location Rate

Hotel Preference *room type *Room types vary by hotel. Please call the housing bureau for details, including suite information and rates 1st choice Rate . (1) Single (1 person) 2nd choice Rate (2) Double (2 people, 1 bed) (3) Double/Double (2 people, 2 beds) 3rd choice Rate (4) Triple (3 people, 2 beds) (5) Quad (4 people, 2 beds)

room type names of occupants Arrival Departure *List corresponding # for room type

CREDIT CARD INFORMATION All rooms require a deposit in the amount of a night’s lodging at the time of booking.

ADDITIONAL RESERVATION INFORMATION: 1. Reservations will not be processed without a first night’s deposit. 2. If you are making more than one reservation, you will need to provide a card and billing address for each room. 3. Billing address should be provided if different than address of card holder. 4. Once a credit card deposit has been applied to a reservation, it cannot be transferred to another card. 5. Once a deposit has been posted to a reservation, it cannot be transferred to another reservation. 6. Each credit card must be valid through the reservation dates of the stay. 7. To pay by check, make check payable to requested hotel. 8. For fax or group reservations, you will receive a confirmation within five business days. 9. No refunds on room deposits will be given after April 6, 2012.

Credit card number Exp. date

Signature Print name as it appears on card

IMPORTANT – PLEASE READ: If you do not receive a confirmation within five days, please call for assistance. Please note duplicate/double booking of reservation will result in “No show” charges on your credit card. Deposit policy: Reservations will only be accepted with a credit card or check payment. All credit cards will be charged a one-night room and tax deposit at the time of reservation. Reservations and changes are subject to hotel availability. Cancellation policy: All cancellations must be made in writing through the CDA Housing Bureau. Reservations must be canceled before 5 p.m. Pacific Time on Friday, March 9, 2012, to receive a full refund. Reservations canceled after March 9, but before 5 p.m. Pacific Time on Friday, April 6, 2012, will be charged a $35 processing fee per room. No refunds on room deposits will be given after April 6, 2012. Registration Information

• Extended online registration will be available starting Three Ways to Register March 2, 2012. (Faxed and mailed registrations will not be accepted after March 1, 2012.) If you register online during Online: cdapresents.com this extended period, obtain your materials at Email Express (Best option) Receive immediate confirmation Pick-Up at the Anaheim Convention Center beginning at 6:30 a.m. on Thursday, May 3, 2012. Fax: 877.714.3184 • If you register an employee who is no longer attending, bring the badge of the person not attending to exchange Mail: CDA Presents on-site for a new badge at no charge. 1201 K St., 16th Floor Sacramento, CA 95814 • To ensure a seat for every ticket holder, courses will not be oversold. Registration Information • Refunds will be given if requested in writing and badges • Register at cdapresents.com to secure an immediate spot in and tickets are returned by March 28, 2012. your preferred workshop, required course or special event • CDA will process and mail your registration materials based on availability. A confirmation email will be sent at least two weeks prior to the meeting. If you do not upon completion of your registration. receive your materials within this time frame, please • Registration forms that are faxed or mailed to CDA will call CDA at 800.232.7645. If you have corrections, be processed in the order received and do not guarantee additions or changes, please notify CDA in writing an immediate spot in workshops or special events. Phone before March 28, 2012. registrations cannot be accepted. • CDA member dentists will be registered at no charge. • Dentists may register staff and guests, but not other dentists. Dentists may not register under any category except dentist, and nonmembers must be identified. Membership dues must be paid for the current year to register as a member. • Special $75 registration fee for California nonmembers: Nonmembers can save $815 on registration by taking advantage of a special $75 one-time meeting registration fee. If you are already a member, tell your nonmember colleagues about this limited offer. Materials for this category will not be mailed in advance, but will be available on-site at the membership counter. If you have already taken advantage of this special rate at either CDA Presents meeting, your fee will be the standard nonmember rate. If you had a membership in 2011, you are not eligible for the nonmember $75 one-time registration fee for 2012. • Register by March 1, 2012, to have your materials mailed to you in advance. (Note: Badge mailing will begin early March for registrations completed prior to this time.) This excludes the one-time nonmember reduced rate. Registration Categories and Fees

Dentist Registration Categories Abbreviation Registration Category Advance Reg. Fee On-Site Fee A CDA member dentist (2012 dues must be current) Free Free B ADA lifetime member Free Free C Out-of-state ADA member dentist $200 $225 D International dentist $200 $225 E Active military dentist (VA, federal, state dentist) $75 $100 F CA nonmember dentist (one-time rate) $75 $75 G CA nonmember dentist $800 $890 H Inactive dental license $250 $275 I Dental student/CDA member Free Free J Dental student/graduate non-CDA member $25 $50 Please Note: Dentists may register staff and guests, but not other dentists. Dentists may not register under any category except dentist, and nonmembers must be identified.

Allied Dental Health Professional Categories (ADHP) ADHP includes RDA, RDH, RDA(EF), RDH(EF), RDHAP, DA, business administrative staff (AS), and dental laboratory technician (LT). Include license number and type on form when registering.

Abbreviation Registration Category Advance Reg. Fee On-Site Fee K ADHP CDA member* (2012 dues must be current) Free Free L ADHP Non-CDA member registering with a dentist $5 $25 M ADHP Non-CDA member registering without a dentist $20 $25 N Guest of ADHP $20 $25 *An ADHP member is a dental professional who is not a dentist but has an independent, paid 2012 membership with CDA.

Other Registration Categories

Abbreviation Registration Category Advance Reg. Fee On-Site Fee O Non-exhibiting dental dealer, manufacturer, consultant $150 $175 P Non-dental professional (MD, DVM, RN etc.) $150 $175 Q Guest of dentist (includes ADHP nonmember) $5 $25

Saturday Exhibits-Only Pass Nonmember dentists who want to explore the exhibit hall can register on-site for a one-day pass on Saturday, May 5. The cost is $175 and is for Saturday exhibit hall hours only. It is not valid for continuing education courses. To register, please visit the membership counter during on-site registration hours on Saturday, May 5. Then experience all that the CDA Presents exhibit hall has to offer. Registration Categories and Fees $30 $1,695 $199 $12 $12 $12 $10 $65 Fee $155 $155 $595 $295 $195 $195 $125 $125 $45 $50 $50 $95 $95 $225 $225 $595 $150 $150 $545 $545 $250 $250 $195 $195 $50 Friday Saturday Saturday Thursday Friday Saturday N/A Friday Day/a.m./p.m. a.m. p.m. Full day p.m. a.m. p.m. a.m. p.m. a.m. a.m. p.m. a.m. p.m. a.m. p.m. Full day a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. 2 056 057 058 059 060 061 062 055 Course # 031 032 033 034 035 036 037 038 041 761 762 042 043 044 045 046 047 048 049 050 051 052 053 054 763 Speaker Guichet Hempton Little Padilla Coluzzi Industry speakers Jansen/Weiss A. Cardozo/K. Cardoza Graeber Hempton Miles Paxton Sorenson TBD Jansen/Weiss Resort tickets, visit cdapresents.com ® ® Invisalign Clear Essentials I Invisalign Clear Essentials II (Thurs. only) Pre-Paid Parking Voucher (Fri. only) Pre-Paid Parking Voucher (Sat. only) Pre-Paid Parking Voucher Pre-Paid Food Voucher purchase Disneyland To Wine Seminar Friday Workshops, May 4 (continued) Friday Workshops, Technology Crown Lengthening Implants Sports Dentistry Lasers Practice Opportunities TDIC Risk Management Courses Saturday Workshops, May 5 Saturday Workshops, Laser – RDH Lasers Crown Lengthening Cone Beam Oral Surgery Esthetics Pediatric TDIC Risk Management Course Special Events Night at Disney CDA’s Advance Registration Deadline: March 1, 20 1 Fee $20 $20 $20 $20 $20 $20 $50 $75 $140 $250 $250 $295 $295 $295 $185 $185 $125 $125 $50 $50 $350 $350 $375 $375 $250 $250 $475 $75 $75 $205 Day/a.m./p.m. Thursday Thursday Friday Friday Saturday Saturday a.m. a.m. p.m. a.m. p.m. a.m. p.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. Full day Full day Full day Full day Course # 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 759 760 021 022 023 024 025 026 027 028 029 030 Speaker Robin Robin Simon Curley Simon Curley Andrews Gunn Gunn Gunn Koerner Kugel Little Yaeger Sr./Yaeger Jr. Sr./Yaeger Yaeger Coluzzi Jansen/Weiss Brave/Koch Brady Clark Clark Clark Industry Speakers Industry Speakers Dunn The Art and Science of Dentistry RESENT S P Required Courses California Dental Practice Act Infection Control California Dental Practice Act Infection Control California Dental Practice Act Infection Control Thursday Workshops, May 3 Thursday Workshops, Embezzlement (dentist) Embezzlement(dentist & spouse) QuickBooks Oral Surgery Esthetics – Veneers Implants Equipment Repair Lasers TDIC Risk Management Courses Friday Workshops, May 4 Friday Workshops, Endodontics Provisionals – Anterior Composites Composites – Anterior Composites a.m. & p.m. combined Practice Transition Track (junior dentist) Track Practice Transition Practice Transition Track (senior dentist) Track Practice Transition Photography Photocopy for additional registrants. Only one dentist per form.

Primary Registrant (Print or Type) Membership dues must be paid for the current year. Advance registration deadline is March 1, 2012. Register today!

Name Online: Register at cdapresents.com (secures an immediate seat in a workshop or special event) Fax: Register by fax at 877.714.3184 License # ADA # Mail: Register by mail at CDA Presents, 1201 K St., 16th Floor, Sacramento, CA 95814 Mailing Address To ensure that proper C.E. credits are granted, licensed dental professionals must include their license number and formal name as listed with the Dental City State Zip Board of California. Please complete all areas of this form legibly. Be sure to include titles and badge categories. Registrations are processed in the order they are received. ■ Home ■ Office ■ Other ■ Check here if new address • • If your registration is received by the deadline, you will receive your order at least two weeks prior to the meeting. Telephone Fax ( ) ( ) • Mailing will begin early March. E-mail Address • Refund requests for ticketed programs must be made in writing and materials returned to CDA no later than March 28, 2012. CDA member dentists will receive complimentary registration. All staff/guests registering with a ■ I require special assistance ■ I do not wish to receive promotional materials for this meeting. dentist are $5 per person. Dentists must register separately. Primary Registrant (Print or type only primary registrant’s name only.) Registration Information Workshops and Required Courses Total Fees Last Name Formal First Name and Middle Initial Category Letter License # Title Fee $ Course # Fee $ Course # Fee $ Course # Fee $ Fee $

Staff/Guests Badges (Dentist cannot be registered as guests/staff.) Registration Information Workshops and Required Courses Total Fees Last Name Formal First Name and Middle Initial Category Letter License # Title Fee $ Course # Fee $ Course # Fee $ Course # Fee $ Fee $ 1. 2. 3. 4. 5. 6. 7. Special Event Tickets Total Fees Event # Fee $ X Quantity of Tickets = Fee $ This area is for the purchase of membership party and special event tickets. Please indicate the total number of tickets per event you wish to purchase in the X = adjacent area. Use the above area to purchase registrant-specific workshop tickets. X =

Method of Payment Grand Total

■ Check or Money Order (Payable to California Dental Association) Credit Card # Exp. Date

■ American Express ■ MasterCard ■ Visa Signature (Your signature will indicate approval for charges to your account.) $ ______Questions? Printed Name Visit cdapresents.com or call 800.232.7645 (Please print name as it appears on card.) introduction

cda journal, vol 40, nº 2

Dental Sleep Medicine michael s. simmons, dmd

Sleep is taken for granted in much of our society; and cheating sleep is considered glorious, as there is more time for personal growth and enjoyment of the pleasures in our lives. The truth is you cannot cheat sleep, just as you cannot cheat death. Without sleep, we cannot function; and poor sleep can lead to serious consequences.

guest editor As dentists, we have been focused to severe sleep apnea. Sleep-disordered

Michael S. Simmons, dmd, on the teeth and surrounding peri- breathing is an enormous unmet health is a diplomate ABOFP, odontium, oral health, esthetics, and care problem, with many medical illness FAGD, lecturer at the function. Dental professionals have a associations, that could benefit from the University of California, tendency to look in the mouth and stop involvement of the dental profession. Los Angeles, a clinical at the distal enamel or retromolar pads. Topics addressed in this Journal include: assistant professor at the n University of Southern Medical professionals, on the other Medical associations and conse- California, serves on the hand, tend to look right past the teeth quences of sleep-disordered breathing, Board of AADSM and and peer at the pharyngeal areas and by Daniel Norman, MD; Paul B. Haber- ASAA, and is engaged beyond, if they choose to look at all. man, MD; and Edwin M. Valladares, MS; in furthering dentistry’s This issue of the Journal of the Califor- n A variety of health care viewpoints involvement in sleep medicine. nia Dental Association speaks to one of the in addressing sleep-disordered breath- clear overlapping areas between dentistry ing with multidisciplinary approaches and medicine. Dentistry and medicine are and suggested treatment algorithms, by no more separate than the head is to the this author and multiple other authors; whole body. The dental/medical overlap n The neurology of sleep-disordered addressed here is sleep medicine, and, breathing and relationship to brux- in particular, sleep-disordered breath- ism, by Jerald H. Simmons, MD; and ing, a topic that ranges from snoring n Past, present, and future use of oral

february 2012 127 introduction

cda journal, vol 40, nº 2

appliance therapy in sleep-disordered cal point where there is enough inter- sore throat, he said, “I know you are just breathing, by Robert R. Rogers, DMD. est in the dental community, scientific a dentist and don’t really know anything, Somnology is a young field. The first proof of effective treatments, and overall but would you take a look at my sore U.S. medical sleep society was created in general awareness to recognize that throat?” So, I took a look and found the the 1970s. Dentistry engaged in research- dentists are important collaborators in cause of his complaint, a rather large ing oral appliance therapy for sleep- addressing specific sleep disorders. ulceration in the left pharyx ngeal pillar. disordered breathing in the early 1980s, Collaboration speaks to the question The real eye-opener, however, was and pioneers of dental sleep medicine of how many health professionals are something else: the unmistakable kiss- are still actively engaged in this topic. really looking at the upper airway and taking tonsils. How could I have missed Over recent years our own California ing note of its dimensions? Who routinely them all these years? Perhaps this also Dental Association’s House of Delegates checks tongue dimensions, tonicity and explained why he occasionally slept has debated resolutions addressing the resting position, mandibular and maxil- with his mouth open and head hyper- dentist’s involvement in specific sleep lary arch forms and their relationships, extended. More importantly, who else disorders. This culminated in November tonsil size, soft palate extension, pha- missed this airway blockage and why? 2011 with the passage of resolution 25RC ryngeal walls, neck circumference, nasal We are talking about yearly physicals proposed by CDA’s Policy Development patency, and the length of the uvula? by different physicians and many other Council. WeCDA havead Feb now 2012.pdf reached 1 a criti1/23/12- 1:18When PM my oldest son complained of a visits to medical specialists to address a myriad of medical issues in growing up. Maintaining the upper airway is tan- tamount to survival. When one is awake, the upper airway is maintained by muscle tonicity. During sleep, especially during REM muscle paralysis sleep, tonicity is reduced. Our tongues may also drop back during sleep, further reducing our YOUR DENTAL SLEEP MEDICINE PRACTICE air flow. As dentists, we have significant WILL REACH NEW HEIGHTS IN 2012 experience in addressing airway issues and we manage the tongue and airway C 85% to 90% of individuals with sleep apnea remain undiagnosed, untreated, and dimension well. However, dentistry as unrecognized by the medical profession. Many of those treated with CPAP cannot M a health care field must be increasingly tolerate the device. Most do not know that dentists have a solution. Promoting Y recognized as a major player in the area your dental sleep medicine practice directly to those who snore, undiagnosed of identifying and treating specific sleep CM sleep apneics and those who cannot tolerate CPAP must be part of any disorders that involve the airway. This is MY successful marketing strategy. an opportunity for dentistry to make a CY BUT ONLY IF PEOPLE KNOW YOU EXIST! huge impact on society in a meaningful CMY and beneficial way. We already look into

K the oral cavity, so we are poised precisely MARKETING EXCLUSIVELY FOR THE DENTAL SLEEP MEDICINE PRACTICE to be main “gatekeepers” of upper airway Learn more at www.snoringisntsexy.com/doctorsonly encroachment issues. We simply have to look with more intent and request answers to a few pointed questions Call or e-mail today! about sleep. By including this routine in our initial and update examinations, 888.203.0488 we become team players in the medical [email protected] field of sleep, and we contribute to the http://www.snoringisntsexy.com overall health of society and the specific health needs of our patients.

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cda journal, vol 40, nº 2

Somnology 101: A Primer on Sleep Disorders, Their Impact on Society, and a Role for Dentistry

michael s. simmons, dmd

abstract Sleep is necessary for our existence. It is one-third of a commitment to health along with nutrition and exercise. While we spend one-third of our lives asleep, studies show one-third of the U.S. population suffers with a significant sleep disorder at some point in their lifetime. This manuscript introduces sleep and sleep disorders, focuses on those sleep disorders within the domain of dentistry, and addresses contributions the dental community can make toward specific sleep problems.

author leep is not optional, at least if animals such as bottlenose dolphins have

Michael S. Simmons, peak performance is desired, adapted to deep or slow brain wave sleep DMD, is a diplomate quality health is aspired, and (SWS) with half a brain and do not have ABOFP, FAGD, lecturer optimum life expectancy is to REM (rapid-eye movement, dream, or at the University of be achieved. However, stud- paradoxical) sleep.4 Studies show humans California, Los Angeles, ies show lack of professional education require about seven hours of sleep for a clinical assistant S professor at the University with U.S. medical schools devoting the longest potential survival, although of Southern California, only about two hours total education extended average sleep time in “long serves on the Board of in their four-year MD programs to sleepers” of ≥10 hours/day suprisingly AADSM and ASAA, and all sleep-related topics.1 Additionally, increases all cause mortality more signifi- is engaged in furthering only about 2 percent of content in our cantly than the “short sleeper” group with dentistry’s involvement in 5 sleep medicine. standard medical textbooks relates to <5 hours/day. Sleep demands change dur- somnology.2 Normal sleep is defined as ing our lifetimes and while infants sleep “The cyclic, temporary, and physiologic up to 18 hours per day with 50 percent loss of consciousness that is readily, devoted to REM, as we age, the SWS, promptly, and completely reversed REM, and total sleep time (TST) often with appropriate stimuli.” All animals progressively decrease and become more require sleep, starting with the much- disrupted. Why we sleep is still unknown, studied fruit fly, drosophila melano- although many theories abound and in- gaster, used in elucidating molecular clude common sense avoidance of danger mechanisms and functions of sleep.3 in the dark, such as predators or unseen Sleep requirements range according obstacles, like cliffs or crevices underfoot. to species and survival demands. Some More recent scientific evidence showed

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table 1

N1 Classification of Sleep Disorders (Refer to Table 2 for Abbreviations) 2–5% Diagnosis ICSD–2 Categories Prevalence Common Presentation

REM I. Insomnia Sleep onset, sleep 25% Sleepy, irritable 20–25% maintenance, early waking

N2 II. SRBD OSA(S), CSA hyperven- M 24% (4%) Sleepy, irritable, N3 45–55% Sleep-related tilation/hypoxemia F 9% (2%) BMI≥30 M age 35+ 10–23% breathing disorders CSA unknown and postmeno- pausal F

III. Hypersomnias Narcolepsy +/– cata- 0.05% Sudden REM sleep plexy, idiopathic, recur- onset +/- muscle rent, due to medical weakness condition or meds, etc. figure 1. Sleep stage proportion in young adults. IV. Circadian Delayed (or advanced) 11% (1%) Altered time pat- rhythm sleep phase shift, jetlag, tern of sleep; work- the release of growth hormones during disorder shift work type, due related; teenagers SWS improved learning and memory to meds, etc. consolidation with sleep and that sleep V. Parasomnias Sleep-related walking, 17% children Disorders of is essential for immune homeostasis.6-8 eating, groaning, 4% adults arousal from sleep Theories of repair, regeneration, and enuresis, paralysis, RBD 0.8% in NREM and REM recharging are all reasonable but hard to terrors. RBD, confu- sional arousals, due to prove. Rat studies show ill effects of sleep drugs or medical deprivation such as ragged appearance, conditions, etc. increased food intake with weight loss, VI. SRMD RLS, PLMS, rhythmic 10% adults RLS -Need to move poor homeostasis, and the likelihood of Sleep-related movement, leg cramps, 2% children limbs. PLMS limb death within two to three weeks with movement bruxism Bruxism 8% adults movements in sleep 9,10 total sleep deprivation. Even partial disorders children 16% sleep loss and disrupted circadian sleep VII. Isolated symp- Snoring, long/short Snoring Intermittent snoring cycles in humans with development of toms and normal sleeper, sleep talking, M 40% F 24% caused by alcohol, sleep debt results in reduced neurobehav- variants myoclonus 10% children fatigue, allergic ioral function and contributes to many rhinitis, supine daily transportation-type crashes, job position, etc. injuries, and even catastrophic accidents VIII. Other sleep Sleep disorders not Undefined Noisy or moving such as those that occurred at Three Mile disorders classifiable elsewhere, bed partner. Noisy Island, Chernobyl, Bhopal, and the Alas- environmental noise, etc. surroundings kan grounding of the Exxon Valdez.11,12 Sleep is divided into non-REM (NREM) and REM states. Each state has different but characteristic brain wave Each night’s sleep is not homogeneous Sleep Disorders, Epidemiology and patterns. The awake and REM brain wave but a cycling up and down through sleep Their Impact on Society patterns are very similar in both ampli- levels and typically a healthy adult will The 2003 National Heart Lung and tude and frequency consistent with the experience about four to six 90-minute Blood Institute report conservatively notion that the brain is very active during sleep cycles interspersed with increas- estimated that 50-70 million in the United REM sleep. NREM sleep ranges between ing periods of REM dream sleep. NREM States are chronically affected by sleep the lightest stage N1 to the deepest SWS sleep may also include dreams but they disorders, and the 2006 landmark report N3 sleep. Early on in the daily sleep cycle lack the depth of storyline and if woken by the Institute of Medicine validated there is more SWS implying its relative and questioned, subjects recall few details that sleep disorders and sleep deprivation importance, and following sleep depriva- compared to the subject woken to recall remain an enormous unmet public health tion, there is often SWS rebound recovery. their dream during REM sleep (figure 1). problem.13,14 Sleep deprivation costs the

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table 2 table 1

Dangers of Drowsy Driving

Important Aspects of Drowsy Driving (DD) Reference#

57% of MVC with truck driver death attributed to fatigue/sleepiness 57

110,00 injuries, 5,000 fatalities/yr DD involve commercial trucks 58 grinding have been debated as to cause 16-29 y.o. drivers are most likely age group to have fall asleep MVC 59 and relationship to the occlusion and psychophysiologic status of the individual. Sleep-deprived adults drive as poorly as alcohol-challenged 60 While SB is noted to be more prevalent in 10% of drivers report nodding off while driving ≥1-2 days/month 35 children affecting almost 20 percent under age 11, SB continues in many adults with 60% drivers self-report drowsy driving 61 an overall incidence averaging 8 percent 27,28 41% drivers report fallen asleep at the wheel at some point in their lives 62 but reducing to 3 percent at age 60. SB may be primary/idiopathic or secondarily 20% MVC attributable to drowsy driving 63 caused by a myriad of medical/ psychiatric 20% of all serious MVC associated with driver sleepiness 64 conditions, and/or in response to medications. It can be subdivided into tonic OSA w/AHI ≥10 have odds ratio for MVC of 6.3 times normals 65 or rhythmic masticatory muscle activity (RMMA). Tonic activity could be viewed as clenching or abnormal jaw posturing U.S. economy an estimated $40 billion 39 percent to 58 percent of patients with whereas RMMA would be reflected in annually in lost productivity and, across OSA report insomnia symptoms, and 29 complex movements such as newborn numerous settings, accidents attributable percent to 67 percent of patients with in- infants suckling or tooth grinding. to sleepiness are estimated at $43 billion somnia have OSA.20 Startling statistics on SB is now being investigated in its to $56 billion in 1988 dollars.15,16 The esti- sleep disorders include >20 percent of the relationship to sleep patterns and some mated annual medical cost alone for un- 146 million U.S. labor force performs some interesting associations are found. SB treated obstructive sleep apnea (OSA), a sort of shift work, many never adapt, and occurs mainly in stage 1-2 sleep, 10-25 subcategory of sleep-related breathing dis- about 10 percent of these develop shift percent in REM sleep with its associated orders (SRBD), in 1999 was $3.4 billion.17 work disorder (SWD) with its attendant skeletal muscle paralysis/atonia but rarely There currently are about 100 dif- risk increases in breast cancer, duodenal occurs in deep sleep.29 In a sample popula- ferent sleep disorders classified into ulcers, cardiovascular morbidity and mor- tion of bruxers, 74 percent of RMMA eight categories by the International tality.21-26 Therefore, it is prudent for those and swallowing events were scored in the Classification of Sleep Disorders -Ver- health care providers involved in treating supine position compared to 23 percent in sion 2 (ICSD-2)18 (tables 1 and 2). one common sleep problem to have more the lateral decubitus position.30 SB occurs Some of the most fascinating sleep than superficial knowledge of the others. subsequent to alpha (awakening) EEG disorders are parasomnias such as brain activity and 60-80 percent of SB sleepwalking, sleep eating, sleep terrors, Dentistry’s Connection to Somnology episodes are associated with leg muscle exploding head syndrome, and REM The two main associations between activity.31,32 This suggests that bruxism and behavior disorder (RBD) where sub- the fields of dentistry and somnology other motor activity are connected to the jects physically act out dream content. occur with movement and breathing dis- arousal mechanism from sleep. One study However, it is the more common sleep orders. SRMDs are a group ranging from concluded that the primary treatment for disorders that appear to earn less than sleep-related leg cramps to periodic limb- bruxism, an occlusal splint, is associated their deserved time and attention.19 The movement disorder, restless leg syndrome, with risk of aggravation of SRBD as the four most common ICSD-2 sleep dis- and also include sleep bruxism (SB). apnea hypopnea index (AHI) increased orders account for the vast majority of Dentistry has long held the connection to > 50 percent in half the subjects tested.33 all sleep disorders and are from most to sleep via oromotor activity witnessed of- While SRMDs are important and a great least prevalent: insomnia, SRBD, sleep- ten as tooth gnashing sounds during sleep deal more information is available else- related movement disorders (SRMD) and and noted by parents and bed partners. where, this manuscript focuses primar- circadian rhythm sleep disorders (CRSD). For many years these oral parafunctional ily on sleep-disordered breathing (SDB) Some sleep problems have signifi- habits, which include clenching, grimacing, as an area where the dental community cant overlap with others. For example cheek biting, tongue activity, and tooth has the potential for greater impact.

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No (never) snoring q responsive snoring (alcohol, common cold, allergic rhinitis, exhaustion, etc.) q infrequent (occasional) snoring q positional snoring q habitual (≤ 3 wk) snoring q chronic daily snoring q loud chronic daily snoring q snoring with breathing pauses q snoring with EDS SDB is frequently considered synony- (UARS) mild OSA mild OSAS mild OSA w/medical associations mous with SRBD but they are important q q q moderate OSA severe OSA mixed OSA central sleep apnea to distinguish. SDB is a more global q q q q term that includes SRBD, upper airway resistance syndrome (UARS), and snoring, figure 2. Potential snoring progression. making SDB the most prevalent sleep disorder group. Snoring is classified in the ICSD-2 under the heading “isolated are not well-dissected and certainly Hungary on 12,643 subjects found 60 symptoms and normal variants,” whereas not identical, this ICSD-2 category of percent prevalence of PS. This study UARS is not specifically classified due isolated symptoms and normal vari- revealed increasing incidence of CV dis- to the ongoing question in the medical ants appears of less interest to medi- ease, EDS, motor vehicle crashes (MVC) community as to its existence. UARS was cal somnologists and they are content and workplace accidents occurring from first described in 1993 to help explain to defer its management elsewhere. nonsnorers, through habitual snor- unrestful disrupted sleep believed to Epidemiologic studies, however, point ers, and, most of all, in loud snorers.48 be caused by respiratory effort-related to about 50 percent of habitual snorers as Another recent study showed intensity/ arousals (RERAs).34 Both UAR(S) and having OSA. This 50 percent figure results loudness of snoring increased in a dose- OSA(S) are termed (S)yndromes when from juxtapositioning Lugaresi’s epide- dependent fashion with the increased they include symptomatic sleepiness miologic snoring data that shows approxi- OSA severity and another study found often referred to as excessive daytime mately 40 percent males and 20 percent human carotid atherosclerosis increased somnolence (EDS). Terms “sleepiness” females aged 30-60 chronically snore with in a dose-dependent fashion with snor- or “drowsiness” while similar, should be Young’s seminal work on the same age ing severity independent of the severity distinguished from tiredness or fatigue, group showing approximately 24 per- of OSA.49,50 Carotid atherosclerosis was which are not readily reversible by sleep. cent males and 9 percent females having not matched by femoral artery athero- OSA.36,37 This is consistent with Young’s sclerosis and the authors hypothesized Snoring additional data showing snoring affecting that transmitted snoring vibrations led “Laugh and the world laughs with 40 percent males and 24 percent females. to the nearby carotid vascular endo- you, snore and you sleep alone,” coined The prevalence of snoring increases thelial damage and atherogenesis. by British composer and novelist with age peaking at 65-70 years old. Clearly all snoring is not benign but Anthony Burgess (1917-1993) has never While the ICSD-2 snoring category clarity on which type(s) of snoring should be been more apparent. Increased societal includes the term “benign,” there are a addressed remains to be determined. This snoring manifests in the reported 23 number of studies indicating snorers is an important issue for dentists treating percent of bed partners now sleeping have increased medical comorbidities PS without medical collaboration especially separately.35 Snoring is attributed to the as compared to nonsnorers including since snoring typically worsens over time. vibration of soft tissues that may arise neurocognitive deficits, stroke, demen- While it is a significant burden on the from discrete areas of the nose down tia, cardiovascular (CV) conditions, medical health system for dentists to repeat- to the epiglottis. Diagnostic criteria myocardial infarct, as well as increased edly refer the snoring patient for medical includes a recognizable snoring noise, mortality rates.38-43 Snoring in children consult, and physicians typically do not wish without specific decibel, waveform or has been associated with increased to manage benign snoring, it is challenging frequency attributes, that is not associ- blood pressure in 6- to 13-year-olds for the dental team to determine when to ated with airflow limitation, arousal and neurobehavioral changes in 5- to refer. Only a sleep study interpreted ide- from sleep, oxygen desaturation, or 7-year-olds suggesting it takes little ally by a medical sleep specialist (MSS) in dysrhythmia. ICSD-2 snoring terms time to develop comorbidities.44-46 The conjunction with a medical exam can rule in include benign, simple, habitual snoring dose-dependent nature of snoring and or out benign snoring. Increased associ- (HS), primary snoring (PS), continu- medical comorbidities has been shown ated medical comorbidities such as CV or ous, rhythmic, nonapneic and snoring in large population studies.47 A recent metabolic disorders should however serve without sleep apnea. While these terms door-to-door survey taken by nurses in as red flags for physician referral (figure 2).

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sleeping

A Muscle tone How many micro- Snoring breathing lapses in excess of a minute, A Airway patency arousals does it take G Muscle tone that are quite perplexing to an observer. Resaturation per hour of TST before upper airway collapse Not all microarousals are attributed to you experience EDS? Desaturation obstructed breathing. Other causes may include SRMD activity or an extrinsic event like an infant briefly crying. Apneas, defined as breathing cessation Arousal (>70 percent reduction of airflow) of from sleep ≥10 seconds duration, are tabulated and averaged per hour as the apnea index (AI). Hypopneas, or reduced breathing, are defined by ICSD-2 as a sudden figure 3. Relationship between sleep-disordered breathing and excessive daytime somnolence. decrease in SaO2 by >4 percent along with >30 percent diminished airflow or amplitude of thoracoabdominal Historical to Current Approaches be considered the primary alternative movement, often in conjunction with in Dentistry treatment to continuous positive airway an arousal. Combined, the apneas and The historical connection of dentistry pressure (CPAP) for managing OSA hypopneas are averaged per hour over to SDB was first published in 1923 by when provided by trained dentists.54,55 the TST becoming the AHI. An AHI of Pierre Robin, a French stomatologist, While CPAP is more universally ef- less than 5 is normal, ≥5<15 mild, ≥15<30 who noted micrognathia and glossoptosis fective when consistently used, OAT moderate, and ≥30 is severe OSA. problems often included upper airway enjoys more patient compliance and in The respiratory disturbance index obstruction and U-shaped cleft palate.51 crossover trials where subjects choose (RDI), is another common measure Treatment options included suturing CPAP or OAT after using both therapies, which adds RERAs to the AHIs and may the tongue forward to the lower lip, and OAT was preferred.56 Patient treatment reflect more sleep disruptions. Some promoting survival by opening the airway preference of OAT, along with proof patients are more resistant to the ravages that was otherwise obtunded. While of OAT effectiveness, has supported of disrupted sleep and therefore a high Robin also proposed the first intraoral dentistry’s increased interest in treating index may not reflect pathology. Sleep appliance a “monobloc” in 1902 for the SDB. Additionally, the proven effective- indexes are also typically higher when retrognathia, it was not until 1982 that a ness of telegnathic surgical approaches limited to time periods spent supine or peer-reviewed publication first validated to anteriorize tongue position by during REM sleep with its attendant use of oral appliances in enabling airway maxillofacial surgeons as a “cure-” type muscle atonia. Outcomes of sleep stud- patency during sleep.52 Dentistry has since therapy has further engaged dentistry in ies therefore depend on the amount engaged in proving the positive impact treating SDB conditions. While orth- of REM sleep, recent events such as on the sleeper’s airway of moving the odontic approaches to increasing the sleep deprivation, alcohol or medication mandible and/or tongue both surgically, airway are a reasonable consideration, intake, body position, level of sleepiness, via oral appliance therapy (OAT) and validated long-term research is lacking. depression, cardiac issues, and many through orthodontic arch development. other factors. Indexes can reflect differ- The American Academy of Sleep Understanding Measures of SDB ences with the first night of a multinight Medicine (AASM) took note of den- Sleep studies reflect defined sleep study or in a split night study where a tists’ contribution in managing SDB in disruption events such as where breath- portion of the study is devoted to testing their 1995 position paper on OAT.53 In ing difficulties may cause microarousals an intervention such as CPAP or OAT.

2006, the AASM published an updated from sleep and/or desaturations (SaO2) It is therefore important for a MSS to position paper based upon in-depth of oxygen in the blood stream. Events interpret sleep study findings in context review, acknowledging that OAT could may include prolonged apneas, or of a medical and sleep history (figure 3).

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table 3 table 1

Brief Comparison of Drunk and Drowsy Driving

Drunk Driving Drowsy Driving .05 – .08 BAC N0 standard measure

Understanding the Effects of Poor Compromised judgment Little ➝ No judgment Sleep From SDB Delayed reaction time Delayed ➝ No reaction time

There are many medical associations Poor avoidance strategy Little➝ No avoidance strategy seen with SDB sleep, which are addressed in another paper in this journal. Social Variable severity crashes Highest severity crashes consequences of SDB may range from 15,000 deaths/year 1,500 deaths/year? (x5-10) sleeping alone to national catastrophes. Serious legal consequences No? Legal consequences However, work accidents and transportation crashes may be preventable with Ubiquitous education No➝ minimal education appropriate dissemination of information MADD since 1981 DADD ? Since 2008 about the importance of restful sleep. AADSM promotes Dentists Against Drowsy Driving (DADD). For example the National Traffic and Highway Safety Association (NHTSA) estimates that drowsy driving is the cause of 100,000 motor vehicle crashes (MVCs) precise measure for drowsiness to be used U.S. dentists routinely treating SDB for the and 1,500 fatalities every year. However, by law enforcement at such crashes, and, to conservatively 40 million affected; there is this is probably a gross underestimate as further complicate matters, the combina- a need for more treating dentists. This is it accounts for only about 2-3 percent of tion of a little alcohol with drowsiness is a rewarding field for those committed to all MVCs. Other developed countries aver- dramatically worse than either individually. providing excellent care but the journey age about 20 percent of all MVCs attribut- Focusing on reducing MVCs, two grass roots to expertise may take several years. able to drowsy driving (DD) and landmark campaigns developed in the early 1980s and Integration of sleep disorders into a studies, such as the 2005 Virginia Tech expanded over time with national to global dental practice can be done stepwise and Transportation Institute ground-breaking impact. These include Mothers Against could begin by including: 1) subjective 100-car naturalistic study, confirm the Drunk Driving (MADD) and Students information through a few screening ques- 20 percent attribution of all MVCs to Against Destructive Decisions (SADD). tions verbally or added to health history drowsiness. A few important facts on Both campaigns changed the attitudes of forms. The questions are simple such drowsy driving are listed in table 3. society resulting in improved road safety. as “Do you snore frequently or loudly?” Subjects driving after 24 hours awake Dentists now have started a small mea- “Do you have pauses in breathing dur- display equally poor reaction time and sure in this direction and, while proposed ing sleep?” and “Do you have daytime judgment to driving with a blood-alcohol by the AADSM, the concept of Dentists sleepiness?” Bed partners often give more count of 1.0 ppm, which is above the Against Drowsy Driving (DADD) is in its accurate answers and, if complaints of legal limit of .08 percent blood-alcohol infancy and has yet to realize its potential. the snoring noises preceded moving to content in all U.S. states. New Jersey another room, it may give some useful passed General Assembly Bill 74-4, known Approaches by the Dental Community insights. For the dental office wanting to as Maggie’s Law, on Aug. 5, 2003, as a to the Patient With SDB include more detailed screening, there are result of, and six years following, the Two main approaches to the SDB many validated sleep questionnaires, some untimely death of Maggie McDonnell. patient by the dental field relate to screen- shown in table 4. 2) Objective morphomet- She was a 20-year-old driver killed by a ing and co-treatment with physician ric information can be added as part of the drowsy driver awake for 30 hours. Due colleagues. While all dental offices would oral cancer exam. Data to consider collect- to lack of drowsy driving laws at that ideally screen for SDB as with high blood ing at the time of screening include neck time, the drowsy driver received the pressure and oral cancer, SDB treatment circumference, modified Mallampati or same minimal penalty as if he hit a tree. requires medical collaboration. Those Friedman scoring of upper airway patency, Essentially, Maggie’s Law made choos- interested in somnology must invest the and documenting if the uvula, tonsils, ing to drive when drowsy the same reckless time and effort in developing the neces- tongue, pharyngeal tissues or soft palate behavior as choosing to drive drunk. sary expertise. Given >2,500 AADSM crowd the airway. If considering treating Unfortunately, there still does not exist a members in 2011 among perhaps 5,000 SDB, a more in-depth history and exam

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table 4 table 1

Some Standardized Sleep Questionnaires

Questionnaire Number and Type of Questions Use or Advantage

Epworth (ESS) 8 subjective score 0-24 (≥10 = sleepy) Standard drowsiness survey

STOP 3 subj 1 objective score 0-4 (≥2) high risk Anesthesiology based – quick

STOP-bang 3 subj 5 objective score 0-8 (≥3) high risk Quick + high accuracy

ARES ESS + 18 subjective 2 objective Fits well with ARES Home Test

Apnea score “Kapuniai” 2 subjective – stops breathing + loud snoring V. Quick – minimal

Karolinska & Stanford Subjective 1 Range K(0-9 ) S (0-7) Research use scales - higher # = more sleepy

Pictorial For children

VAS Just about asleep -> As wide awake as can be Visual analogue scale I------10 cm line------I

Berlin 9 subjective 1 objective put into 3 categories Category scoring grid

Pittsburg quality index 19 subjective questions Quality of sleep previous month

Sleep 50 50 subjective Screens most sleep disorders is indicated prior to generating a medical Future Challenges effects of OAT in slowing the progression of report and collaborating with the patient’s 1) At this time, Medicare has refused SDB, and determining which populations physician. On average, a typical dental payment when dentists prescribe or ad- are most and least likely to benefit from office would note a frequency of signifi- minister sleep testing and other insurance OAT and other dental interventions. cant SDB of > 1 in 6 adult patients seen. companies may follow suit. This is not The dental team interested in treat- in the best interest of patients who may Conclusion ing SDB with OAT requires a differ- go undiagnosed until significant medical ent mindset and model to the typical comorbidities are present. Learn to Look and Look to Learn surgical-based dental practice. Other than 2) Sleep is a much overlooked aspect Dentists should incorporate active a potential cure from some telegnathic of health and requires more focused at- viewing of the mouth not only for decay surgical procedures such as the mandibu- tention by health professionals. Dentists and periodontal disease but also to rule lar and maxillary advancement (MMA) could actively engage their patients in out the life-threatening issues such as or possible preventive approaches with the topic of sleep, employ sleep health lesions and airway crowding. By visual- orthodontics, SDB patients are managed questionnaires, view the upper airway, izing the upper airway, the dental team rather than cured. This is most similar and ask questions to better help serve can learn about the patient’s potential to periodontal disease where contin- their patients health. difficulty with SDB. A few questions can ued diligence, monitoring, and ongoing 3) Dentists could investigate sleep open the conversation to further discov- care are indicated. Dental practitioners organizations and credible websites ery. It is only with such unified focus that must be prepared for higher failure rates (table 5), take an active role in societal dentistry can significantly impact our than experienced with routine dental aspects of sleep disorders and thereby epidemic of sleep disorders. It is there- procedures, and, until better prognostic contribute to greater public safety. fore incumbent on dentists as health information is available, the failure rate 4) Dentistry should encourage addi- care professionals, positioned as sentries for OSA single therapy with OAT may be tional research in the sleep field and the to the gateway of the upper airway, to as high as 70 percent with severe OSA. early manifestations of the SDB continu- keep a look out for potential problems. The success rate may, however, exceed 80 um. This would include dissecting out truly This is good for the patients we serve percent in milder presentations of SDB. benign from nonbenign snoring, validating and it promotes the field of dentistry

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table 5 table 1

A Few Sleep Organizations and Credible Web Sources of Information

aadsm.org American Academy of Dental Sleep Medicine. More than 2,500 members aasmnet.org American Academy of Sleep Medicine. More than 9,000 members population. Atherosclerosis 201(1):205-11, 2008. 27. Laberge L, Tremblay RE, et al, Development of parasom- nhlbi.nih.gov/about/nesdr The U.S. National Center on Sleep Disorders Research of nias from childhood to early adolescence. Pediatrics 106(1 the NIH. Coordinates government-supported sleep research pt 1):67-74, 2000. training and education to improve health 28. Lavigne GJ, Montplaisir JY, Restless legs syndrome and sleep bruxism: prevalence and association among Canadians. Sleep sleepapnea.org American Sleep Apnea Association. Dedicated to reducing (17):739-43, 1994.

29. Miyawaki S, Lavigne GJ, et al, Association between sleep injury, disability and death from sleep apnea through education, awareness, and research. Also promotes voluntary bruxism, swallowing-related laryngeal movement, and sleep support groups. positions. Sleep 26(4):461-5, 2003. 30. Kato T, Rompré P, et al, Sleep bruxism: an oromotor activity sleepfoundation.org The U.S. National Sleep Foundation –independent nonprofit secondary to micro-arousal. J Dent Res 80(10):1940-4, 2001. organization dedicated to improving public health and safety 31. Macaluso GM, Guerra P, et al, Sleep bruxism is a disorder by achieving understanding of sleep and sleep disorders. It related to periodic arousals during sleep. J Dent Res 77(4):565-73, supports education and sleep-related research and advocacy. 1998. 32. Gagnon Y, Mayer P, et al, Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: a pilot study. Int J Prosthodont 17(4):447-53, 2004. 33. Segal Y, Malhotra A, Pillar G, Upper airway length may be as- in a positive collaborative manner with 12. Mitler MM, Carskadon MA, et al, Catastrophes, sleep, and sociated with the severity of obstructive sleep apnea syndrome. other health providers. Dentists can public policy: consensus report. Sleep 11(1):100-9, 1988. Sleep Breath 12(4):311-6, 2008. 13. National Heart Lung Blood Institute 2003 report on National 34. Guilleminault C, Stoohs R, et al, A cause of excessive daytime make an enormous difference in society Sleep Disorders Research Plan. National Center on Sleep Dis- sleepiness. The upper airway resistance syndrome. Chest and serve the public in a meaningful orders Research. U.S. Dept of Health and Human Services NIH 104(3):781-7, 1993. way by catching SDB early on in the publication No. 03-5209, July 2003. www.nhlbi.nih.gov/health/ 35. National Sleep Foundation annual report Adult Sleep Habits prof/sleep/res_plan/sleep-rplan.pdf and Styles, 2005. sleepfoundation.org/article/sleep-america- continuum and co-treating with physi- 14. Colten HR, Altevogt BM, Committee on sleep medicine polls/2005-adult-sleep-habits-and-styles. Accessed Dec. 7, 2011. cian colleagues. We can save more than and research, sleep disorders and sleep deprivation: an 36. Lugaresi E, Cirignotta F, et al, Some epidemiological a tooth. We may even save a life. unmet public health problem. The National Academies Press, data on snoring and cardiocirculatory disturbances. Sleep Washington D.C., 2006. 3(3-4):221-4, 1980. 15. Stoller MK, The socioeconomics of insomnia: the materials 37. Young T, Palta M, et al, The occurrence of sleep-disordered references and methods. Eur Psychiatry 12, 41s-48s, 1997. breathing among middle-aged adults. N Engl J Med 328:1230-5, 1. Rosen R, Mahowald M, et al, The Taskforce 2000 survey 16. 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AAA Foundation for Traffic Safety Report -Asleep at the             Wheel. www.aaafoundation.org/pdf/2010DrowsyDriving Report. pdf, November 2010. Accessed Dec. 21, 2011.  63. The 100-car naturalistic driving study: a descriptive analysis   of light vehicle-heavy vehicle interactions from the light vehicles  driver’s perspective. U.S. Department of Transportation, Federal Motor Carrier Association 2005. fmcsa.dot.gov/facts-research/  research-technology/report/100-car-naturalistic-study/100-car-  naturalistic-study.pdf. Accessed Dec. 7, 2011.          64.Connor J, Norton R, et al, Driver sleepiness and risk of serious  injury to car occupants: population-based case conrol study. Br  Med J 324(7346):1125, 2002.             65. Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J, The association between sleep apnea and the risk of traffic  accidents. Cooperative group Burgos-Santander. N Engl J Med 340(11):847-51, 1999.   to request a printed copy of this article, please contact  Michael Simmons, DMD, Department of Oral Medicine and Orofacial Pain, University of California, Los Angeles, School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90024.

february 2012 139 Dentist Lawyer Broker Specializing In Dental Practice Sales, Transitions & Valuations

A. Lee Maddox, DDS, Esq. Kerri McCullough California offices in La Jolla, Los Angeles, Newport Beach and Walnut Creek We have been involved with more than 1000 dental practice transactions. Here are some of our current listings: $7,500,000 Implant Practice in Orange County, Southern California. $950,000 Pedo Practice in the Inland Empire, San Bernardino County, $275,000 Orthodontic Practice in Long Beach, Los Angeles County, This is a large, state-of-the-art practice with an in-house, full-service Southern California with six (6) dental chairs, five (5) open bay, one (1) Southern California with four (4) chairs, open bay, plus one (1) chair lab, private office, call center, and much more all located in a beautiful surgical suite, sterilization room, private office and great cash flow in a in consultation room, includes equipment, digital Pan/Ceph machine, professional building. mixed-use building. In Escrow. paperless office, private office in a Medical/Dental Building. Over 50 years of Goodwill. NEW LISTING – Dental Practice and condo, Santa Ana, Orange $150,000 Orthodontic Practice in Pico Rivera, Los Angeles County, County, Southern CA, with five (5) operatories, price to be determined - Southern California, with four (4) chairs, open bay, sterilization-lab combo, $430,000 Prosthodontic Practice in Walnut Creek, Contra Costa more information coming soon adjustment lab, reception area, business office/consultation room, and County, Northern California with three (3) operatories, fully equipped, two- $470,000 General Dentistry Practice in East San Diego County, private office in a professional building. desk laboratory, administrative office, and private office near a retirement Southern California with four (4) operatories, fully equipped, in a great community. Doctor retiring, 28 years in the same location. $300,000 General Dentistry Practice in Brea, Orange County, Southern retail center with digital x-rays. 33 Years of Goodwill. SOLD California, with four (4) operatories, includes equipment, sterilization $475,000 General Dentistry Practice in La Verne, Los Angeles County, $375,000 General Dentistry Practice in Irvine, Orange County, Southern room, private office in a shopping center near mall and freeway. Southern California with four (4) operatories, private office, staff lounge, California with five (5) operatories, three (3) fully equipped, two (2) plumbed, sterilization/lab combo, adjustment lab, x-ray room, dark room, reception $500,000 General Dentistry Practice in South Orange County, wired and medical-grade cabinetry and sinks. Beautiful, modern office in area in a retail center. Over 33 years of Goodwill. In Escrow. Southern California with four (4) operatories, fully equipped, sterilization- soothing neutral colors. lab combo, adjustment lab, staff lounge, private office, over 31 years of $650,000 - FOR SALE - 2 Suite Dental Building in Garden Grove, $500,000 Pedo practice located in Santa Ana, Orange County, Southern goodwill, doctor retiring. Orange County, Southern California. Total building square footage is California with eight (8) operatories, a three (3) chair ortho bay, sterilization/lab approximately 2400 sq.ft. Both are plumbed for dental. In Escrow. $475,000 Pedo Practice located in Costa Mesa, Orange County, combo, adjustment lab, x-ray room, dark room, reception area, staff lounge, Southern California with five (5) operatories, private office, staff lounge, $250,000 Leasehold Improvements in Pasadena, Los Angeles County, business office, consultation room, storage room, private office, in a professional sterilization/lab combo, adjustment lab, x-ray room, dark room, reception Southern California with six (6) Adec Chairs/Lights in a great part of town. building. 4000 square foot suite. In Escrow. area, private office. 1500 square foot suite. In Escrow. Contact our office for more information. $225,000 General Dentistry Practice in San Juan Capistrano, South NEW LISTING - Amalgam-free General Dentistry Practice in NEW LISTING – Los Alamitos, Orange County, Southern CA, with Orange County, Southern California with three (3) operatories, Westwood, Los Angeles, Southern California, with four (4) operatories, seven (7) operatories, Fully equipped in a great location, 5,000 square sterilization room, adjustment lab, 2 x-ray rooms, staff lounge, private includes equipment, wet lab, consultation/seminar room, sterilization foot suite. Price to be determined - more information coming soon. office in a business complex. 31 years of goodwill, doctor is retiring. room. Price To Be Determined. Call our office for more information. A. Lee Maddox, DDS, Esq. Broker Number - 01801165 888-685-8100 l [email protected] l www.MaddoxPracticeGroup.com Comprehensive & Professional Legal Services Exclusivly for Dentists We at the Law Offices of A. Lee Maddox, DDS look forward to assisting you with your practice transition needs. • Lease Reviews • Space Sharing Group / Solo Agreements • Partnership Agreements • Associate / Independent Contractor Agreements • Practice Purchase Agreements • MSO /BSO Agents Law Offices of • Corporation Formation / Dissolutions • LLC Formation and Agreements MA. Lee Maddox, DDS Email: [email protected] l www.cadentallaw.com breathing disorders

Dentist Lawyer Broker cda journal, vol 40, nº 2 Specializing In Dental Practice Sales, Transitions & Valuations

Medical Consequences and Associations With Untreated Sleep-Related

A. Lee Maddox, DDS, Esq. Kerri McCullough Breathing Disorders and California offices in La Jolla, Los Angeles, Newport Beach and Walnut Creek We have been involved with more than 1000 dental practice transactions. Outcomes of Treatments Here are some of our current listings: daniel norman, md; paul b. haberman, md; and edwin m. valladares, ms $7,500,000 Implant Practice in Orange County, Southern California. $950,000 Pedo Practice in the Inland Empire, San Bernardino County, $275,000 Orthodontic Practice in Long Beach, Los Angeles County, This is a large, state-of-the-art practice with an in-house, full-service Southern California with six (6) dental chairs, five (5) open bay, one (1) Southern California with four (4) chairs, open bay, plus one (1) chair lab, private office, call center, and much more all located in a beautiful surgical suite, sterilization room, private office and great cash flow in a in consultation room, includes equipment, digital Pan/Ceph machine, abstract Sleep-related breathing disorders are a broad group of disorders that professional building. mixed-use building. In Escrow. paperless office, private office in a Medical/Dental Building. Over 50 years of Goodwill. include obstructive sleep apnea, central sleep apnea, and periodic breathing disorders. NEW LISTING – Dental Practice and condo, Santa Ana, Orange $150,000 Orthodontic Practice in Pico Rivera, Los Angeles County, County, Southern CA, with five (5) operatories, price to be determined - Southern California, with four (4) chairs, open bay, sterilization-lab combo, $430,000 Prosthodontic Practice in Walnut Creek, Contra Costa This article reviews the scientific literature that links SRBD to various medical conditions more information coming soon adjustment lab, reception area, business office/consultation room, and County, Northern California with three (3) operatories, fully equipped, two- $470,000 General Dentistry Practice in East San Diego County, private office in a professional building. desk laboratory, administrative office, and private office near a retirement including hypertension, coronary artery disease, cardiac arrhythmias, stroke, diabetes Southern California with four (4) operatories, fully equipped, in a great community. Doctor retiring, 28 years in the same location. $300,000 General Dentistry Practice in Brea, Orange County, Southern mellitus, obesity, and depression. Pathophysiologic mechanisms by which SRBD may retail center with digital x-rays. 33 Years of Goodwill. SOLD California, with four (4) operatories, includes equipment, sterilization $475,000 General Dentistry Practice in La Verne, Los Angeles County, contribute to these disorders will be discussed, as will data on the degree to which $375,000 General Dentistry Practice in Irvine, Orange County, Southern room, private office in a shopping center near mall and freeway. Southern California with four (4) operatories, private office, staff lounge, California with five (5) operatories, three (3) fully equipped, two (2) plumbed, sterilization/lab combo, adjustment lab, x-ray room, dark room, reception $500,000 General Dentistry Practice in South Orange County, treatment of SRBD may improve these conditions. wired and medical-grade cabinetry and sinks. Beautiful, modern office in area in a retail center. Over 33 years of Goodwill. In Escrow. Southern California with four (4) operatories, fully equipped, sterilization- soothing neutral colors. lab combo, adjustment lab, staff lounge, private office, over 31 years of $650,000 - FOR SALE - 2 Suite Dental Building in Garden Grove, $500,000 Pedo practice located in Santa Ana, Orange County, Southern goodwill, doctor retiring. Orange County, Southern California. Total building square footage is California with eight (8) operatories, a three (3) chair ortho bay, sterilization/lab authors approximately 2400 sq.ft. Both are plumbed for dental. In Escrow. $475,000 Pedo Practice located in Costa Mesa, Orange County, combo, adjustment lab, x-ray room, dark room, reception area, staff lounge, Daniel Norman, md, is with Edwin M. Valladares, ms, leep-related breathing disorders have led to a larger volume of research Southern California with five (5) operatories, private office, staff lounge, $250,000 Leasehold Improvements in Pasadena, Los Angeles County, business office, consultation room, storage room, private office, in a professional St. John’s Medical Plaza is with the University of (SRBD) encompass a wide range data regarding medical conditions that sterilization/lab combo, adjustment lab, x-ray room, dark room, reception Southern California with six (6) Adec Chairs/Lights in a great part of town. building. 4000 square foot suite. In Escrow. Sleep Disorders Center in California, Los Angeles, of medical conditions, including may result from, or associate with, these area, private office. 1500 square foot suite. In Escrow. Santa Monica, Calif. Geffen School of Contact our office for more information. disorders involving upper airway disorders versus other types of SRBD. $225,000 General Dentistry Practice in San Juan Capistrano, South Medicine, Department of NEW LISTING - Amalgam-free General Dentistry Practice in NEW LISTING – Los Alamitos, Orange County, Southern CA, with Orange County, Southern California with three (3) operatories, Paul B. Haberman, md, Neurobiology, and Desert narrowing or obstruction during In all individuals, there exists a normal Westwood, Los Angeles, Southern California, with four (4) operatories, seven (7) operatories, Fully equipped in a great location, 5,000 square sterilization room, adjustment lab, 2 x-ray rooms, staff lounge, private is with the University of Hills Sleep Disorders Ssleep, disorders of waxing and waning tendency for pharyngeal airway dilator includes equipment, wet lab, consultation/seminar room, sterilization foot suite. Price to be determined - more information coming soon. office in a business complex. 31 years of goodwill, doctor is retiring. California, Los Angeles, Center in Lancaster, Calif. respiratory effort during sleep (such as the muscles to relax during sleep. Ordinarily, room. Price To Be Determined. Call our office for more information. Geffen School of Cheyne-Stokes breathing pattern), and this muscle relaxation is mild and does A. Lee Maddox, DDS, Esq. Broker Number - 01801165 Medicine, Department of disorders characterized by episodic pauses not impede normal patterns of airflow. 888-685-8100 l [email protected] l www.MaddoxPracticeGroup.com Medicine, and St. John’s Medical Plaza Sleep in respiratory effort during sleep (central However, if : 1) there is excessive Comprehensive & Professional Legal Services Exclusivly for Dentists Disorders Center in Santa sleep apnea or CSA). While many patients tendency toward airway muscle relaxation Monica, Calif. who suffer from SRBD have only one type during sleep, or 2) the oropharynx is nar- We at the Law Offices of A. Lee Maddox, DDS look forward to assisting you with your practice transition needs. of breathing disorder, some individuals row to begin with (i.e., from excessive sub- • Lease Reviews • Space Sharing Group / Solo Agreements may have combinations of two or more mucosal fat deposits, large tonsils, a large • Partnership Agreements • Associate / Independent Contractor Agreements categories of SRBD. All of the above SRBD uvula, droopy soft palate, a large tongue • Practice Purchase Agreements • MSO /BSO Agents Law Offices of • Corporation Formation / Dissolutions • LLC Formation and Agreements may present with symptoms of restless base, micrognathia/retrognathia, or other sleep, recurrent nighttime awakenings, structural abnormalities), or 3) any com- A. Lee Maddox, DDS Email: [email protected] l www.cadentallaw.com and/or excessive daytime somnolence. bination of both of the above can impede However, obstructive SRBD are the most airflow from compromised pharyngeal M prevalent of the above categories that structures that reside from the level of

february 2012 141 breathing disorders

cda journal, vol 40, nº 2

Sleep-Related Which Cause: Which May Breathing Disorders Increase Risk of: May Cause: Hypoxia Sympathetic nervous Hypertension Hypercapnia system activation Coronary artery tive event. However, over time, patients with untreated OSA develop heightened Dramatic swings in Increased cardiac wall disease intrathoracic pressure stress Heart failure sympathetic nervous system activity not only at night but also during the daytime.3 Recurrent arousals Oxidative stress Stroke Intermittent hypoxia during sleep also from sleep Endothelial dysfunction Arrhythmias q q triggers increased oxidative stress, contrib- Increased inflamma- Renal disease tory response utes to endothelial dysfunction, and increas- Erectile dysfunction Vasoconstriction es release of vasoactive substances (such Steatohepatitis as endothelin), which may cause lasting Platelet activation Pre-eclampsia vasoconstriction of blood vessels.4,5 These Atherosclerosis Cognitive dysfunction factors may all contribute to reductions in Insulin resistance Depression daytime heart rate variability and increases Sleep deprivation in blood pressure variability noted in pa- Diabetes mellitus tients with OSA.6 Furthermore, autonomic Mortality alterations may result from injury to brain regions that mediate autonomic control.7 Additionally, intermittent hypoxemia and figure 1. Mechanisms by which SRBD may cause or contribute to the development of various medical conditions. sleep disruption or deprivation may also be associated with increased inflammation and increased levels of fibrinogen and platelet the soft palate down to the level of the number of additional pathways by which activation.8,9 These factors, in turn, may con- epiglottis. In mild cases, vibration of apneas and hypopneas adversely affect the tribute to accelerated risk of atherosclerosis these various structures may cause turbu- human body (figure 1). Apneas and hypop- and thrombosis. Lastly, increased adrenergic lent airflow, which manifests as snoring. neas also cause transient carbon dioxide activity and sleep deprivation may both However, if the airway narrows beyond a retention. Chemoreflex-mediated activa- contribute to increased insulin resistance.10 certain point, there can be partial obstruction of the sympathetic nervous system Insulin resistance will be covered in greater tion (called an obstructive hypopnea) ensues from the hypoxia and hypercarbia, detail below, but it is important to mention or complete obstruction (an obstructive which results in a transient spike in blood here as a mechanism by which sleep apnea apnea) of the airway. The physiologic pressure and heart rate during individual contributes to increased risk of cardio- consequences of this airway narrowing, apnea/hypopnea episodes.1 Ongoing respi- vascular disease. While there are many and the body’s responses to it, likely play ratory effort in the setting of upper airway associations of disorders and disease states a significant role in the increased risk of obstruction generates significant negative with SRBD it is far more difficult to prove medical morbidity and mortality associ- intra-thoracic pressures, which may impact cause. In the paragraphs below, research ated with obstructive sleep apnea (OSA). systolic and diastolic heart function, affect data will be presented for various medical Before discussing specific conditions as- cardiac preload, and put additional wall conditions with an emphasis on whether an sociated with sleep apnea, it makes sense stress on the heart chambers and aorta.2 association or causal data has been found. to discuss the physiologic mechanisms The strain on the cardiovascular system that are affected by SRBD, and are likely is magnified as the acute rise in heart rate, Specific Medical Conditions Associated to play a significant role in the associa- blood pressure, heart chamber wall stress, With SRBD tion between SRBD and various diseases. and adrenergic activity associated with obstructive sleep apnea are typically most Hypertension Mechanisms of Disease prominent at the time in which the heart It is estimated that one-half of OSA While many people are aware that apne- is exposed to the greatest levels of hypoxia patients suffer from hypertension.11 Ap- as and hypopneas are associated with recur- and hypercarbia. The increased sympa- proximately one-third of all patients with rent (and sometimes quite severe) episodes thetic nervous system activity is initially essential hypertension and approximately of hypoxemia during sleep, there are a large transient and associated with each obstruc- 83 percent of patients with drug-resistant

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hypertension have OSA.12,13 A large number National Committee on Prevention, Effects of Mandibular Advancement of observational studies have shown a step- Detection, Evaluation and Treatment Appliance Therapy on Hypertension wise association between increasing OSA of High Blood Pressure began recom- An uncontrolled study of 29 consecu- severity and greater risk for (and severity mending that newly indentified hyper- tive OSA patients using a mandibular of) hypertension. One of the most well- tensive patients be screened for OSA.18 advancement device (MAD) reported known of these studies, the Sleep Heart significant reductions in both systolic Health Study (SHHS), was a multicenter Effects of Continuous Positive Airway and diastolic blood pressure at three study which performed polysomnography Pressure Therapy on Hypertension in OSA months and at three years of follow-up.24 on 6,132 middle-aged and older adults. The A number of randomized placebo- Three randomized controlled trials have SHHS results showed significant associa- controlled trials have been performed examined the effects of oral appliance tions between measures of sleep apnea (using subtherapeutic or sham-contin- therapy (OAT) for OSA on blood pres- severity (apnea hypopnea index; AHI) and uous positive airway pressure {CPAP} sure. The first demonstrated an ap- percentage of sleep time with oxygen satu- as a placebo) in order to demonstrate proximately 2 mmHg mean reduction ration below 90 percent and both systolic in 24-hour diastolic blood pressure with and diastolic blood pressure.14 Importantly, four weeks of MAD therapy.25 The second the step-wise increase in risk of hyperten- approximately demonstrated a 2 mmHg improvement sion with increasing levels of apnea sever- one-third of all patients with in nighttime diastolic blood pressure but ity persisted even after controlling for age, no change in nighttime systolic pressure gender, ethnicity, body mass index, smok- essential hypertension and or daytime blood pressure with three ing and alcohol use history, neck size, and approximately 83 percent of months of OAT, and showed no change waist-to-hip ratio. Specifically, when com- in blood pressure with three months pared with subjects who did not have OSA patients with drug-resistant of CPAP therapy for mild to moderate 26 (AHI<1.5/h), the risk of hypertension was hypertension have OSA. OSA. A third showed that 10 weeks of 20 percent higher among those with mild OAT or CPAP similarly reduced morn- OSA (AHI= 5-14.9/h), 25 percent higher ing diastolic blood pressure (mean 5 among those with moderate OSA (AHI=15- mmHg reduction with CPAP, 3 mmHg 29.9/h), and 37 percent higher among those the effects of CPAP therapy on 24-hour reduction with oral appliance) in pa- with severe OSA (AHI>30/h). Another ambulatory blood pressure. One demon- tients with mild to moderate OSA.27 large-scale population study found similar strated dramatic (~10 mmHg) reductions trends: there were higher mean arterial in daytime and nighttime mean arterial Effects of Upper Airway Surgery on blood pressures both during wakefulness pressure (MAP) with nine weeks of CPAP Hypertension and sleep in those with OSA compared to versus subtherapeutic CPAP therapy.19 Early studies in the 1970s described those without, and threefold higher preva- Other studies have shown more mod- substantial (~40 mmHg) reduction lence rates of hypertension among those est reductions (of 2-4 mmHg) in day and in mean arterial blood pressure (and with severe OSA (AHI>30/h) compared nighttime MAP with two to four weeks pulmonary artery pressures) following with those without OSA (AHI=0/h).15,16 of CPAP therapy, while yet others have tracheostomy for treatment of OSA.28 Prospective studies of patients with shown no significant change in MAP with While one would anticipate that the OSA have found that presence of mild CPAP use.20,21 A recent meta-analysis of likelihood of improving blood pressure OSA at baseline doubles the risk of 16 randomized clinical trials comparing would depend on the degree to which subsequent development of hyperten- at least two weeks of CPAP use to control respiratory disturbances were eliminated, sion four years later, and the presence of showed a mean net decrease of 2.2 mmHg published data on the effects of other up- moderate or severe sleep apnea increases in MAP day and night with CPAP thera- per airway surgeries (such as uvulopala- the risk by nearly threefold.17 The as- py.22 Another recent meta-analysis esti- topharyngeoplasty (UPPP), genioglossus sociation between hypertension and mated that there would be a 1.39 mmHg advancement, hyoid suspension, and OSA is so well-established that in 2003, decrease in MAP for every one-hour maxillomandibular advancement surgery) the National Institutes of Health’s Joint increase in effective nightly use of CPAP.23 on blood pressure in adults with OSA has

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been lacking. A study of normotensive of normal breathing.34 Furthermore, the atrial fibrillation at an average of seven snorers found that patients undergo- type of arrhythmia appears to be associ- months follow-up after a single radiofre- ing UPPP and nasal septoplasty had a ated with type of SRBD.35,36 Mehra and quency ablation procedure. This study tendency toward a transient increase in colleagues have found an association also reported that the presence of OSA nighttime systolic blood pressures during between atrial fibrillation with central was the strongest predictor of recurrence the first postoperative day, related to tran- sleep apnea; and complex ventricu- for atrial fibrillation following radiofre- sient increase in the respiratory distur- lar ectopy with OSA in older men.35 quency ablation, even when compared bance index (perhaps due to short-term Lanfranchi and colleagues also found against many of the risk factors that are upper airway edema) following surgery.29 a higher incidence of nonsustained traditionally associated with atrial fibril- In children with OSA, adenotonsil- ventricular tachycardia in patients with lation, such as patient age, duration of lectomy is usually considered first-line severe CSA.36 Yet, other studies have atrial fibrillation, BMI, hypertension, left therapy and there are a couple of stud- shown that the prevalence of OSA is atrial size, and left ventricular ejection ies demonstrating effects of surgery on fraction.39 Furthermore, a Japanese study blood pressure. One study using 24-hour found that CPAP significantly reduced ambulatory blood pressure monitor- the prevalence the occurrence of multiple arrhythmias, ing on 44 children with OSA found of OSA in patients including paroxysmal atrial fibrillation, that diastolic blood pressure decreased premature ventricular contractions, significantly following adenotonsillec- with heart failure sinus bradycardia, and sinus pauses.40 tomy. Six of the eight children who were has been estimated hypertensive prior to surgery actually Heart Failure became normotensive following surgery.30 to be between 40 percent The prevalence of OSA in patients However, another study demonstrated and 70 percent. with heart failure has been estimated to that children, who have recurrence of be between 40 percent and 70 percent.41 obstructive OSA after adenotonsillec- One prospective study with an aver- tomy, have a higher risk of development age of 2.9 years of follow-up found that of hypertension one year following heart failure patients with moderate to surgery than those who do not experi- significantly higher (48 percent) in severe untreated OSA (AHI>15/hour) ence recurrence of their sleep apnea.31 patients with atrial fibrillation compared have more than twice the mortality with unselected patients from a general compared with those with an AHI<15/ Cardiac Arrhythmias cardiology group practice (32 percent).37 hour.42 OSA has been associated with OSA has been associated with the CPAP therapy has been strongly both systolic and diastolic heart fail- development of various arrhythmias.32 associated with a reduction in rate of ure.43 CSA has also been reported in 21 Patients with severe SRBD are more arrhythmias in patients with OSA. In percent of patients with systolic heart likely to develop complex arrhythmias a prospective study of 43 patients with failure and 55 percent of patients with than controls without sleep-disordered known OSA who were undergoing elec- diastolic heart failure.36,43 The American breathing.33 In a sample of 57 participants trical cardioversion for atrial fibrillation, College of Cardiology and the Ameri- from the Sleep Heart Health Study who the risk of recurrence of atrial fibrillation can Heart Association have recom- had arrhythmias during their polysom- at 12 months follow-up was 82 percent in mended sleep apnea screening in newly nography, the odds of an arrhythmia those who were not using CPAP (or using diagnosed heart failure patients.44 (including paroxysmal atrial fibrillation it inappropriately) versus a risk of recur- Effective OSA treatment in heart and nonsustained ventricular tachycar- rence of only 42 percent among those failure patients improves Left Ven- dia) during the 90 seconds following a who were using CPAP therapy.38 Another tricular Ejection Fraction (LVEF).45 In respiratory disturbance were nearly 18 study found that 59 percent of patients patients with moderate to severe OSA, times higher than that of having an ar- with OSA (versus only 37 percent of pa- six months of CPAP therapy can result rhythmia following a 90-second period tients without OSA) had a recurrence of in significant improvement in systolic

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and diastolic dysfunction.46 Compli- sociated with increased risk of coronary major depressive disorder symptoms ance with CPAP therapy may reduce artery disease (odds ratio 3.1, 95 percent despite pharmacotherapy, two months the mortality rate in heart failure CI 1.2-8.3).52 Furthermore, among pa- of CPAP therapy resulted in significant patients who have Cheyne-Stokes tients with pre-existing coronary artery improvements in depression symptoms respiration and CSA.47 However, given disease, the presence of and severity as measured by the Beck Depression that heart failure patients may have a of OSA both predict increased risk for Inventory and the Hamilton Rating Scale greater tendency toward central ap- mortality over the following five years.52 for Depression.57 Another study of 132 neas, CPAP or OAT may not always be While people without OSA are at high- OSA patients and controls found that the best treatment.48 Adaptive servo- est risk of sudden cardiac death between patients with severe OSA had poorer ventilation is a type of positive airway 6-11 a.m., those with known OSA are at quality of life scores and were more de- pressure therapy that adapts to the highest risk between 10 p.m.-6 a.m., the pressed than control subjects at baseline, patient’s periodic breathing patterns period most often associated with sleep.53 but that depressive symptoms, excessive and provides variable amounts of air daytime somnolence, and overall quality pressure support to reduce tendency of life scores improved with nasal CPAP toward recurrent central apneas.49 depressive symptoms, therapy.58 One randomized controlled Kasai and colleagues studied 31 excessive daytime crossover study of 73 OSA patients found heart failure patients who had OSA improvements on the somatic compo- and Cheyne-Stokes respiration. The somnolence, and overall nent of the Beck depression inventory participants were assigned to either quality of life scores and fatigue-inertia scales of the Profile a CPAP treatment group or an adap- of Mood States test with mandibular tive servo-ventilation treatment group. improved with nasal advancement appliance therapy.59 When compared to the CPAP treatment CPAP therapy. group, the group assigned to use adap- Stroke tive servo-ventilation showed fewer Sleep apnea prevalence rates of up respiratory events, and greater improve- to 72 percent have been reported in ments in LVEF and SRBD treatment patients with a prior stroke.60 However, compliance.50 There has been a paucity While there are no randomized, it has been difficult to evaluate the of literature on mandibular advance- controlled trials on the effects of sleep significance of such findings, as sleep ap- ment device therapy in patients with apnea therapy on risk of developing nea, through many of the mechanisms/ heart failure. One study reported that coronary artery disease or its associat- diseases described above, may contribute the use of mandibular advancement ed mortality, there have been a number to increased risk for stroke, but the neu- device therapy in OSA patients with of observational studies which show rologic injury that results from a stroke stable congestive heart failure was as- that treatment with CPAP significantly may also increase the likelihood of devel- sociated with improvements in sleep reduces risk of occurrence of both fatal oping both obstructive and CSA.61 Some apnea-related symptoms, reductions in and nonfatal cardiovascular events in studies have shown increased mortality plasma levels of brain-natriuretic peptide patients with coronary artery disease.54 risk in stroke patients who have obstruc- (a marker of congestive heart failure), tive (but not central) sleep apnea.62 and reductions in five-year mortality.51 Depression CPAP therapy for OSA significantly It is estimated that 17 percent of reduces risk of new vascular events in pa- Coronary Artery Disease OSA patients in the community suffer tients who have had an ischemic stroke Even after one adjusts for various from depression.55 A study of 51 patients and also reduces mortality rates in these other risk factors, such as age, BMI, with comorbid depression and insomnia patients.63,64 However, no studies have hypertension, hypercholesterolemia, found that 39 percent suffered from at been published on the efficacy of OAT diabetes mellitus, cigarette smoking, the least moderate (AHI>15/hour) OSA.56 In a or upper airway surgery in morbidity or presence of OSA is independently as- study of 17 OSA patients with continued mortality in patients with prior stroke.

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Diabetes Mellitus been reported among obese patients Mortality The prevalence of OSA among men undergoing bariatric surgery.75,76 Longi- In a prospective observational study with type 2 diabetes mellitus has been tudinal data from the Wisconsin Sleep of men with OSA or simple snorers from estimated at 28 percent.65 In a study Cohort have demonstrated that, rela- a sleep clinic, and age- and BMI-matched of 595 men referred to a sleep lab for tive to stable body weight, a 10 percent control subjects from the community, suspected OSA, Meslier et al. found that increase in body weight translates into a patients with untreated severe sleep type 2 diabetes was present in 30 percent 32 percent higher AHI and sixfold higher apnea had more than three times the rate of OSA patients, versus 14 percent of risk of developing moderate-to-severe of fatal cardiovascular events (myocardial nonapneic snorers.66 OSA may contribute OSA. Conversely, a 10 percent decrease infarction, stroke), versus simple snor- to increased insulin resistance through in body weight results in an average of 26 ers and healthy participants.54 Men with sympathetic nervous system activation percent decrease in AHI.77 While indi- untreated mild-to-moderate OSA had a and sleep deprivation. In both obese and viduals with normal body weight may smaller (~1.6-fold) increase in mortality nonobese patients with OSA, AHI and also suffer from OSA, obesity is thought rates versus snorers and healthy controls minimum oxygen saturation during sleep a difference that was not statistically have been reported by some as indepen- significant. Recently published 18-year dent determinants of insulin resistance.67 osa may contribute mortality follow-up data from the Wis- However, other studies have not found consin Sleep Cohort Sample showed that an independent link between OSA and to increased insulin patients with untreated severe SRBD had insulin resistance.68 Some authors have resistance through 3.8-fold higher all-cause mortality, and 5.2 found improvements in insulin sensitiv- times higher cardiovascular mortality ver- ity in nonobese OSA patients following sympathetic nervous sus those without SRBD.80 Treatment with as little as two days of CPAP therapy system activation and CPAP lowers mortality rates in patients whereas others studying obese OSA with OSA to rates similar to that of simple patients have found improvements in sleep deprivation. snorers and healthy controls.54 To our insulin sensitivity only after three months knowledge, there are no studies reporting of CPAP therapy.69,70 However, the data a mortality benefit from OAT or upper air- on this subject are conflicting, as other to increase OSA risk through a number way surgery for adults with OSA. One ret- studies have not demonstrated signifi- of mechanisms, including upper airway rospective study compared OSA patients cant changes in insulin resistance with narrowing from increased submuco- treated with UPPP to those treated with CPAP therapy or have shown no change sal fat deposition, greater degrees of CPAP and found that their mortality rates in insulin, but significant changes in pharyngeal collapsibility due to dimin- were similar over six years of follow-up.81 leptin levels following CPAP therapy.71,72 ished traction on the trachea associ- In addition to cardiovascular dis- ated with lower lung volumes in people ease, another potential contributor to Obesity who have higher abdominal girth, and higher mortality rates in OSA patients There is a clear association between through central nervous system signal- may be motor vehicle accidents (MVA). obesity and increased risk for OSA. ing proteins released by fat cells.78 One study found that untreated OSA Body mass index and neck girth are Some authors have speculated patients had three times the rate of MVA both significant predictors of OSA.73 that OSA may in turn contribute to than nonapneic controls.82 Furthermore, In the Wisconsin Sleep Cohort, each obesity, through a variety of puta- OSA patients had twice as many driv- standard deviation increase in BMI was tive mechanisms, including decreased ing citations as the controls.83 CPAP has associated with a greater than four- daytime physical activity related to been shown to reduce the risk of MVA fold increase in risk for having sleep fatigue, increased insulin resistance, in OSA patients.82 Although long-term apnea.74 While estimated prevalence changes in sympathetic nervous sys- data regarding changes in MVA risk rates for OSA in the general population tem activity, and changes in levels of with OAT are not available, a 25-minute are typically between 2 and 7 percent, hormones (such as leptin) related to simulated driving performance test on OSA prevalence rates of 77 percent have hunger regulation and metabolism.79 16 control subjects and 20 OSA patients

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before and after randomized treatment surgery that demonstrate that treatment medical doctors and dentists to not only with either CPAP or OAT showed that of OSA can lower the risk of morbidity identify patients who might be at risk, OSA patients had significantly higher and mortality associated with many of but also help them understand the risks lapses of attention than controls prior the above disorders and conditions. and benefits of all treatment options, to treatment, and that OAT and CPAP CPAP is more effective than OAT at as well as the significant risks of not both resulted in significant and similar normalizing respiratory disturbances and undergoing, or not adhering to therapy. improvements in simulated driving.84 oxyhemoglobin saturation during sleep, No matter which treatment option the particularly as apnea severity increases.97 patient chooses, long-term follow-up Other Disorders However, it is often quoted that compliance should also be planned, to look for and In addition to the above, SRBD have with CPAP therapy is poor, with 54 percent address potential side effects from treat- been associated with a number of other of patients initially prescribed CPAP still ment, and to make sure that the therapy medical conditions, including cognitive using it after a mean follow-up period of that has been prescribed is still in use, impairment, dementia, attention defi- 64 months.98 While patients who respond and is still effective. If a patient has had cit disorder, impotence, kidney disease, significant weight gain, has started using gastroesophageal reflux disease, nocturia, sedatives or chronic opioid pain medica- erythrocytosis, pulmonary hyperten- if residual osa tions, has had recurrence of symptoms of sion, polycystic ovary syndrome, pre- SRBD (i.e., increased intensity of snoring, eclampsia, and Down syndrome.85-96 While remains present, CPAP increased daytime somnolence or inat- detailed discussions of these conditions settings or oral appliances tentiveness), or has developed worsening is beyond the scope of this article, it is hypertension, new arrhythmias, conges- important to note that anatomic and/ may need adjustment, or tive heart failure, stroke, or other signifi- or neurologic features associated with additional airway surgery may cant change in their health status, it may some of these conditions (i.e., Down be necessary to have a sleep specialist syndrome) may be predisposed to OSA. be considered. re-evaluate the patient, and see if apnea However, for most of the above condi- type or severity has changed, and evaluate tions, it is believed that oxidative stress, whether their therapy is still effective. hypertension, insulin resistance, and adequately to both CPAP and OAT often If residual OSA remains present, increased sympathetic nervous system find OAT more comfortable than CPAP, the CPAP settings or oral appliances may activity from SRBD play a causative role. long-term compliance data for OAT (51-62 need adjustment, or additional airway percent at two years, and only 38 percent surgery may be considered. If CSA or Conclusion at five years), also leave significant room periodic breathing disturbances of sleep SRBD have been linked with a myriad for improvement.26,99,100 Soft-tissue upper are found, other therapies, such as adap- of medical conditions. There are multiple airway surgeries (such as UPPP and tongue tive servo-ventilation, may be warranted. pathophysiologic mechanisms by which advancement procedures) typically have Additionally, some patients may SRBD are likely to play a causal or contrib- lower success rates than CPAP or OAT, and benefit from combinations of oral ap- utory role to the development of hyper- are generally not recommended as first line pliance, CPAP, and/or upper airway tension, coronary artery disease, stroke, treatment for OSA.101 Patients undergoing surgical therapy, to either treat residual heart failure, arrhythmias, insulin resis- maxillomandibular advancement (MMA) obstruction, to lower therapeutic air- tance, depression, and perhaps even gas- surgery demonstrate more substantial way pressure requirements, or to bet- troesophageal reflux. Through excessive improvements in AHI, but there are limited ter accommodate their lifestyle. Lastly, daytime somnolence and inattentiveness, data on long-term effects of MMA on vari- follow-up office visits present an ideal OSA also increases the risk of accidents. ous medical disorders described above.102 time to look for evidence of development While the greatest amount of efficacy In light of the significant potential or exacerbation of any comorbid medi- data exists for CPAP therapy, there is also for morbidity and mortality related to cal conditions and intervene, hopefully a growing body of data on the efficacy the various medical conditions associ- before significant health effects from of OAT, and some data on upper airway ated with SRBD, it is important for both these conditions have occurred.

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Am J Respir Crit Care Med 177(6):654-9, 2008. treatment with auto-CPAP, but improved by adaptive servo- 14. Nieto FJ, Young TB, et al, Association of sleep-disordered 32. Guilleminault C, Connolly SJ, Winkle RA, Cardiac arrhythmia ventilation. Intern Med 49(5):415-21, 2010. breathing, sleep apnea, and hypertension in a large and conduction disturbances during sleep in 400 patients with 50. Kasai T, Usui Y, et al, Effect of flow-triggered adaptive community-based study. Sleep heart health study. JAMA sleep apnea syndrome. Am J Cardiol 52(5):490-4, 1983. servo-ventilation compared with continuous positive airway 283(14):1829-36, 2000. 33. Mehra R, Benjamin EJ, et al, Association of nocturnal pressure in patients with chronic heart failure with coexisting 15. Hla KM, Young TB, et al, Sleep apnea and hypertension. A arrhythmias with sleep-disordered breathing: the sleep heart obstructive sleep apnea and Cheyne-Stokes respiration. Circ population-based study. Ann Intern Med 120(5):382-8, 1994. health study. Am J Respir Crit Care Med 173(8):910-6, 2006. Heart Fail 3(1):140-8, January 2010. 16. Young T, Peppard P, et al, Population-based study of sleep- 34. Monahan K, Storfer-Isser A, et al, Triggering of nocturnal 51. Eskafi M, Cline C, et al, The effect of mandibular advance- disordered breathing as a risk factor for hypertension. Arch arrhythmias by sleep-disordered breathing events. J Am Coll ment device on pharyngeal airway dimension in patients with Intern Med 157(15):1746-52, 1997. Cardiol 54(19):1797-804, 2009. congestive heart failure treated for sleep apnea. Swed Dent J 17. Peppard PE, Young T, et al, Prospective study of the asso- 35. Mehra R, Stone KL, et al, Nocturnal arrhythmias across a 28(1):1-9, 2004. ciation between sleep-disordered breathing and hypertension. spectrum of obstructive and central sleep-disordered breath- 52. Peker Y, Kraiczi H, et al, An independent association N Engl J Med 342(19):1378-84, 2000. ing in older men: outcomes of sleep disorders in older men between obstructive sleep apnea and coronary artery disease. 18. Chobanian AV, Bakris GL, et al, The 7th Report of the Joint (MrOS sleep) study. Arch Intern Med 169(12):1147-55, 2009. Eur Respir J 14(1):179-84, 1999. National Committee on Prevention, Detection, Evaluation, and 36. Lanfranchi PA, Somers VK, et al, Central sleep apnea in 53. Gami AS, Howard DE, et al, Day-night pattern of sudden Treatment of High Blood Pressure: the JNC 7 report. JAMA left ventricular dysfunction: prevalence and implications for death in obstructive sleep apnea. N Engl J Med 352(12):1206-14, 289(19):2560-72, 2003. arrhythmic risk. Circulation 107(5):727-32, 2003. 2005. 19. Becker HF, Jerrentrup A, et al, Effect of nasal continuous 37. Gami AS, Pressman G, et al, Association of atrial fibrillation 54. Marin JM, Carrizo SJ, et al, Long-term cardiovascular out- positive airway pressure treatment on blood pressure in and obstructive sleep apnea. Circulation 110(4):364-7, 2004. comes in men with obstructive sleep apnea-hypopnoea with or patients with obstructive sleep apnea. Circulation 107(1):68-73, 38. Kanagala R, Murali NS, et al, Obstructive sleep apnea and without treatment with continuous positive airway pressure: 2003. the recurrence of atrial fibrillation. Circulation 107(20):2589- an observational study. Lancet 365(9464):1046-53, 2005. 20. Norman D, Loredo JS, et al, Effects of continuous positive 94, 2003. 55. Harris M, Glozier N, et al, Obstructive sleep apnea and airway pressure versus supplemental oxygen on 24-hour 39. Jongnarangsin K, Chugh A, et al, Body mass index, obstruc- depression. Sleep Med Rev 13(6):437-44, 2009. ambulatory blood pressure. Hypertension 47(5):840-5, 2006. tive sleep apnea, and outcomes of catheter ablation of atrial 56. Ong JC, Gress JL, et al, Frequency and predictors of ob- 21. Barbe F, Mayoralas LR, et al, Treatment with continuous fibrillation. J Cardiovasc Electrophysiol 19(7):668-72, 2008. structive sleep apnea among individuals with major depressive

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disorder and insomnia. J Psychosom Res 67(2):135-41, 2009. 74. Young T, Palta M, et al, The occurrence of sleep-disor- 94. Tasali E, Van Cauter E, Ehrmann DA, Polycystic ovary 57. Habukawa M, Uchimura N, et al, Effect of CPAP treatment dered breathing among middle-aged adults. N Engl J Med syndrome and obstructive sleep apnea. Sleep Med Clin 3(1):37- on residual depressive symptoms in patients with major 328(17):1230-5, 1993. 46, 2008. depression and coexisting sleep apnea: Contribution of 75. Punjabi NM, The epidemiology of adult obstructive sleep 95. Bourjeily G, Raker CA, et al, Pregnancy and fetal outcomes daytime sleepiness to residual depressive symptoms. Sleep apnea. Proc Am Thorac Soc 5(2):136-43, 2008. of symptoms of sleep-disordered breathing. Eur Respir J Med 11(6):552-7, 2010. 76. Sareli AE, Cantor CR, et al, Obstructive sleep apnea in 36(4):849-55, October 2010. 58. Kawahara S, Akashiba T, et al, Nasal CPAP improves patients undergoing bariatric surgery-a tertiary center experi- 96. Fitzgerald DA, Paul A, Richmond C, Severity of obstructive the quality of life and lessens the depressive symptoms in ence. Obes Surg 21(3):316-27, 2009. apnea in children with Down syndrome who snore. Arch Dis patients with obstructive sleep apnea syndrome. Intern Med 77. Peppard PE, Young T, et al, Longitudinal study of moder- Child 92(5):423-5, 2007. 44(5):422-7, 2005. ate weight change and sleep-disordered breathing. JAMA 97. Ferguson KA, Cartwright R, et al, Oral appliances for snor- 59. Naismith SL, Winter VR, et al, Effect of oral appliance 284(23):3015-21, 2000. ing and obstructive sleep apnea: a review. Sleep 29(2):244-62, therapy on neurobehavioral functioning in obstructive sleep 78. Schwartz AR, Patil SP, et al, Obesity and obstructive sleep 2006. apnea: a randomized controlled trial. J Clin Sleep Med 1(4):374- apnea: pathogenic mechanisms and therapeutic approaches. 98. Wolkove N, Baltzan M, et al, Long-term compliance with 80, 2005. Proc Am Thorac Soc 5(2):185-92, 2008. continuous positive airway pressure in patients with obstruc- 60. Johnson KG, Johnson DC, Frequency of sleep apnea in 79. Pillar G, Shehadeh N, Abdominal fat and sleep apnea: the tive sleep apnea. Can Respir J 15(7):365-9, 2008. stroke and TIA patients: a meta-analysis. J Clin Sleep Med chicken or the egg? Diabetes Care 31 Suppl 2:S303-9, 2008. 99. Ghazal A, Sorichter S, et al, A randomized prospective 6(2):131-7, April 2010. 80. Young T, Finn L, et al, Sleep-disordered breathing and long-term study of two oral appliances for sleep apnea treat- 61. Mohsenin V, Is sleep apnea a risk factor for stroke? A criti- mortality: 18 follow-up of the Wisconsin sleep cohort. Sleep ment. J Sleep Res 18(3):321-8, 2009. cal analysis. Minerva Med 95(4):291-305, 2004. 31(8):1071-8, 2008. 100. Martinez-Gomis J, Willaert E, et al, Five years of sleep 62. Sahlin C, Sandberg O, et al, Obstructive sleep apnea is a 81. Keenan SP, Burt H, et al, Long-term survival of patients with apnea treatment with a mandibular advancement device. Side risk factor for death in patients with stroke: a 10-year follow- obstructive sleep apnea treated by uvulopalatopharyngo- effects and technical complications. Angle Orthod 80(1):30-6, up. Arch Intern Med 168(3):297-301, 2008. plasty or nasal CPAP. Chest 105(1):155-9, 1994. January 2010. 63. Martinez-Garcia MA, Soler-Cataluna JJ, et al, Continuous 82. George CF, Reduction in motor vehicle collisions following 101. Sundaram S, Bridgman SA, et al, Surgery for obstructive positive airway pressure treatment reduces mortality in treatment of sleep apnea with nasal CPAP. Thorax 56(7):508- sleep apnea. Cochrane Database Syst Rev (4):CD001004, patients with ischemic stroke and obstructive sleep apnea: a 12, 2001. 2005. five-year follow-up study. Am J Respir Crit Care Med 180(1):36- 83. George CF, Smiley A, Sleep apnea and automobile crashes. 102. Caples SM, Rowley JA, et al, Surgical modifications of 41, 2009. Sleep 22(6):790-5, 1999. the upper airway for obstructive sleep apnea in adults: a 64. Martinez-Garcia MA, Galiano-Blancart R, et al, Continuous 84. Hoekema A, Stegenga B, et al, Simulated driving in systematic review and meta-analysis. Sleep 33(10):1396-407, positive airway pressure treatment in sleep apnea prevents obstructive sleep apnea-hypopnoea; effects of oral appli- October 2010. new vascular events after ischemic stroke. Chest 128(4):2123- ances and continuous positive airway pressure. Sleep Breath 9, 2005. 11(3):129-38, 2007. 65. West SD, Nicoll DJ, Stradling JR, Prevalence of obstructive 85. Kim HC, Young T, et al, Sleep-disordered breathing and to request a printed copy of this article, please contact sleep apnea in men with type 2 diabetes. Thorax 61(11):945-50, neuropsychological deficits. A population-based study. Am J Daniel Norman, MD, 1301 20th St., Suite 360/370, Santa 2006. Respir Crit Care Med 156(6):1813-9, 1997. Monica, Calif., 90404. 66. Meslier N, Gagnadoux F, et al, Impaired glucose-insulin 86. Cohen-Zion M, Stepnowsky C, et al, Changes in cognitive metabolism in males with obstructive sleep apnea syndrome. function associated with sleep-disordered breathing in older Eur Respir J 22(1):156-60, 2003. people. J Am Geriatr Soc 49(12):1622-7, 2001. 67. Ip MS, Lam B, et al, Obstructive sleep apnea is indepen- 87. Goraya JS, Cruz M, et al, Sleep study abnormalities in dently associated with insulin resistance. Am J Respir Crit children with attention deficit hyperactivity disorder. Pediatr Care Med 165(5):670-6, 2002. Neurol 40(1):42-6, 2009. 68. Gruber A, Horwood F, et al, Obstructive sleep apnea is 88. Szymanski FM, Filipiak KJ, et al, The high risk of obstruc- independently associated with the metabolic syndrome but tive sleep apnea-an independent risk factor of erectile not insulin resistance state. Cardiovasc Diabetol 5:22, 2006. dysfunction in st-segment elevation myocardial infarction 69. Harsch IA, Schahin SP, et al, Continuous positive airway patients. J Sex Med 8(5):1434-8, May 2011. pressure treatment rapidly improves insulin sensitivity in 89. Sekizuka H, Osada N, et al, Relationship between chronic patients with obstructive sleep apnea syndrome. Am J Respir kidney disease and sleep blood pressure in patients with sleep Crit Care Med 169(2):156-62, 2004. apnea syndrome. Hypertens Res 33(12:1278-82, December 70. Harsch IA, Schahin SP, et al, The effect of continuous 2010. positive airway pressure treatment on insulin sensitivity in 90. Demeter P, Visy KV, Magyar P, Correlation between patients with obstructive sleep apnea syndrome and type 2 severity of endoscopic findings and apnea-hypopnea index in diabetes. Respiration 71(3):252-9, 2004. patients with gastroesophageal reflux disease and obstruc- 71. Smurra M, Philip P, et al, CPAP treatment does not affect tive sleep apnea. World J Gastroenterol 11(6):839-41, 2005. glucose-insulin metabolism in sleep apneic patients. Sleep 91. Romero E, Krakow B, et al, Nocturia and snoring: predictive Med 2(3):207-13, 2001. symptoms for obstructive sleep apnea. Sleep Breath 14(4)337- 72. Chin K, Shimizu K, et al, Changes in intra-abdominal visceral 43, December 2010. fat and serum leptin levels in patients with obstructive sleep 92. Nistico A, Iliescu EA, et al, Polycythemia due to obstruc- apnea syndrome following nasal continuous positive airway tive sleep apnea in a patient on hemodialysis. Hemodial Int pressure therapy. Circulation 100(7):706-12, 1999. 14(3):333-6, July 2010. 73. Young T, Shahar E, et al, Predictors of sleep-disordered 93. Prisco DL, Sica AL, et al, Correlation of pulmonary hyper- breathing in community-dwelling adults: the sleep heart health tension severity with metrics of comorbid sleep-disordered study. Arch Intern Med 162(8):893-900, 2002. breathing. Sleep Breath 15(4):633-9, December 2011.

february 2012 149 TAKE YOUR IN THE CAREER RIGHT DIRECTION JOIN THE AMERICAN ACADEMY OF DENTAL SLEEP MEDICINE The AADSM promotes research and the clinical use of oral appliances and upper airway surgery for the treatment of sleep related breathing disorders and provides training and resources for those who work directly with patients. In joining the AADSM there will be opportunities for networking and collaboration between dental & medical colleagues as well as education through peer-reviewed publications, the AADSM Annual Meeting, continuing education courses & study clubs. THE NEXT STEP IN YOUR JOURNEY . . . .

INTRODUCTION TO DENTAL SLEEP MEDICINE COURSE March 3-4, 2012 • Orlando, Florida TOPICS PRESENTED: • Practice Marketing and Patient Management: A Team Approach • Scope of Practice, Medico-legal Issues and ABDSM Board Certification • OSA Metabolism and Case Presentations • Insurance Reimbursement

The AADSM is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. The AADSM designates this activity for 13.00 continuing education credits. appliance therapies

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Past, Present, and Future Use of Oral Appliance Therapies in Sleep-Related Breathing Disorders

robert r. rogers, dmd

abstract Upper airway patency is a delicate balancing act pitting pharyngeal anatomy and baseline muscle tone against the negative pressures created upon inhalation. This uniquely human phenomenon has created for some patients the need for upper airway management during sleep. In this regard, the ability of removable oral appliances utilized during sleep to create and maintain a patent airway has seen the creation of a new area of interest in dentistry termed dental sleep medicine.

author “The acquisition and processing of oxygen extends up behind the soft palate to di-

Robert R. Rogers, dmd, is the primary mission of any air-breathing rectly join the larynx to the nasopharynx. d.abdsm, is the director vertebrate. Chewing, walking, reproducing This provides a firm, uninterrupted air of Clinical Services for and thinking are all fine, but first one must channel from the external nares, through Pittsburgh Dental Sleep breathe … ”1 the nasal cavities and nasopharynx, past Medicine, PC, Wexford, he human pharynx is unique in the larynx, and down to the trachea and Penn. He is the founding president of the American the animal kingdom in that it is lungs. As such, no pharyngeal muscles Academy of Dental Sleep predisposed to collapse during were designed specifically to maintain Medicine. sleep. Being intimately involved upper airway patency since none were with swallowing, breathing, and necessary. In addition, the tongue is Tspeaking, it is called upon to be alternate- located anteriorly, entirely within the oral ly stiff or flexible depending on the task at cavity and separate from the pharynx, so hand. Upper airway patency is a delicate it cannot impact the pharyngeal space at balancing act pitting pharyngeal anatomy any time. This allows the animal to eat and baseline muscle tone against the neg- and breathe at the same time, preserving ative pressures created upon inhalation. a sense of smell so necessary for survival. Why is this so? Comparing the dif- Over time, however, human evolu- ferences in pharyngeal function between tion has given rise to the separation of humans and other mammals is revealing. the epiglottis and soft palate to create Postmortem dissections on many types an upper airway that is longer and more of mammals reveal that the epiglottis flexible.2 This separation allows the tongue

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to reside partially within the pharynx to Since then, substantial progress has the lateral dimension during mandibu- create a soft-walled oropharynx unique been documented in the growing litera- lar advancement in awake patients.6,9 to modern humans, which provides a ture. In 1995, a milestone review of the It is quite likely that the interplay of resonating chamber for refined vocaliza- topic appeared in literature that effec- the muscles of the tongue, soft palate, tions (speech and language). Unfortu- tively summarized the efficacy of this new lateral pharyngeal walls, and related nately, it also provides the opportunity therapy and for the first time, suggested mandibular attachments are responsible for sleep-induced collapse of the upper practice parameters.4,5 A decade later, in for these changes due to the mechani- airway. To complicate matters, continu- 2005, these two documents were revised cal stretching of the palatoglossal and ing evolution of our species resulted in and republished reflecting the newer data palatopharyngeal arches. In addition, an erect posture that brought the facial in this burgeoning field.6,7 Today, the lit- stabilization of the mandible and hyoid skeleton to lie below the frontal region erature is replete with scientific investiga- bone prevents posterior rotation of the of the brain case, rather than in front tions supporting OAT and most recently, mandible and relapse of the tongue dur- of it as in most quadruped animals. the American Academy of Sleep Medicine ing sleep.10 A positive effect on airflow This uniquely human phenomenon dynamics has also been demonstrated has created the need for upper airway with use of mandibular advancement due management during sleep. In this regard, to diminished airway curvature in the the ability of removable oral appliances stabilization of the velopharynx.11 Finally, neuromuscular utilized during sleep to create and main- mandible and hyoid bone properties of the upper airway appear to tain a patent airway has seen the creation be affected by mandibular repositioning.12 of a new area of interest in dentistry prevents posterior rotation Of critical importance to the clinical and medicine — dental sleep medicine. of the mandible and relapse practitioner is the variability in airway By manipulating the mandible, and, response to oral appliances, most likely due hence, related oropharyngeal tissues, a of the tongue during sleep. to the inconsistent effect of mandibular/ properly trained and experienced dentist tongue movement to these muscle systems. can utilize intraoral devices to manage sleep-disordered breathing (SDB). Validation of Efficacy The basic concept underlying oral has, for the first time, published guide- Subjectively, reports from patients appliance therapy (OAT) has been lines for the evaluation, management, and and their bed partners indicate that well-known for many years. In the early long-term care of obstructive sleep apnea oral appliance therapy generally results 1900s, surgeons occasionally saved the (OSA) in adults that cites OAT as an effec- in a significant reduction of snoring lives of micrognathic infants by suturing tive option for the management of SDB.8 in a high proportion of cases.13 the tongue in a forward position to the Improvements in daytime sleepiness, lower lip in an effort to open and stabilize Mechanism of Action work performance, and sleep quality of the upper airway during sleep. By 1930, It is generally thought that the efficacy both patient and bed partner are also helmets and chin straps were utilized by of oral appliances (mandibular-reposi- reported benefits.14,15 Objectively, sleep physicians for mandibular repositioning tioning devices and tongue-retaining tests show improvements in snoring in an effort to accomplish the same goal. devices) stems from the anterior move- frequency and intensity, apnea-hy- The first use of an intraoral mandibular ment of the tongue and resulting increase popnea index (AHI), oxygen desatura- repositioning device (MRD) is gener- in the anteroposterior dimensions of tion frequency and intensity, and the ally attributed to Pierre Robin, a French the oropharynx. Interestingly, studies number of arousals during sleep.15-17 pediatrician, in 1934. More recently, utilizing computed tomography, magnetic Significant increases in slow wave and surgical advancement of the maxilla resonance imaging and nasopharyngos- rapid eye movement sleep have also and mandible has been reported and, copy indicate that the cross-sectional been demonstrated in studies.17,18 in 1982, Charles Samuelson, a Chicago area of the velopharynx increases in both Complete treatment success, defined psychiatrist, designed a tongue-retaining the lateral and anteroposterior dimen- as an AHI of fewer than five events per device that was shown to be effective.3 sions, while the oropharynx increases in hour and resolution of symptoms, has

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category of MRDs, which are utilized far more often worldwide and are supported by the most research. Tongue-retaining devices (TRDs) represent a very tiny percentage of appliance utilization and are figure 2. Tongue-retaining device. studied far less often (figures 1 and 2). MRDs all function to reposition and figure 1. MRD with anterior-adjusting mechanism. stabilize the mandible in a protruded position during sleep. Within this functional classification, numerous design variations been reported to occur in 19 percent to 75 As such, a gradual, diminution in treat- exist giving rise to the plethora of MRDs. percent of patients with mild to moder- ment effect can be expected in some cases To date, no significant research has clearly ate OSA. Higher success rates have been that may be due to aging, increasing body demonstrated any great advantage of one reported in studies using a more liberal weight, and failure to properly monitor design feature over another; however, definition of success, namely an AHI the therapeutic mandibular position.24 studies suggest they may impact efficacy of fewer than 10 events per hour.6,15 and tolerance.25,26 Dual-block MRDs con- A blood pressure-lowering effect Follow-Up sist of maxillary and mandibular com- has been demonstrated in more recent Following titration of the oral appli- ponents that are joined by one of several studies with mandibular reposition- ance based on resolution of subjective modes, including elastic or plastic con- ing devices where the results were symptoms, the patient is referred back nectors, metal rod and tube connectors, similar in magnitude to that achieved to the medical clinician for objective hook connectors, acrylic resin extensions, with continuous positive airway pres- evaluation of the treatment outcome. A or magnets. These dual-block devices are sure (CPAP).19 In addition, other stud- follow-up sleep study is generally recom- most advantageous because they facilitate ies demonstrated improvements in the mended, especially in cases of moderate incremental adjustment of mandibular quality of life and aspects of neurocog- to severe OSA because baseline improve- position over time. Fixed or mono-block nitive performance such as psychomo- ment in symptoms is not always accom- appliances are quite tedious and time- tor speed when MRDs are used.20 panied by an adequate reduction in AHI. consuming to adjust requiring physical The clinical practitioner should Long-term follow-up evaluation by separation and rejoining of the upper and keep in mind that even against the the sleep-disorders dentist is generally lower component, which precludes pre- background of an inadequate improve- undertaken six months after final titra- cise, incremental, reproducible, and easily ment in AHI, patients may report fewer tion and then annually thereafter.6 At referenced jaw positions (figures 3-5). symptoms when initiating oral appli- these periodic visits, the dentist monitors Certain trends are driving the evolu- ance therapy.6 In fact, an increase in usage, general satisfaction, symptoms, tion of appliance design and are vital for AHI has been reported in approximately weight increase, side effects, dental and the practitioner to recognize. Of primary 13 percent of OSA patients following oral health, degree of jaw repositioning, importance are the serial protrusive appliance therapy.21 Due to this risk of and integrity of the appliance. Ongo- adjustability of the MRD and the no- increased or suboptimal AHI, an ob- ing communication with the appropri- tion of titrating the device to ascertain jective, follow-up sleep study should ate medical clinicians is necessary to both an effective and comfortable always be performed to verify efficacy. ensure adequate long-term care. jaw position. Other important design Long-term effectiveness of oral appli- variations include durability to resist ances in treating OSA appears to be in the Design Variations the hostile environment of the oral proximity of 80 percent after follow-up Presently, there are nearly 100 differ- cavity, improved materials to increase periods ranging from two to five years.22,23 ent oral appliance designs available to the the retention to the dentition, and A similar, but slightly lower percent- dental practitioner with many accepted freedom of mandibular movement to age of patients experience a long-term by the Food and Drug Administration. allow greater temporomandibular joint satisfactory effect on snoring with OAT. The vast majority of them fall into the (TMJ) comfort (figures 6 and 7).

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figure 3. figure 4. figure 5. figures 3-5. MRDs with buccal adjustment mechanisms.

figure 6. MRD with palatal adjustment mechanism figure 7. MRD with nonmechanical adjustment figure 8. MRD; noncustom appliance mechanism

Custom-made laboratory appliances sition without having to engage the denti- limited to the neurological, musculoskeletal, are generally felt to offer more comfort, tion or significantly stressing the TMJ. As cardiac, and respiratory systems as well as better retention, increased durabil- such, these appliances may offer signifi- possess a good knowledge of the symptoms ity, and more sophisticated protrusive cant advantage for patients with loose or associated with sleep-related breathing engineering than the noncustom “boil no teeth, or those with TMJ dysfunction. disorders. In addition, the dental practitioner and bite” designs whose major advan- It is incumbent upon the sleep- should be proficient in understanding various tages seem to be limited to immediate disorders dentist to become familiar diagnostic and follow-up testing modalities availability and decreased cost. A recent with the design variations of numerous including, but not limited to the polysom- study has shown that custom-made appliances and develop clinical prefer- nographic evaluation, multiple sleep latency appliances are superior in efficacy ences over time based on experience test (MSLT), maintenance of wakefulness and patient acceptance27 (figure 8). and objective scientific observation. test (MWT), Epworth sleepiness scale (ESS) TRDs do not enjoy the popularity of and pulse oximetry, and be adept at interact- MRDs but nonetheless offer the practitio- The Sleep-Disorders Dentist ing with medical sleep specialists and other ner and the patient an alternative to man- Qualifications and Competency attending physicians for the purposes of dibular repositioning. Therapy with TRDs A 2006 review of the literature by the proper diagnosis, treatment, and follow-up. has been objectively studied, most notably American Academy of Sleep Medicine Finally, the dentist who provides therapy in the mid-1980s, and shown to be effec- stated that, with oral appliances should understand tive in some cases.28 TRDs function by “The dentist who provides therapy with the functional characteristics and design directly engaging the tongue and holding oral appliances for the management of variations of many different oral appliances it in a forward position to open the upper sleep-related breathing disorders should have and must be able to recognize and manage airway during sleep. Few variations of the adequate knowledge and skill to provide safe the side effects and complications associ- TRD exist and many practitioners have lit- and effective treatment. Therefore, the dental ated with oral appliances, especially occlusal tle or no experience with this design type. clinician must be thoroughly familiar with changes, tooth movement and temporo- The major advantage of the TRD may be the sleep-induced changes in the physiology mandibular joint symptoms. The prudent its ability to promote forward tongue po- of various organ systems including, but not practitioner understands the implications

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of lifelong therapy and the importance of ation as is customary within the dental any problem areas. Home-monitoring regular, periodic, follow-up examinations. profession. Additionally, the history of devices may be employed by the den- Qualified practitioners are those who present illness places specific emphasis tist to more objectively assess snoring, are board-certified as diplomates of the on symptoms of snoring and daytime airflow, and nocturnal oxygen saturation. American Board of Dental Sleep Medicine or sleepiness while the oral exam places Following adequate subjective response, others who have undertaken comprehensive additional emphasis on the pharyngeal the patient is referred back to the physi- training in sleep medicine and/or sleep- aperture including data on tongue size cian for objective, medical evaluation of the related breathing disorders with an emphasis and uvula/soft palate configuration. treatment outcome. Adjustments to the on the scientific literature and the use of General consensus holds that the presence appliance can be made pending the outcome appropriate protocol for diagnosis, treat- of eight to 10 healthy teeth in each arch data. Long-term follow-up is essential to ment, and follow-up. Treatment provided and a minimum 5 mm protrusive capacity monitor subjective satisfaction, compliance, by individuals who have little or no training of the mandible are usually required for resolution of symptoms, integrity of the oral and education in this unique multidisci- optimum results from MRD treatment. appliance, and health of the oral structures. plinary area should be discouraged.”6 In-Lab Titration Clinical Protocol presently, diagnosis The estimation of the proper, therapeu- Treatment of sleep-disordered tic jaw position prior to objective testing is breathing with oral appliances requires falls within the realm generally predicated on resolution of sub- a team approach. Presently, diagnosis of physicians while jective symptomatology, i.e., diminution of falls within the realm of physicians snoring and daytime somnolence as per pa- while construction and management of construction and management tient/bed partner report. Then, historically, the oral appliance dwells in the dental of the oral appliance dwells an objective sleep test is performed to as- arena. As the experience, technology, sess the efficacy of that particular jaw posi- and skills of dentists evolve, the den- in the dental arena. tion. If shown to be less than adequate, the tist may play a larger role and the lines patient returns to the dentist for further between diagnosis and treatment may appliance adjustment and then additional blur. Today, however, it is ethically and Following medical/dental assess- objective testing. While this protocol can legally prudent for the dentist to appreci- ment, the dentist engages the patient in produce positive outcomes, it tends to be ate an objective medical diagnosis prior a discussion exploring chances of treat- time-consuming, expensive, and tedious. to any treatment with an oral appliance. ment success versus side effects. The Presently, protocols are develop- According to published Practice need for objective follow-up testing and ing that allow for the real-time titration Parameters, oral appliances are indicated long-term monitoring is emphasized, and of mandibular repositioning devices for patients with mild to moderate OSA written informed consent is obtained. during an attended, in-lab sleep study who prefer this form of treatment over High-quality intraoral impressions are much the same as a CPAP titration. CPAP or who do not respond to or are made along with a therapeutic bite, then Recent studies demonstrate 55 percent unable to tolerate CPAP.29 The guidelines an appropriate oral appliance is custom- of patients who are subjectively self- also recommend that, whenever pos- fabricated by the dental laboratory. The titrated at home are successfully treated sible, CPAP be considered for patients appliance is delivered with instructions on after polysomnographic assessment.30,31 with severe OSA in preference to oral use, care, and jaw advancement protocol. Notably, 27 percent to 32 percent of the appliances, given its greater efficacy. The appliance is typically advanced (titrat- self-titrated failures become successes Following an objective diagnostic ed) slowly, as comfort allows, over a period utilizing the added in-lab PSG titration. evaluation by a physician, the patient may of weeks or months to achieve resolution While this new approach to appli- be referred to the dental practitioner for of subjective symptoms such as snoring ance titration seems to provide for more consideration of oral appliance therapy. and daytime sleepiness. The patient may efficient and better outcomes, it must The dentist conducts a thorough dental/ be seen in two- to four-week intervals to be refined and validated with regard to medical and oral/craniomandibular evalu- monitor these changes and troubleshoot adjustment protocols during the study.

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BenefitV ersus Risk of Treatment Over time, oral appliance therapy As with any therapeutic modality, the may aggravate TMJ disease in certain benefits of treatment must be weighed patients or increase the tendency for against the adverse effects inherent in bruxism.22,32 However, in the clinical the therapy. When oral appliances are situation signs or symptoms of TMJ effective in treating SDB, patients may disorders resulting from OAT are not figure 9. Combination oral appliance/CPAP interface. realize a diminution in snoring, daytime commonly reported.37 On the other somnolence and social disruption, as hand, orthodontic effects on the teeth well as decreased risk of cardiovascular and dentofacial structures are observed be extraordinarily effective in creating and neurocognitive impairment. How- more frequently and may be perma- and maintaining a patent airway dur- ever, utilization of oral appliances pres- nent.37 In most cases these orthodontic ing sleep but lack a great measure of ents the patient and practitioner with an effects amount to permanent alterations success because of poor compliance array of side effects ranging from minor in the dental occlusion.38 The over- often due to poor mask fit, mask leak, and transient to significant and per- jet and overbite may diminish and discomfort from straps, and excessive manent. Prior to initiating therapy the the occlusion may open laterally.39 air pressure requirements. Therapy patient and clinician should thoroughly It is considered reasonable to continue with oral appliances is much more review all possible side effects and be with oral appliance therapy in the pres- acceptable to patients but lacks the comfortable with the benefit versus risk. ence of acceptable and nonprogressive ability to adequately open the airway During the initial period of use, adverse effects contingent upon appro- in a significant number of cases. tenderness of the teeth and jaws, gum priate patient follow-up given the risk For more than a decade, inventors irritation, excessive salivation, or xero- of medical comorbidity associated with have been focusing on a variety of com- stomia may be reported by patients.32,33 untreated OSA. Bite change is inevitable bination oral appliance/CPAP interfaces Mild complaints of pain and strain of with many oral appliance patients and in an effort to utilize the benefits of the masticatory muscles and the TMJ simply needs to be managed by an experi- each while minimizing shortcomings. As also occur frequently during the initial enced sleep-disorders dentist. Orthodon- such, several products are available that period of use.34 In addition, a transient tic correction would merely be reversed by offer a positive airway pressure mask occlusal change after removal of the further appliance usage. Ultimately, the directly attached to an oral appliance. appliance each morning almost always effective treatment of a life-threatening It is believed that the oral appliance occurs in patients.35 Although unsup- disease such as OSA supersedes the component of the interface can offer ported in the scientific literature, it is maintenance of baseline occlusion.39 superior anchorage for the mask provid- thought that this phenomenon may be ing added comfort and stability in the attributed to a partially contracted lateral Combination Oral Appliance/CPAP absence of straps and headgear. In addi- pterygoid muscle and accumulation of Therapy tion, since the oral appliance provides a retrodiskal blood in the TMJ area after Traditionally, definitive therapy to measure of mandibular splinting and/ full-night mandibular protrusion. Small manage sleep-disordered breathing has or protrusion, it is believed that posi- movements of the anterior teeth due included positive airway pressure, oral tive airway pressure requirements may to the nocturnal forces of the appliance appliance therapy and surgery. Most be decreased in many cases. The positive may also play a role. Occasionally, treat- often, these approaches are independent airway pressure component can serve ment may be complicated by involuntary of each other and are recommended based to maintain airway patency where an removal of the device, an exaggerated gag on the background and experience of oral appliance alone is not effective. reflex, periodontal damage, or fractured the practitioner. It is understood that no Support in the scientific literature for teeth and fillings.34,36 Fortunately, these treatment modality is universally accepted this approach is scant with no large-scale relatively minor and transient occur- and effective, and it is quite evident that or long-term studies. However, more rences are easily managed by the experi- new approaches are warranted (figure 9). and more attention is being focused on enced practitioner or gradually subside Positive airway pressure modali- this new area and appliance manufactur- naturally as treatment progresses. ties (CPAP, BiPAP) have been shown to ers are constantly refining technology.

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Future Trends references of snoring and obstructive sleep apnea: a review. Sleep 18:501- 10, 1995. Presently, oral appliance therapy has 1. Laitman J, et al, What the nose knows: new understandings of Neanderthal upper respiratory tract. Proc Natl Acad Sci 22. Walker-Engstrom M, et al, Four-year follow-up of treatment reached a critical tipping point with the ac- USA 93:10543-5, 1996. with dental appliance or UPPP in patients with obstructive ceptance by physicians, dentists, patients 2. Crelin ES, The human vocal tract: anatomy, function, devel- sleep apnea: a randomized study. Chest 121:739-46, 2002. 23. Rose E, Barthlen GM, Therapeutic efficacy of an oral appli- and insurance companies as a legitimate opment and evolution. New York, Vantage Press, 1987. 3. Cartwright R, Samelson C, The effects of a nonsurgical ance in the treatment of obstructive sleep apnea: a two-year and necessary treatment for SDB. We have treatment for obstructive sleep apnea-the tongue-retaining follow-up. Am J Orthod Dentofacial Orthop 121(3):273-9, 2002. arrived at this juncture following several device. JAMA 248:705, 1982. 24. Marklund M, et al, Mandibular advancement device in patients with obstructive sleep apnea: long-term effects on decades of basic research and clinical 4. Schmidt-Nowara W, et al, Oral appliances for the treatment of snoring and obstructive sleep apnea: a review. Sleep 18:501- apnea and sleep. Chest 120:162-9, 2001. application with dental sleep medicine be- 10, 1995. 25. Gauthier L, Laberge L, Efficacy of two mandibular advance- coming a rapidly growing field in the sleep 5. American Sleep Disorders Association Standards of ment appliances in the management of snoring and mild- moderate sleep apnea: A cross-over randomized study. Sleep arena. The American Academy of Dental Practice Committee. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. Med 10(3):329-36, March 2009 (epub: June 25, 2008). Sleep Medicine (AADSM) membership has Sleep 18:511-3, 1995. 26. Pitsis AJ, Darendeliler MA, et al, Effect of vertical dimen- grown 645 percent over the last decade and 6. Ferguson K, et al, Oral appliances for snoring and obstruc- sion on efficacy of oral appliance therapy in obstructive sleep apnea. Am J Respir Crit Care Med 166(6):860-4, Sept. 15, 2002. now boasts more than 2,000 members. tive sleep apnea: a review. Sleep 29(2):244-62, 2006. 7. Kushida C, et al, Practice parameters for the treatment of 27. Vanderveken OM, et al, Comparison of a custom-made and The use of oral appliances to impact snoring and obstructive sleep apnea with oral appliances: an thermoplastic oral appliance to treat mild OSA. Am J Respir the upper airway during sleep will con- update for 2005. Sleep 29(2), 2006. Crit Care Med 178:197-202, 2008. 28. Cartwright RE, The effects of a nonsurgical treatment for tinue to evolve. As mentioned above, the 8. Epstein L, et al, Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. obstructive sleep apnea-the tongue retaining device. JAMA application of intraoral devices in tandem J Clin Sleep Med 5(3): 263-76, 2009. 248:705, 1982. with positive airway pressure appears to 9. Hoekema A, Efficacy and comorbidity of oral appliances 29. Kushida C, et al, Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an be a very promising direction. In addition, in the treatment of obstructive sleep apnea-hypoxemia: A systematic review. Crit Rev Oral Biol Med 15:137-55, 2004. update for 2005. Sleep 29:240-3, 2006. preliminary work is being done in areas 10. Loube D, Oral appliance treatment for obstructive sleep 30. Krishnan V, et al, Evaluation of a titration strategy for pre- seemingly tangential to the direct applica- apnea. Clin Pulm Med 5:124-8, 1998. scription oral appliances for OSA. Chest 133:1135-41, 2008. 31. Parker J, et al, Effect of a titration polysomnogram on treat- tion of the oral appliance to mechanically 11. Tsuriki S, et al, Effects of mandibular advancement on airway curvature and obstructive sleep apnea severity. Eur ment success with a MAD. JCSM 5(3)181-292, June 2009. reposition the tongue/mandible. For ex- Respir J 23:263-8, 2004. 32. Mehta A, et al, A randomized, controlled study of a man- ample, oral appliances that utilize intrinsic 12. Yoshida K, Effects of a prosthetic appliance for treatment dibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 163:457-61, 2001. (genomic) and extrinsic (epigenetic) factors of sleep apnea syndrome on masticatory and tongue muscle activity. J Prosthet Dent 79:537-44, 1998. 33. Ferguson KA, et al, A randomized crossover study of an oral in cephalic growth are being studied in an 13. Lindman R, et al, A review of oral appliances in the treat- appliance versus nasal continuous positive airway pressure effort to regulate and improve craniofacial ment of habitual snoring and obstructive sleep apnea. Swed in the treatment of mild-moderate obstructive sleep apnea. Chest 109:1269-75, 1996. form and possibly airway patency.40 In ad- Dent J 25:39-51, 2001. 14. Arai H, et al, Changes in work performances in obstructive 34. Panton C, et al, Dental side effects of an oral appliance to dition, work is underway to examine how sleep apnea patients after dental appliance therapy. Psychia- treat snoring and obstructive sleep apnea. Sleep 22:237-40, 1999. unique oral devices can impact the “chroni- try Clin Neurosci 52:224-5, 1998. 35. Lindman R, et al, A review of oral devices in the treatment of habitual snoring and obstructive sleep apnea. Swed Dent J cally overstimulated” autonomic nervous 15. Gotsopoulos H., et al. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, con- 25:39-51, 2001. system by positively affecting the ease of trolled trial. Am J Respir Crit Care Med 2002; 166:743-748 36. Rose E, et al, A comparative study of two mandibular ad- breathing, swallowing, and speaking. 16. Mehta A, et al, A randomized, controlled study of a man- vancement appliances for the treatment of obstructive sleep apnea. Eur J Orthod 24:191-8, 2002. Finally, commercial entities have seri- dibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 163:1457-61, 2001. 37. Hoekema A, et al, Efficacy and comorbidity of oral appli- ously entered the fray due to the recent 17. Bloch K, et al, A randomized, controlled crossover trial of ances in the treatment of obstructive sleep apnea-hypopnea: a rapid growth of oral appliance therapy and two oral appliances for sleep apnea treatment. Am J Respir systematic review. Crit Rev Oral Biol Med 15:137-55, 2004. 38. Rose EC, et al, Occlusal side effects caused by a mandibular the obvious commercial opportunities. Crit Care Med 162:246-51, 2000. 18. Clark G, et al, A crossover study comparing the efficacy of advancement appliance in patients with obstructive sleep In this regard, the next decade will wit- continuous positive airway pressure with anterior mandibular apnea. Angle Orthod 71:452-60, 2001. ness further transformation as appliance repositioning devices in patients with obstructive sleep apnea. 39. Almeida FR, et al, Long-term sequelae of oral appliance therapy in obstructive sleep apnea patients. Am J Orthod manufacturers, home care companies and Chest 109:1477-83, 1996. 19. Gotsopoulos H, et al, Oral appliance therapy reduces blood Dentofacial Orthop 129:205-13, 2006. sleep labs work with clinicians, scientists pressure in obstructive sleep apnea. A randomized, controlled 40. Singh D, et al, Epigenetic orthodontics in adults, Smile and professional academies to balance trial. Sleep 27:934-41, 2004. Foundation, 2009. the need for easy access to care with the 20. Naismith S, et al, Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: A to request a printed copy of this article, please contact necessity of well-trained practitioners and randomized controlled trial. J Clin Sleep Med 1:374-80, 2005. Robert R. Rogers, DMD, D.ABDSM, 11676 Perry Highway, high-quality clinical outcomes. 21. Schmidt-Nowara W, et al, Oral appliances for the treatment Building III, Suite 3201, Wexford, Penn., 15090.

february 2012 157 Do your patients snore?

The EMA Custom oral appliance will help them sleep! California Complete Dental Laboratories will help your practice thrive!

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EMA is the perfect way for your patients to discover how they can get a better night’s sleep. FDA cleared for the treatment of To prescribe an obstructive sleep apnea and snoring, EMA’s patented design increases airway space by advancing the mandible using EMA appliance interchangeable elastic straps. EMA offers advantages not for your patient, found in other oral appliances: t QBUJFOUTDBOUBMLBOEFWFOESJOLXBUFSXIJMFXFBSJOHJU call to schedule t JUJTDPNQMFUFMZGSFFPGNFUBMBOEUIF&."FMBTUJDTUSBQT are latex free your case pick-up t QBUJFOUTDBOFBTJMZDIBOHFUIF&."FMBTUJDTUSBQT today! at home 866.955.LABS (5227) completedentallab.com your EMA specialist & full service dental lab

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ema CALIFORNIA COMPLETE AD TOGO.indd 1 1/25/12 2:26 PM sleep physiology Do your patients snore? cda journal, vol 40, nº 2

The EMA Custom oral appliance will help them sleep! California Complete Dental Laboratories Neurology of Sleep will help your practice thrive! and Sleep-Related Breathing Disorders and Their Relationships to Sleep Bruxism jerald h. simmons, md

abstract Conditions that affect sleep can impact overall health. More than 70 million Americans suffer from problems with sleep. The purpose of this article is to provide the basic science of sleep physiology and how it relates to disorders that are pertinent to dentistry. Concepts are presented that explain airway dynamics and how the jaw and tongue influence airway obstruction. Additionally, explanation is given on an association myersontooth.com between temporomandibular jaw dysfunction and bruxism during sleep.

EMA is the perfect way for your patients to discover how they can get a better night’s sleep. FDA cleared for the treatment of To prescribe an obstructive sleep apnea and snoring, EMA’s patented design EMA appliance author elative to other disciplines, in 1991 and has grown extensively in the increases airway space by advancing the mandible using Jerald H. Simmons, md , sleep medicine is in its infancy. past 20 years. Now dentists can become interchangeable elastic straps. EMA offers advantages not for your patient, faasm, is a neurologist/ For years the delay in develop- involved, and, to assure they properly found in other oral appliances: sleep disorders specialist, ment of this field stemmed address sleep medicine, there now ex- past co-director at the primarily from the limited ists a dental sleep medicine board that t QBUJFOUTDBOUBMLBOEFWFOESJOLXBUFSXIJMFXFBSJOHJU call to schedule University of California, technology available to assess the sleep- provides guidelines for dentists who wish Los Angeles’ Sleep Center, R t JUJTDPNQMFUFMZGSFFPGNFUBMBOEUIF&."FMBTUJDTUSBQT ing process.1 As technology developed to credential in this area of medicine.2,3 your case pick-up and currently directs both are latex free Comprehensive Sleep and improved, the ability to understand There is a full spectrum of conditions t QBUJFOUTDBOFBTJMZDIBOHFUIF&."FMBTUJDTUSBQT Medicine Associates and the governing mechanisms of sleep in that affect sleep that have a far-reaching today! the Sadler Clinic Sleep a meaningful fashion became possible. impact on patients with a variety of condi- at home Disorders Center in Texas. Over the past 50 years, tremendous tions. The purpose of this article is to pro- strides have occurred that led to the cur- vide the basic science of sleep physiology rent knowledge and establishment of the and how it relates to disorders that are 866.955.LABS (5227) field of sleep disorders medicine. Unlike pertinent to dentistry. Concepts are pre- other areas of the medical field, sleep sented and build toward a knowledge base completedentallab.com medicine focuses on a physiologic process that will bring the reader to understand your EMA specialist & full service dental lab and not an organ system, and it integrates not only how modification of the jaw re- many disciplines under a single umbrella. lationship can enhance breathing but also © 2012 Myerson, LLC EMA® is a trademark of Frantz Design, Inc. US Patent Numbers 6,109, 265; D611, 153 & Patent Pending The American Academy of Dental Sleep explains how abnormal conditions during Medicine (AADSM) was originally found- sleep can be associated with sleep brux- ed as the Sleep Disorders Dental Society ism (SB) and TMJ dysfunction (TMD). CCDL is High End Full Service Dental Laboratory with the emphasis on the Complex Rehabilitation cases, utilizing CAD/CAM technology. Implant abutments, Crowns, Bars and Bridges can be milled out for you from Titanium, Zirconium february 2012 159 Dioxide and Lithium Disilicate (eMax). We are vendors for a number of the Dental Schools of the leading Universities.

ema CALIFORNIA COMPLETE AD TOGO.indd 1 1/25/12 2:26 PM sleep physiology

cda journal, vol 40, nº 2

Non-REM Sleep Wakefulness The reticular thalamic nucleus inhibits sensory The ascending reticular activating input from the thalamus along the thalamo- system inhibits the reticular thalamic cortical pathways which produces synchro- nucleus allowing the cortex to be nous EEG activity during Non-REM sleep. active during wakefulness. not suppressed, sends output to both the lower brainstem and to the thalamus with fibers that release Ach as its transmitter. REM sleep occurs when the locus coeruleus and the dorsal raphie nucleus stop their inhibitory activity over the PPT nucleus. In effect, this results in activation of the two Ach pathways of the PPT nucleus. Pathway 1 ascends into the thalamus as part of the ascending reticular activating system having an activating affect on the cortex creating hallucinatory phenomena during REM sleep. Pathway 2 descends to the bottom of the brainstem (medulla) ending at the reticulo-spinal figure 1. In non-REM sleep the cortex is not processing information from sensory input and the two hemispheres track nucleus. The reticulo-spinal track display EEG that is synchronized, meaning that the activity is similar on both sides of the head. This synchronization is consists of neurons that descend down governed by the reticular thalamic nucleus and is a key feature of non-REM sleep. During wakefulness the ascending reticular activating system stimulates the thalamus in regions that turn down the filtering mechanism of the reticular into the spinal cord and release glycine thalamic nucleus. This allows sensory input to pass through the thalamus, onto the cortex. In so doing each cortical as a neurotransmitter. This causes post- region performs specific processing and this result in changes in changes in the EEG that are different in each region, synaptic inhibition on the motor neurons thus desynchronizing the EEG signal. that leave the spinal cord, resulting in paralysis of the body during REM sleep. Basic Sleep Physiology and the level.7 The filtering is most robust dur- Therefore, during REM sleep the body Stages of Sleep ing stage N3 and it is during this portion becomes paralyzed while the cortex is very Sleep is divided into two main catego- of sleep that certain hormonal changes actively hallucinating. This muscle paraly- ries or stages: REM and non-REM. REM take place. For example, growth hormone sis prevents the body from acting out on refers to rapid-eye movement sleep, but secretion achieves its highest level dur- the impulses generated from the brain’s first it would be appropriate to describe ing stage N3 sleep. It is now recognized cortex during REM sleep.6,8-10 This change non-REM sleep, since it constitutes the that the greatest restoration of the body of muscle tone activity that occurs during majority of the sleeping process. Non-REM occurs during non-REM sleep, and most REM sleep has significant ramifications sleep is divided into three progressively specifically during stage N35,6 (figure 1). on aspects of breathing and influences deeper stages, referred to as N1, N2, and REM sleep has very different charac- the degree of obstructive breathing as N3.4 N3 is considered the deepest, most re- teristics. During REM, an individual is will be outlined later below11 (figure 2). storative level of sleep and is also referred actively dreaming or hallucinating and the During the day, a person maintains to as slow wave sleep.5,6 During non-REM cortex acts almost as though it is awake. a focused attention that shifts from one sleep, the brain utilizes a filtering mecha- There are three neurotransmitters that play object or thought to another. This capa- nism within the deep brain structures in an important role in REM sleep. These are bility of shifting our concentration in a a region known as the reticular thalamic acetylcholine (Ach), norepinephrine (NE) focused fashion is provided by the brain’s nucleus that blocks the sensory input and serotonin (5HT). In the brainstem, the ability to filter out irrelevant stimuli.12-14 coming from throughout the body from dorsal raphe nucleus, which utilizes 5HT As the brain fatigues there is a break- reaching the cerebral cortex. This filtering and the locus coeruleus that utilizes NE, down in the brain’s ability to filter out mechanism involves gamma aminobuteric are actively firing while awake and during irrelevant stimuli. This results in inatten- acid (GABA), an inhibitory neurotransmit- non-REM sleep. These two nuclei, through tion and distractibility and occurs with ter. During non-REM sleep there is a global 5HT and NE, suppress a region of the sleep deprivation.15 The part of the brain filtering of the incoming sensory signals brainstem known as the pedunculopontine that provides the filtration and focusing from throughout the body at the thalamic tegmental (PPT) nucleus which, when of attention is also within the thalamus.

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Brainstem regulation and control of REM

Fragmentation of Sleep and Daytime pedunculopontine Consequences nucleus (acetylcholine) Repetitive disruptions in sleep ascending — cortical activation continuity lowers the restorative proper- descending — skeletal muscle dorsal raphe nuclei inhibition via the reticulo spinal tract (serotonin) ties that sleep is intended to provide. locus coeruleus Increased sleepiness throughout the reticulo spinal tract (norepinephrine) day results from a heightened level of (glycine) filtering from the reticular thalamic post synaptic inhibit of decease firing rate the anterior horn cells which results in nucleus as it attempts to put the brain disinhibition of the to sleep.7 There are several common pedunculopontine conditions that disrupt the continuity nucleu of sleep and are important to understand in order to identify common sleep figure 2. Diagram shows the brainstem regions responsible for the regulation of REM sleep. disturbances. One common condition referred to as periodic limb movements As described above, during non-REM proximately every 90 minutes throughout of sleep or PLMS. This phenomena sleep, the thalamus provides a global the night. Each of these 90-minute seg- frequently occurs in patients who have filtration of incoming sensory stimuli. ments is referred to as a sleep cycle. As restless leg syndrome (RLS) but can As we become more sleep deprived this the brain progresses through these sleep also be seen in people without RLS.6,20 filtering effect is enhanced in order to cycles there is a decreased amount of N3 A more elaborate discussion of this achieve sufficient filtration of sensory sleep and an increase in the amount of condition is outside the scope of this input necessary for us to fall off to sleep. REM sleep.4,19 As a result, the last por- article. Another common condition While wide awake maintaining a tion of the night typically has no N3 or that is important for dentists to rec- focused attention on a complex task the slow wave sleep and the largest portion ognize relates to obstructive breathing brain is functioning in a completely op- of REM sleep of the night. Therefore, during sleep. The hallmark condi- posite fashion as to what occurs during most of REM sleep occurs during the tion in this category is referred to as non-REM sleep, during which there is no second-half of the night (figure 3). obstructive sleep apnea (OSA).6,21,22 specific cortical processing taking place and the cortex is globally under inhibition by the reticular thalamic nucleus. Trying to maintain focused attention while sleep deprived may prove challenging because of a globally enhanced degree of filtering exhibited by the reticular thalamic nucleus. Frequently, to maintain wakefulness when sleep deprived a person increases their stimulation level to stay awake. This is achieved by changes in behavior such as fidgeting, shifting in a chair, getting up to walk around etc. In essence they become hyperactive as a compensation to override the enhanced sleep drive of the reticular thalamic nucleus.16-18 The brain cycles through stages of N1, N2, N3, and REM over a 90-minute period, with REM sleep occurring ap- figure 3. Diagram shows a typical hypnogram of the different sleep stages that occur throughout the night.

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Normal Airway The Principles of Obstructive Breathing During Sleep To understand obstructive breathing, first refer to a principle of the physics known as the Bernoulli Effect. As flow goes through a space, there is a negative pressure or vacuum that develops within Obstructure sleep that space. If the space becomes nar- apnea (OSA) occurs rower and the flow volume is maintained from the airway constant then there is an increase in the collapsing degree of negative pressure or vacuum. An example of this phenomena is demonstrated by flow of water in the shower The jaw falls back while asleep results in the tongue and soft where the shower curtain is pulled in palate collapsing the airway Collapsing Airway toward the flow of water if the water Breathing through a collapsing airway stream is brisk. If the shower curtain causes a vacuum to be created in the is pushed away from the water, expand- throat. This pulls on the soft tissue ing the space, this lowers the amount of making it vibrate, causing snoring and complete collapse in OSA. negative pressure within the space. This same principle occurs in the back figure 4. Diagram demonstrating the changes in the airway structure during sleep and the resulting effects of of the throat. The tongue attaches to the breathing with the development of negative prssure within the pharynx. inner aspect of the mandible and then travels posterior toward the pharyngeal Abnormal degrees of negative pressure with various degrees of partial blockage wall and also curves upward and forward in the posterior pharynx causes the tissue in between. With partial blockage, airflow into the oral cavity. As the mandibular of the posterior pharynx to vibrate as it continues to be maintained but may be muscles relax and the mandible retrudes, is pulled downward. This vibration causes decreased without pauses in breathing. the base of the tongue moves with it and snoring. Depending on the muscle tone of Frequently when this occurs there may encroaches on the posterior pharyngeal the entire pharyngeal region, which is influ- even be a reduction in the blood oxygen wall. As this occurs the posterior pharynx enced also by the various sleep stages and level resulting from the decreased amount narrows and this results in an increase other factors, the airway may collapse from of air flow. However, many experts in negative pressure during breathing. this negative pressure vacuum. In some contend that a reduction in the oxygen When an individual goes to sleep it is patients the pharyngeal walls have more re- level is not necessary for an event to be normal for there to be an increase in the sistance toward collapse where –50 cm H2O significant if there is a disruption in sleep magnitude of negative pressure of the does not cause complete collapse of the continuity from the partial obstruction. posterior pharyngeal airway. Typically, airway. In other cases, the airway may be These partial obstructions lasting 10 sec- an awake person generates approxi- very collapsible and completely collapse at onds or longer are known as hypopneas. 6,25,26 mately –2 to –5 cm H2O pressure in this lower magnitudes of negative pressure. Respiratory events that occur during an region. When they fall off to sleep, OSA is classically described when the individual’s sleep, including both apneas generally it increases to –5 to –8 cm H2O. airway completely collapses, cutting off and hypopneas are reported using the Under abnormal conditions, such as flow while the chest muscles continue apnea hypopnea index (AHI) that refers with patients who have OSA, when the to attempt respirations. This type of to the averaged, hourly frequency of these individual falls asleep, the pharyngeal phenomena can clearly be seen on a sleep types of events. These events are reported space narrows to a degree where the study. From a practical standpoint, there together in the AHI because research has negative pressures can range from –15 to is a spectrum of the degree of obstructive not demonstrated a distinction in the

–30 cm H2O and, when severe, can even events with complete obstruction on one detrimental effects produced by severe 6,23-28 figure 4 generate levels beyond -100 cm H2O. end and normal breathing on the other hypopneas versus severe apneas ( ).

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The Upper Airway Resistance Syndrome Factors That Change in the As a result, the full severity of the person’s Many subtle respiratory events from Collapsibility of the Upper Airway obstructive respirations may go unrecog- partial airway obstruction occur and are Throughout the Night nized. For this reason, it is important to demonstrated with an increased magni- The likelihood of airway collapse not rely on sleep studies conducted with tude of negative pressure with each breath, fluctuates during the night based on sleep a split night protocol when establishing leading to disrupted sleep. Frequently, stage and body position, in addition to a severity rating of obstructive breathing these subtle events go untabulated by other factors. When someone is lying in for an individual, unless, however, the half routine PSG testing methods because the a supine position, gravity plays a role in night demonstrates severe OSA. Frequent- breathing efforts recording belt technology, the collapsibility of the pharynx.11 Gravity ly, partial night studies show individuals airflow monitors, and oxymetry monitoring can pull the tongue and mandible down- to have a lesser severity of obstructive used do not always demonstrate changes ward, increasing the degree of obstructive respiration than would have otherwise associated in breathing leading to arousals breathing as compared to lying in the been recognized had the diagnostic study in sleep. These subtle events trigger the lateral position. Frequently, individuals been performed the entire night. Render- muscles of the throat, tongue, and man- ing a designation of mild or moderate dible, increasing muscle tone and opening OSA to a patient who has had a split night the airway to normalize respirations. More it is frequently study is not appropriate for this reason. subtle respiratory events known as respira- For reasons not yet fully understood, tory effort-related arousals of sleep (RERAS) demonstrated that patients the upper airway is more resistant to col- are best identified and tabulated when the with severe sleep apnea lapse during slow wave or N3 sleep.32-34 Fre- sleep study is performed with the addition quently, individuals exert large degrees of of a small, soft catheter placed through have their worst obstructive negative pressure during slow wave sleep an individual’s nose and swallowed by the respiratory episodes during to breathe against a partially collapsed air- patient such that the tip of the catheter way and do not develop complete collapse resides in the esophagus within the midtho- REM sleep. of the upper airway. The same individual racic level. This probe, measuring internal during other stages of sleep, such as N1 or negative pressures during sleep, allows N2, will have complete airway collapse at for the proper tabulation of these RERAs with severe obstructive respirations during much lower degrees of negative pressure. that would otherwise go undetected and is sleep tend to prefer sleeping in the lateral Various medications such as those called esophageal pressure (Pes) testing. (Pes or prone position. This preference in body that cause muscle relaxation are known denotes pressure within the esophagus.) position is probably a subconscious prefer- to enhance the degree of collapsibility When an individual has fragmented ence to improve respiration. Sleep stage of the upper airway by decreasing the sleep and sleepiness primarily resulting from also influences the collapsibility of the airway muscle tone. Opiate medications these more subtle respiratory events the di- airway primarily as a function of muscle can also blunt the ability to increase agnosis of upper airway resistance syndrome tone. For example, during REM sleep, airway tone in the presence of increased (UARS) is given.29-31 Another method for muscle paralysis is manifested throughout negative pressure and thus enhance picking up RERAs using a pressure cannula the body as it decreases the muscle tone of obstructive respirations. Alcohol has a at the nostrils show patterns of flow restric- the upper airway muscles contributing to similar effect to that of muscle relaxants tion, known as flow limitation, do not show its collapsibility. As a result, it is frequently medications.34,35 Sleep deprivation also the degree of effort being exerted and are demonstrated that patients with severe has the effect of blunting the ability to not the gold standard of measuring RERAs. sleep apnea have their worst obstructive increase upper airway tone in the presence The UARS, consisting of subtle respi- respiratory episodes during REM sleep. of obstruction, and, as a result, obstruc- ratory events, is a very common disorder Since REM sleep occurs more toward the tive respirations become worse when a but its occurrence is unknown in part last portion of the night there would be a person is sleep deprived. This clearly is due to the fact that most sleep disorders minimal amount of REM sleep measured observed in individuals who provide a centers do not employ Pes testing to with a split night study (in which only half history of snoring to a greater degree objectively establish the diagnosis.29-31 the night is done in a diagnostic fashion). after having been awake for 24 hours.6

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Muscle Tone Inversely Related to Upper Airway Obstuction

Decreased muscle Increased muscle tone tone when not bruxing associated with tonic bruxing Treatment of Obstructive Respirations Phasic Bruxing Event During Sleep There are a variety of methods that can be implemented to treat OSA. Surgical methods are provided elsewhere. For patients in whom adipose tissue is a significant factor, weight reduction is beneficial. The most reli- able method for treating this condition is through the administration of continuous positive airway pressure Higher Pes pressures (more Lower Pes pressures (less (CPAP), which was initially studied negative pressure from negative pressure from less greater airway obstuction) airway obstruction by Colin Sullivan, MD, and published in 1981.37 Over the past 30-plus years, significant improvements in CPAP figure 5. The two tracings above are from the same patient at different points during the night. The tracing on the left demonstrates less EMG activity in the muscles influencing the mandible, when compared to the tracing on the right. treatment have been implemented. As a result, there is a greater degree of obstruction and negative pressure on the left tracing compared to the right. This CPAP works by providing positive is a demonstration of how tonic bruxism opens up the airway and reduces the obstruction. The phasic increase in EMG pressure to nullify the Bernoulli Effect, seen the left tracing as part of the arousal is a result of the obstructive hypopnea. described earlier, and neutralizing the vacuum of the upper airway, preventing upper airway collapse. This allows from an impression of the patient’s Bruxism During Sleep as a Protective an individual to maintain respirations face that attach to a dental appliance. Mechanism of Upper Airway Collapse without repetitive arousals, improving This results in a mask covering the nose The brain has inherent mechanisms sleep so individuals awaken refreshed. and mouth without any straps around utilized to decrease or eliminate the Various types of masks have been the head. The advantage of using a obstruction of the upper airway during developed to accommodate the variety of dental appliance in conjunction with a sleep. The preference of body position facial structures and personal preferenc- CPAP mask is that it helps stabilize the mentioned above is one subconscious es that exist within a general population. mandible in a more anterior or at least technique frequently utilized. Another CPAP therapy has been successfully im- in a neutral position, enhancing the method may be sleep clenching or brux- plemented in patients as young as under treatment from CPAP alone by opening ism. SB brings the mandible into occlu- the age of 1 and in the elderly beyond 90 the posterior pharyngeal airway space. sion, with or without tongue thrusting, years old. In some, special accommoda- Standard full-face masks have a tendency and may reduce obstruction of the upper tions are necessary to overcome pitfalls to push the mandible back, particularly airway that would otherwise occur in the in CPAP therapy. Sometimes simple mea- if the straps are tightened, and this has absence of such mechanical maneuvers. sures such as the addition of an elastic the effect of increasing airway obstruc- Historically, it has been recognized chin strap that holds the mandible closed tion and making the administration of that SB and TMD have been associated can provide the difference between treat- CPAP therapy more difficult. Stabilizing with obstructive sleep apnea patients.40-43 ment failure and treatment success. The the mandible with a dental appliance has The cause for this association has not been mouth falling open may result in CPAP demonstrated to improve the use of full- previously well-established and assumed pressure leakage that nullifies the effect. face masks when this problem occurs.39 to be brought on by the arousals trig- Recently there have been innovative Properly administering CPAP requires gered by OSA. Thus, bruxing or clenching techniques that utilize a combination a PSG study that carefully assesses the phenomena were considered part of the between dental appliances and CPAP changes in breathing with the differ- arousal process.44-46 Recent research by such that the CPAP mask is anchored ent CPAP levels, and the technologist Simmons and Prehn has demonstrated onto an appliance resulting in a stable titrates the pressure to identify the that SB or clenching may occur as a mech- mask without straps around the head.38 optimal settings for each patient. Many anism to prevent airway collapse. Their Also made are full-face masks moulded patients require very specific settings. studies have demonstrated that during the

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SB process there is a reduction of negative pressures of the upper airway, measured by pressure catheter Pes monitoring.47-49  When the SB process is not present, there is an increase in airway obstruc-  tion. Studying this population is difficult  because SB throughout the night mini-         mizes the obstruction and, as a result, the          degree of obstruction referenced by the           AHI may not meet the threshold necessary         to be considered abnormal by most sleep   disorder centers not utilizing Pes monitor-  ing, and not tabulating RERAs properly.   Treatment of obstructive breathing with  CPAP alone reduces the bruxism/clench-  ing and improves TMD symptoms in a  high percentage of patients.50-52 This sheds additional light on the importance of  airway dynamics and dentistry (figure 5).   Establishing the sleep-disorder diag-  noses early could result in a significant   improvement in overall health. This is  significant for cardiovascular and cerebral  vascular disease since these conditions are  now known to be worsened by the ongoing  process of obstructive breathing during   sleep.50-55 Establishing that a patient’s air-             way is vulnerable to collapse at a point in          the pathogenesis when they are attempt-  ing to compensate for the collapse by  bruxing may prevent the escalation of this       disturbance into OSA when compensation  either no longer is being exerted or no lon-           ger provides adequate airway protection.   As our heath care system matures, op-  portunities for collaboration between phy-        sicians and dentists are clearly evolving.           Changes in the upper airway, particularly  the mandibular anatomy and position, affect airway dynamics and can influence sleep. Only through greater initiative   within dentistry will the dentist’s impact  in our overall health care system be fully  recognized. The aspects of sleep and sleep  physiology covered in this article can help  the dentist work closer with physicians to improve their patient’s health.

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THE WORLD’S MOST TALENTED DENTISTS DIDN’T LEARN THEIR

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cda journal, vol 40, nº 2 Dentistry-Based Approaches to Sleep-Disordered Breathing, Algorithms, and Multidisciplinary Perspectives michael s. simmons, dmd; roy artal, md; miguel a. burch, md; richard p. cain, md; ruwanthi campano, md, ms; harry g. cohen, md; christopher a. mann, phd; todd morgan, dmd; judith a. owens, md, mph; andrew pullinger, dds, msc; robert relle, dds; john m. roesler, md; john sotos, md; john a. yagiela, dds, phd; ronald b. ziman, md; and jerald h. simmons, md

abstract Sleep disorders affect more than 20 percent of the U.S. population, but less than 7 percent have been medically diagnosed. Dentists are ideally positioned to identify many patients who fall under the grouping of sleep-disordered breathing. This paper presents perspectives on sleep-related issues from various medical specialties with a goal to broaden the dentist’s appreciation of this topic and open avenues of communication. Algorithms are proposed to guide dentists following positive screenings for sleep-disordered breathing.

authors

Michael S. Simmons, dmd, Miguel A. Burch, md, is ccording to a 2006 landmark lems (7 percent to 16 percent), sleep-relat- is a diplomate ABOFP, the associate director report by the Institute of ed movement disorders (4 percent to 12 FAGD, lecturer at the of general surgery and Medicine, sleep disorders and percent), and sleep-related breathing dis- University of California, Los minimally invasive surgery 4-12 Angeles, a clinical assistant at Cedars-Sinai Medical sleep deprivation remain an orders (SRBDs, 3 percent to 25 percent). professor at the University Center in Los Angeles. enormous unmet public health These ranges in prevalence vary by the of Southern California, Aproblem, yet sleep disorder “awareness population sample and the inclusionary serves on the Board of Richard P. Cain, md, is a among the general public and health care diagnostic criteria. For example, Schroeder AADSM and ASAA, and cardiologist, a fellow at professional is low, given the magnitude et al. determined that obstructive sleep is engaged in furthering Wadsworth VA, director 1 dentistry’s involvement in of cardiac rehabilitation at of the burden.” About 50 to 70 mil- apnea (OSA, a most serious form of SDB) sleep medicine. Providence Tarzana Medical lion people were reported in 2003 to be occurred in 50 percent of individuals >65 Center, and in private chronically affected by sleep disorders in years old in a random community sam- Roy Artal, md, fccp, practice in Tarzana, Calif. the United States, with these numbers ple.13 Shochat et al. found the prevalence faasm, is a diplomate increasing in concert with the obesity of insomnia to be 69 percent in a primary in sleep medicine and Ruwanthi Campano, md, 2,3 pulmonology, clinical ms, otorhinolaryngology/ epidemic. The International Classifica- care population, and Sack et al. reported instructor, University of head and neck surgery/ tion of Sleep Disorders (ICSD-2) lists ap- circadian rhythm disorders in >50 percent California, Los Angeles, and facial plastics and proximately 100 different sleep disorders.4 of the totally blind.14,15 In addition to those School of Medicine; reconstructive surgery, The four main sleep disorder categories, directly affected by sleep disorders and medical director of Tower is in private practice in according to most people affected, include sleep deprivation are bed partners, nearby Sleep Medicine in Los Lancaster, Calif. Angeles. insomnia (5 percent to 35 percent of the sleepers, parents of affected children, authors continue on 169 U.S. population) circadian rhythm prob- and even children of affected parents. It

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authors, continued from 168 is therefore reasonable to conclude that nal medicine, family practice, pediatrics, Harry G. Cohen md, facp, John M. Roesler, at least one-third of the U.S. popula- otolaryngology and neurology/psychiatry. is assistant professor of md, is an assistant tion will be impacted by a significant These would all be considered medical family medicine at Keck clinical professor in School of Medicine at the otolaryngology at 16 sleep disturbance during their life. sleep specialists (MSS). Additionally, University of Southern University of California, In terms of morbidity and mortal- the American Academy of Dental Sleep California, and a visiting Los Angeles’ David Geffen ity, the most important ICSD-2 sleep Medicine (AADSM), the premier dental physician for Vitas Hospice. School of Medicine and in disorder diagnostic category is SRBD group devoted to sleep issues, now has private practice in Tarzana, (which includes OSA), and it is here that a membership of more than 2,500 with Christopher A. Mann, phd, Calif. faasm, interprets sleep dental professionals can make significant more than 160 diplomates, and is one studies for multiple sleep John Sotos, md, is chief contributions as part of the sleep medi- of the fastest-growing professional sleep centers and performs site executive officer of cine team.17 Only about 5 percent to 10 organizations. In support of this interest visits for the American Apneos Corporation, percent of patients with OSA are diag- by dentistry is the increasing education Academy of Sleep a cardiologist, and an nosed; overlooked are 82 percent of males given at the predoctoral level, where the Medicine. adjunct professor of medicine at the University and 93 percent of females with moderate time devoted to sleep medicine has in- Todd Morgan, dmd, is a of North Carolina. 18,19 to severe and symptomatic OSA Even creased from a mean of about 30 minutes diplomate ABDSM, chief fewer patients receive adequate treat- in 2003 to almost three hours in 2009.25 of dentistry, Scripps John A. Yagiela, dds, ment with therapies such as continuous If a dentist wishes to include sleep Memorial Hospital- phd, is a distinguished positive airway pressure (CPAP).20 Given medicine as a part of his/her clinical Encinitas. He also is an professor emeritus, inventor and collaborator, Section of Dental the 300 million dental patient visits per practice, gaining perspectives of clinicians NIH research: oral Anesthesiology, University year in the United States, the dental office from other medical specialties provides appliance therapy, and a of California, Los Angeles, may be an ideal environment to apply insights that can enhance multidisci- board member of AADSM. School of Dentistry, in Los routine SDB or sleep wellness screen- plinary care. Primary care physicians Angeles. ing, possibly identifying many affected (PCPs), along with dental sleep medicine Judith A. Owens, md, mph, dabsm, is the director Ronald B. Ziman, md, facp, individuals before the onset of serious experts (DSEs), can together adequately of Sleep Medicine at faan, is board-certified 21 medical and psychosocial consequences. manage a large number of the simpler Children’s National in internal medicine, In spite of the high prevalence of sleep SDB cases. For those dentists who would Medical Center in neurology, vascular disorders, there is a great deficit in our prefer to just screen for SDB, they may Washington, D.C. neurology, a clinical health care educational system address- consider the PCP, DSE, or MSS for referral associate professor of Andrew Pullinger, dds, neurology at University ing sleep medicine. In 1978, Orr et al. to manage the case. More involvement msc, is a professor at the of California, Los reported less than one hour was spent on by the dentist still requires reliance on University of California, Angeles, and practices in sleep medicine during the four-year MD the MSS and/or other medical special- Los Angeles, School of Northridge, Calif. educational process.22 By 1993, educational ists to assist in management, depend- Dentistry, Section of Oral time had increased to about two hours, ing on the complexity of each case. Medicine and Orofacial Jerald H. Simmons, md, Pain, co-director UCLA faasm, is a neurologist and by 1998 reported time spent was Orofacial Pain and Oral and a sleep 23,24 up to 2.11 hours. With such limited Specialist Input Medicine Faculty Practice. disorders specialist exposure it is no wonder that physicians who trained at Stanford are generally not well-prepared to identify Anesthesiologist Robert Relle, dds, is University. He is past and address the gamut of sleep disorders. OSA is an independent risk factor for a diplomate ABOMS, co-director of University practices in Century of California, Los Angeles’ On the positive side, there is a burgeoning anesthetic mortality and is linked to vari- City, Calif., focusing on Sleep Disorders Center, interest in sleep medicine. The American ous comorbidities that also have implica- orthognathic surgery, and and currently directs Academy of Sleep Medicine (AASM) now tions for anesthesia care: morbid obesity, is a lecturer at University multiple sleep centers boasts more than 9,100 members, with pulmonary and treatment-resistant hyper- of California, Los Angeles, in Texas. 3,655 diplomates of the American Board tension, congestive heart failure, cardiac School of Dentistry. of Sleep Medicine. Additional boarded dysrhythmias, metabolic syndrome and sleep specialists are recognized since type 2 diabetes mellitus, hypothyroidism, 2007 in the medical disciplines of inter- gastroesophageal reflux disease (GERD),

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table 1

OSA and Anesthesia Management n Screen patients for OSA preoperatively. Refer patients for preoperative evaluation and treatment where the probability of OSA is high, surgery is elective, and there is a likely need for postoperative opioid analgesia or sedation.

n Develop an anesthetic plan tailored to the severity of the patient’s OSA and the planned pected OSA have been developed.27,28 procedure. Several instruments exist that can n When diagnosed with OSA and compliant with PAP, encourage its use preoperatively and help clinicians identify and classify ensure it is available for perioperative use. patients with OSA, including the Ber- n Where previously diagnosed but not compliant with PAP, reinstruct in its use. lin Questionnaire, the ASA Checklist, 28 n Avoid sedative premedication unless the patient’s ventilation is being continuously monitored. and the Stop-Bang Questionnaire. Of these, the Stop-Bang Question- n Use regional anesthesia and analgesia where feasible. naire is easy to use and has the highest n When general anesthesia is used, intubation is preferred. Be prepared for difficult sensitivity with acceptable specificity. intubation and other problems in airway maintenance. Use techniques that allow early return table 1 outlines the anesthetic man- of consciousness (e.g., desflurane, nitrous oxide, propofol, remifentanil). agement of patients with OSA.27,29 n Try to minimize postoperative opioid analgesia or sedation (consider acetaminophen, The recommendations listed intable 1 nonsteroidal analgesics, dexmedetomidine, low-dose ketamine). directly apply to dentists (oral surgeons, n Keep patients on continuous ventilatory monitoring postoperatively and resume PAP as dentist anesthesiologists) who admin- soon as feasible. Continuous monitoring may be discontinued if oxygen saturations during ister deep sedation/general anesthesia. sleep remain above 90 percent while breathing room air. Patients requiring ongoing opioid For other dentists, the implications analgesia or sedation should remain monitored until this need abates. inherent in table 1 strongly suggest that n Avoid the supine position. Use lateral positioning, a nasopharyngeal airway, and oxygen patients with OSA are poor candidates for therapy where PAP is refused and upper airway obstruction is problematic. in-office sedation using oral or paren- n Inform patients with unanticipated difficult airways of the possibility of OSA and refer for teral benzodiazepines or similar agents. sleep studies when clinically indicated. Even the prescription of oral opioids Modified from references Nos. 27 and 29. for postoperative pain relief may be problematic and should be approached with caution. This speaks clearly to the dentist minimally screening for SDB. and head and neck cancer. Anesthetic con- patency following acute obstruction and cerns specific to OSA begin preoperatively hypoxia/hypercarbia, patients with OSA Bariatric Surgeon and extend well into the postoperative pe- are at increased risk of anoxic death. Dur- The most common modifiable cause of riod. The same anatomic and neurophysi- ing induction, there is a much greater likeli- sleep apnea is obesity, which is defined as ologic derangements in people with OSA hood of encountering a difficult airway, a body mass index (BMI) >30 kg/m2. For that promote repeated collapse of the air- which can complicate both ventilation and every 10-point increase in BMI there is a way during sleep underlie the respiratory intubation. The greatest danger, however, 32 percent increase in the apnea-hypopnea complications associated with anesthesia. lies in the postoperative period. Airway index (AHI, the number of episodes of These derangements include a narrow su- obstruction and apnea are particularly sleep-disordered breathing per hour).30 praglottic airway and excessive relaxation likely when parenteral opioids are required As the epidemic of obesity continues to of muscles that, during consciousness, for postoperative pain relief. Case reports spread, one-third of Americans are now maintain pharyngeal wall tension (e.g., document lethal outcomes when such considered obese, and the fastest-growing sternohyoid) and prevent the tongue (e.g., patients are not intensively monitored subset is the super morbidly obese (BMI genioglossus) and soft palate (e.g., tensor for extended periods after anesthesia.26 >50, or 150 pounds above the ideal body veli palatini) from occluding the airway. In 2006, the American Society of weight).29,31,32 Management approaches Benzodiazepines and other sedative Anesthesiologists (ASA) published utilizing oral appliances and even upper drugs prescribed or administered for pre- guidelines for the perioperative man- airway soft- and hard-tissue surgery operative anxiety control may easily induce agement of patients with OSA; subse- have their greatest failures within this sleep in chronically fatigued individuals. quently, algorithms for the preoperative population as a result of the anatomical Because these drugs obtund the protec- evaluation and perioperative manage- and functional restrictions of the obese tive arousal response that restores airway ment of patients with known or sus- airway. Only tracheostomy is a predict-

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able upper airway surgical approach. severe repeated oxygen desaturations tion with the cardiologist is advisable in Although a loss of 10 percent of occurring with OSA can cause various these patients. Patients taking multiple body weight was found to decrease AHI dysrhythmias, such as severe bradycardia, blood pressure or heart medicines are an- by 26 percent, only intensive medically heart block, and premature ventricular other population of concern, for the same supervised diets produced 10 to 20 kg contractions. Finally, OSA has been asso- reasons. Finally, in the unlikely event that of weight loss within six months, and ciated with increased risk of death from a dentist is asked to treat central sleep this weight was universally regained nocturnal cardiac events, in particular apnea, cardiological consultation should within weeks of ceasing dieting.30,33,34 from midnight to 6 a.m., when sudden be obtained first as the apnea may be a Bariatric surgery, either gastric bypass death from cardiac causes occurred in 46 sign of inadequately treated heart failure. or lap-band surgery, has been shown percent of people with OSA compared to maintain weight loss for 10 years or to 21 percent of people without OSA.39 Neurologist/Psychiatrist longer and to reduce overall mortality Despite these associations, it is not There are many neurologic and psy- by 24 percent. Sleep apnea resolution possible to describe succinctly the degree chiatric conditions that overlap with sleep after bariatric surgery occurs in concert disorders. Morning headache, for example, with the weight loss and can start in can stem from the sleep pathology of the first three months after surgery. a recent review OSA.42 Similarly, studies show a great range A recent meta-analysis showed that in association of depression (7 percent to 63 postoperatively the AHI improved from identified nine different percent) and anxiety (11 percent to 70 per- 55 to 16 episodes per hour.35 Despite these physiological mechanisms cent) with OSA.43 Several conditions are dis- improvements, the AHI remains suffi- cussed below to assist the dentist’s knowl- ciently high for some patients to warrant by which apneas can edge of conditions they may encounter continued therapy. Since OSA is grossly derange cardiovascular when delving into a patient’s sleep history. underdiagnosed even in patients with Movement disorders may occur during morbid obesity who present for bariatric function. any part of the wake and sleep cycle, and surgery, mandatory testing of all patients restless legs syndrome (RLS) occurs in for OSA with polysomnography before both. It is a common condition present- bariatric surgery is recommended.36 to which OSA causes or exacerbates caring as an irresistible urge to move the diovascular disease or the effect of OSA symptomatic limbs, which then provides Cardiologist treatment on cardiovascular disease, for temporary relief. RLS affects about 10 per- OSA has potentially deleterious two reasons: 1) the relationship depends cent of the adult population (increasingly effects on the cardiovascular system. A on the severity of both the OSA and the in the elderly) and 2 percent of children. recent review identified nine different cardiovascular disease; and 2) data from It occurs in women almost twice as often physiological mechanisms by which the limited clinical studies to date are as in men. A patient lying in the dental apneas can derange cardiovascular func- often equivocal.40,41 Formal communica- chair who keeps shifting may have RLS tion.37 Moreover, these mechanisms tion is recommended as cardiologists are, even though appearing to have anxiety impact all major cardiovascular disease in general, increasingly conscious of the or another psychological condition. RLS entities: hypertension, heart failure, detrimental effects of OSA.41 Cardiology responds well to dopamine agonists and, dysrhythmias, atherosclerosis, and patients with severe OSA and/or severe if unaddressed, can disrupt sleep to a ischemia. Clinical studies show about a cardiovascular disease should generate significant degree. Periodic limb move- 50 percent prevalence of OSA in pa- the most immediate concern. For example, ments during sleep (PLMS) are usually tients with hypertensive cardiovascular some patients with advanced heart failure complaints by the bed partner rather than disease, 33 percent with coronary artery are very sensitive to changes in blood by the patient, although the movements disease, 30 percent to 40 percent with pressure, fluid status, or other demands may disrupt both sleepers sufficiently to heart failure, and 50 percent with stroke. on the heart. Because dental treatment cause excessive daytime sleepiness (EDS). About half of the patients with atrial can transiently alter blood pressure and Clues include disrupted bedding and bed fibrillation have OSA.38 It is believed the cardiac demand for the worse, coordina- partner-witnessed kicking, flailing, or

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other recurrent or potentially violent include cognitive deficits especially in psychiatric conditions generally relates to movements during the middle of the higher levels of executive functioning.45 reduced time in REM sleep, reduced total night. If such a sleep-related movement Chronic pain conditions such as sleep time and reduced sleep efficiency. history is obtained, it should be consid- fibromyalgia have long been recognized Medications addressing some psychiatric ered quite significant and followed up as associated with poor sleep, which disorders influence sleep, as do some with referral. The majority of patients lowers the underlying pain threshold. over-the-counter medications used for with PLMS also have daytime RLS.44 Patients who present with a diagnosis sleep. For example, antihistamines often Nocturnal myoclonus is in some of fibromyalgia or chronic pain without taken as a sleep inducer can cause cogni- ways similar to PLMS except that identifiable pathology should be consid- tive decline and memory problems in the movements are more isolated, not ered for screening of sleep disturbances. elderly, which may not develop for weeks periodic and usually occur in the transi- Narcolepsy is fairly renowned despite to months after starting the medication.46 tion between wakefulness and sleep. its limited prevalence (less than 0.05 Opioids, anxiolytics, and sedative-hyp- REM behavior disorder (RBD) may percent of the population46). Although notics taken for insomnia, may similarly appear as a movement disorder but is a contribute to cognitive disorders, espe- parasomnia in which the patient acts out cially in the elderly who are more sensi- dream content such as talking, swing- reduced sleep tive to such adverse effects. Of course, ing arms, or exiting the bed in elaborate these drugs may also aggravate SDB. imaginary confrontations. A lack of the in psychiatric conditions normal muscle atonia during REM sleep generally relates to reduced Oral and Maxillofacial Surgeon is the cause for this condition. There are Oral and maxillofacial surgeons a variety of etiologies and recent studies time in REM sleep, (OMFSs) have made important con- have described RBD as an early symp- reduced total sleep time tributions to sleep disorder therapy tom of Parkinson’s disease. Additionally by introducing surgical procedures for under the topic of movement disorders and reduced sleep efficiency. OSA and reporting on their outcomes. is nocturnal or sleep bruxism (SB), which No treatment for sleep apnea is eas- may be a forme fruste of a focal, mild, or ily accomplished and acceptable to all more generalized dystonia. SB is inti- this condition is notorious for extreme patients.38 Furthermore, the long-term mately linked with SDB. The presence of hypersomnolence, its most specific compliance required of patients being temporomandibular joint dysfunction characteristic is cataplexy, the sudden treated with positive airway pressure or arthritis in these patients may be a loss of muscle strength brought on by an (PAP) and oral appliances is not an is- result of bruxism or be incidental to it. emotional event, such as laughing. This sue for patients successfully cured with Sleep-induced seizures often arise out muscle weakness is attributed to the surgery.47,48 It is therefore likely that of instability in the brain as it transitions precipitous onset of a REM atonic state. surgery will maintain an important between wakefulness and sleep. While Many psychiatric conditions, such role in the treatment of OSA for those some of these patients also have daytime as depression, are associated with sleep patients who cannot tolerate or who seizures, those with only nocturnal sei- disorders. Falling asleep may be easily fail or decline nonsurgical treatment.49 zures may go undiagnosed for years, and, accomplished, but the affected indi- No one surgical treatment algorithm unless their bed partner is able to give a vidual awakens early, typically around 2 has been adopted by the surgical commu- clear history, they may never be identified. to 4 a.m., and is then unable to fall back nity. Some surgeons treat OSA in an es- Such patients, however, may complain asleep. Sleep-onset insomnia is more as- calating manner, beginning with phase 1 of muscle aches on awakening, enuresis sociated with anxiety, obsessive compul- surgery such as variations of adenoidecto- (bedwetting or nocturnal urinary incon- sive disorder, mania, hypomania, bipolar my, tonsillectomy, uvulopalatopharyngo- tinence), traumatized oral tissues (e.g., disorder, cyclothymic personality (where plasty, nasal or tongue surgery, and hyoid bitten tongue), unexplained bruises or un- mood fluctuates but not to the extent as myotomy and suspension. Patients failing explained confusion on awakening. Other seen in bipolar disorder), and some forms these procedures undergo maxilloman- brain-related manifestations of OSA may of schizophrenia.47 Reduced sleep in dibular advancement (MMA) as a second

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phase. Others advocate MMA as a prima- A less frequent but important Otolaryngologist ry definitive surgery, particularly for those referral to the OMFS is the infant or Snoring and OSA are caused by upper patients with diffuse upper airway ob- child with severe micrognathia who airway obstruction. It is important that struction or facial skeletal anomalies.50-54 has been referred for mandibular dentists be aware of the many separate Over the last two decades, the trend distraction osteogenesis. Although anatomic factors that contribute to these toward MMA as a definitive primary patients with Pierre Robin sequence disorders. Snoring or OSA can result from surgery has gained support.50 The Adult or a craniofacial malformation with nasal airway obstruction, obesity, mouth Obstructive Sleep Apnea Task Force associated micrognathia do not have breathing, lesions within the upper air- of the American Academy of Sleep OSA, there is a much more immediate way, hypertrophy or enlargement of the Medicine stated that, while MMA can risk of death from airway obstruc- adenoids, tonsils and base of the tongue, improve sleep study parameters com- tion. Many other medical and surgical and vibration of structures such as the parable to PAP, most other sleep apnea specialists are generally involved in the uvula and soft palate. Otolaryngologists surgeries may improve clinical outcomes care of these children, who often have can be useful partners to dentists who but are rarely curative for OSA.55 have an interest in screening for or who Referral to the OMFS for surgery is specifically focus on sleep disorders in appropriate when a diagnosis of OSA has it is important their practices. While general dentists been established and when other treat- most commonly focus on ameliorating ment modalities such as PAP and oral ap- that dentists be aware obstruction of airflow by the fabrication pliances have been deemed inappropriate of the many separate of custom oral appliances that advance or ineffective by the clinician or declined the mandible and/or tongue base, otolar- by the patient. In addition to conserva- anatomic factors that yngologists are accustomed to evaluating tive therapy failure, OSA patients who contribute to and managing the nasal and oropharyn- may be referred to the OMFS practice geal blockage leading to upper airway include, most commonly, the adolescent these disorders. obstruction. For example, adenotonsillec- or adult patient with a facial skeletal tomy is a commonly employed proce- anomaly, particularly retrognathia, who dure effective for SDB in children.59,60 has been referred by an orthodontist for additional life-threatening anomalies Otolaryngologists perform several orthognathic surgery. A diagnosis of OSA and comorbid conditions. For these core surgical procedures to improve nasal has often already been established, and patients, decisions about alternative breathing, including septoplasty (straight- the patient is seeking surgery to address airway management, such as naso- ening of the nasal septum), turbinate both concerns. Otherwise, sleep distur- pharyngeal intubation, tongue-lip reduction, and nasal valve reconstruc- bance information is elicited to confirm adhesion and tracheostomy, must be tion (adding internal cartilage grafts that a possible diagnosis of OSA, and formal made by the multidisciplinary team support the nasal sidewalls to prevent sleep consultation and polysomnography of clinicians and the parents.57,58 Even collapse of the nostrils). These can be are obtained as indicated. This work- though mandibular distraction osteo- important to aid the use of nasal CPAP, up is especially important for the cleft genesis offers the possibility of de- reducing dependence on more cumber- population, where OSA is known to be finitive treatment, the benefits of this some full-face masks.61 Other soft-tissue more prevalent.56 All patients undergoing surgery must be weighed against the surgical procedures that may help reduce MMA must be informed of the risk of risks, including damage to tooth buds, snoring and alleviate OSA in appropri- complications, and the discussion should mandibular nerve injury and premature ately selected patients include adenoton- include the heightened risk of sensory consolidation of the osteotomy requir- sillectomy, UPPP, radiofrequency pala- disturbance in the adult patient, stability ing reoperation. Its success is highly toplasty, placement of soft-palate Pillar issues and potential temporomandibular dependent upon the diligence of care- implants, lingual tonsillectomy, radiofre- joint problems owing to the relatively givers to perform daily activation of quency tongue-base reduction and hyoid larger maxillary and mandibular advance- the distraction devices, and it requires suspension.62 The overall efficacy of these ments commonly performed to treat OSA. a certain degree of patient cooperation. individual procedures is still under inves-

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tigation, and although there has been a es, abnormal central respiratory control. not been validated; thus, full-night trend toward concurrent multilevel ap- Studies comparing neuropsychologi- polysomnography in accredited sleep proaches, some procedures have lost favor cal functions in children with OSA have laboratories remains the “gold standard” following long-term results analysis.63,64 found impairments in tasks involving for diagnosing children of all ages and Additionally, otolaryngologists are reaction time and vigilance, attention, development using age-appropriate considered a last resort for unmanage- executive functions, motor skills and equipment and well-trained staff. able SDB for the morbidly obese, failure memory, as well as impairments in school Adenotonsillectomy is usually the of all other reasonable therapies or, in performance.69,70 Measures of behavior first line of treatment for pediatric OSA. rare instances, those who are born with and neuropsychological functioning Reported cure rates after adenotonsil- congenital central hypoventilation in children following treatment (usu- lectomy range from 75 percent to 100 syndrome.65,66 The management of these ally adenotonsillectomy) for SDB have percent in normal healthy children.75 severe disorders requires performance of documented significant improvement in Cure rates in obese children may not be a surgical bypass of the collapsible upper daytime sleepiness, behavior and aca- as good, but even obese children benefit airway, i.e., tracheostomy. Although this from adenotonsillectomy. The severity approach is not as socially acceptable, it is of the OSA affects the timing of surgery life-saving, and patients can learn adap- ethnicity also and the perioperative care. Children with tive techniques for masking the surgical very severe OSA who are at high risk of site. Finally, other upper airway pathol- influences the prevalence operative mortality related to surgery ogy, such as throat cancer, epiglottitis of OSA, with higher warrant stabilization beforehand. A and Ludwig’s angina, may cause acute sleep specialist should be involved in upper airway obstruction and require the rates reported such circumstances. PAP is an effective creation of a surgical airway in the neck. in African-Americans and reasonably well-tolerated treatment option for a wide range of children with Pediatrician and Asians. OSA, including infants, children with The prevalence of OSA in the pediatric craniofacial syndrome, Down syndrome population is estimated to be 1 percent to and those with developmental delay.76 PAP 3 percent for children 2 to 18 years old.67 demic performance and neuropsychologi- has been successfully used as the initial The prevalence of primary snoring in chil- cal measurements of attention, vigilance, treatment for children in whom surgery is dren is believed to be 9 percent to 12 per- reaction time, and cognitive functions.71 not an option, in children who continue cent.68 OSA occurs in all age groups, from Finally, several studies examining the to have OSA despite surgery and also to infancy through senescence, but the peak prevalence of SDB symptoms in children stabilize the child medically before surgery. age of presentation is 2 to 6 years, during with identified behavioral and aca- which time the tonsils and adenoids are demic problems have found an increased Pulmonologist proportionately large relative to the air- prevalence of snoring in children with Many respiratory conditions can affect way. Ethnicity also influences the preva- behavioral concerns and in children being sleep quality. Nocturnal dyspnea from a lence of OSA, with higher rates reported evaluated for or diagnosed with attention- multitude of conditions, including chronic in African-Americans and Asians. Obesity deficit hyperactivity disorder.72 A recent obstructive pulmonary disease (COPD), has become an increasingly important fac- report indicates that children with OSA chronic cough and asthma, can lead to tor in childhood OSA as obesity continues are heavy consumers of health care re- repetitive nocturnal awakenings, poor to increase in the pediatric population. sources and that early diagnosis and treat- quality sleep, and EDS.77 Patients with re- Obesity may further narrow the upper ment may be cost-effective in reducing strictive pulmonary disease, such as those airway because of fat deposition, mass the associated morbidity and mortality.73 who are morbidly obese, or individuals loading of the neck with subcutaneous tis- Routine screening for snoring should with neurologic disease and concomm- sue, decreased upper airway caliber from be a part of normal health care visits.74 itant respiratory muscle weakness, may additional loading of the chest wall and Various testing methods, including hypoventilate during sleep. Patients decreased lung volumes and, in some cas- imaging and home sleep testing, have with chronic lung disease, whether it be

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obstructive or restrictive, may suffer from to handle the full spectrum of sleep also be effective.88,89 Health care provid- chronic dyspnea leading to impaired sleep disorders. The MSS can be considered ers on a routine basis see patients who consolidation and nonrestorative sleep.78 the quarterback for patients who are have insomnia complaints. Patients with Such patients are also predisposed to found to have a sleep disorder. A problems remaining asleep likely require a suffer from abnormalities of gas exchange, properly trained MSS should recognize sleep study, especially if experiencing EDS. making them more susceptible to the the important role OAT plays in the Determining the primary diagnosis development of nocturnal hypoxemia treatment armament. The goal for of sleep disturbances can be challenging. and/or hypercarbia. These complications each dentist expanding his/her practice Many patients referred to sleep centers may arise with or without concomitant to include dental sleep medicine is to often take medication for depression or upper airway obstruction or apnea.79 partner with a MSS so that the dentist anxiety. For some, the primary problem has As a general statement, patients with is not functioning beyond the scope of to do with sleep, or the lack of it. Once the more complex heart-lung disease and con- dentistry while involved in this field sleep disorder is treated, the patient no lon- comitant OSA will require treatment with of clinical practice. ger requires psychoactive medication. Other positive pressure ventilation and are not EDS can be related to time-shift changes or appropriate candidates for initial treatment difficulty adapting to night or swing shifts. with oral appliances.80,81 CPAP-intolerant a bad night’s These circadian rhythm sleep disorders are patients however, may be appropriate can- diagnosed and treated by sleep special- didates for oral appliance therapy (OAT). Pa- sleep on an ists usually with behavioral approaches. tients with a history of cardiopulmonary dis- infrequent basis When possible, the patient’s sleep/wake ease and sleep complaints are best advised schedule is progressively shifted (normal- to speak with their PCP or a pulmonologist. is different from ized) with use of artificial light to stimulate insomnia that lasts a the brain wake times; medications such Primary Care Physician (Internist/Family as melatonin may also help. Individuals Practice) month or more. certified in behavioral sleep medicine by Fortunately, attitudes toward the impor- the American Board of Sleep Medicine tance of sleep health are changing. The re- are highly competent in the utilization of sult is a broader recognition among both the Behavioral Sleep Specialist — Psychologist CBT and other treatments for insomnia. health care community and patients that Insomnia is often associated with SDB, how much and how well we sleep matters. has additive negative effects and therefore The Dentist’s Role in SDB Patients increasingly self-refer to sleep disor- should be addressed to enable better triage Since many patients see their dentist ders centers. The Internet is replete with by the dentist.82,83 A bad night’s sleep on an more regularly than their primary care sleep health websites covering topics rang- infrequent basis is different from insomnia physician, the dentist may be the first ing from insomnia to snoring to sleep apnea. that lasts a month or more. There are many health care provider to interface with the A dentist who is involved with using causes of insomnia, with psychological, patient about sleep-related difficulties, es- appliances for the treatment of snoring or medical, and environmental contributors. pecially regarding snoring, OSA, and brux- OSA needs to recognize that patients with Patients with insomnia report having insuffi- ism. With this increasingly visible role of medical conditions should be followed cient sleep and often present with symptoms dentists in the management paradigm of in conjunction with their PCP. Hope- of daytime hypersomnolence, moodiness, SDB comes an increased responsibility to fully, PCPs will be increasingly receptive reduced affect, and decreased work produc- include sleep-related concerns within the to recognizing sleep disturbances and tivity. The two primary treatment strategies scope of their health survey. Three flow- directing patients toward proper care. are pharmacotherapy and cognitive/behav- sheets in this paper summarize for dentists ioral therapy (CBT). Medications, including the general overview approach to SDB The Medical Sleep Specialist hypnotics, anti-anxiety agents and antide- (figure 1) and specific aspects of screening Sleep specialists come from many pressants, are used particularly in acute cases, (figure 2) and co-treatment (figure 3). In different medical specialties; when but CBT is more effective over extended comparison with other health care provid- properly trained, they should be able periods.84-87 Combining both therapies can ers, the dentist may have a firmer founda-

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Overview Algorithm DDS collaborating with MSS on sleep disorders

Methods of screening Each contributes toward a full key assessment, but referral to a MSS MSS or medical doctor (PCP) can occur by any of these methods Dentist

Sleep questions on routine intake questionnaire

provide screening results Validated sleep questionnaire positive response Medical sleep from specialist’s screening patient develops evaluation Full sleep history, assessments daytime sleepiness, physical exam and hypertension or report of findings some other medical condition Lab PSG testing if indicated Home sleep testing interpreted by a MSS

Treat with a OAT Primary snoring: Mild to Severe OSA: Follow-up regularly and healthy patient, moderate OSA: CPAP Tx reassess if condition changes no sig. medical Hx multiple Tx options typically first line

Notes: If portable sleep monitoring is performed, it should be Tx with OAT or combination therapy. interpreted by a MSS. If there are no MSS locally then a medical Follow-up is done in conjunction with the MSS. doctor (PCP) with expertise in sleep medicine should replace Also consideration of treatment with the role of the MSS. Alternatively, collaborative consultation orthognathic/ENT surgery, depending on with distant MSS is advised. patient’s anatomy and preference.

figure 1. General overview algorithm for dentists.

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Screening Algorithm

Screening algorithm sdb screening by asking DDS not engaged in in routine dental visits sleep questions, checking providing collaborative upper airway, neck, BMI, etc. sleep medicine treatment

Maintenance no dental re-care SDB?

probable probable diagnosed Red arrows possible undiagnosed undiagnosed failed tx require physician follow-up

PCP PCP PCP PCP DSE DSE MedS MSS MSS MSS MSS + med history: no medical co-morbidities cvd, dm, copd, stroke etc.

adult DSE Dental sleep medicine expert ENT Otolaryngologist MedS Medical specialist (cardiology, etc.) Pediatrician Other sleep MSS Medical sleep specialist ENT child problem(s) PCP Primary care physician PSS/MSS +/- SDB PSS Pediatric sleep specialist SDB Sleep-disordered breathing figure 2. Screening algorithm for dentists. tion on many sleep disorder presentations ynx and glottis and be caused by such dis- calls for a complete history and physical and be more comfortable in engaging parate conditions as allergic rhinitis, tonsil- examination. Patients who snore but have other doctors in a multidisciplinary model. lar hypertrophy, and inspiratory pharyngeal only limited or marginal concerns related An important issue for the dental collapse. OAT might be quite successful for to their sleep, no comorbidities, a normal practitioner is to determine when snoring velopharyngeal airway collapse but it would BMI, and a normal head and neck examina- is just simple primary snoring (PS) versus likely not provide any airway benefit for tion should probably only be encouraged when is it nonbenign snoring, a marker allergic rhinitis. Designating a patient with to discuss their condition with their PCP or for OSA or another nocturnal respiratory a diagnosis of PS requires clear exclusion dentist sleep expert. If there are concomitant disturbance. The definition of PS is audible of any associated medical abnormalities. medical problems, such as hypertension, snoring without complaints of insomnia, A history must be void of conditions such coronary artery disease, prior myocardial EDS, or sleep disruption attributable to as hypertension, daytime sleepiness, fatigue, infarction or cerebrovascular accident, GERD, snoring or airflow limitation. The noises etc., and a sleep study, at minimum home diabetes mellitus, or respiratory illness (e.g., are not associated with significant airflow sleep monitoring, needs to yield normal asthma or COPD), they should raise red flags limitation, significant arousals from sleep, results. Also not everyone who snores for the dentist. These problems, along with oxygen desaturation, or cardiac dysrhyth- and is tired has sleep apnea. Just like any complaints of EDS and/or physical findings mias.5 Snoring may emanate from the other medical condition, the diagnosis and strongly correlated with OSA (e.g., obesity or nasopharynx down through the hypophar- management of a sleep-related complaint crowding of the airway), should also heighten

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OAT Treatment Algorithm

start MSS/PCP Snoring MSS/PCP SDB diagnosis by prescription UARS prescribed treatment sleep study interpreted for OAT OSA by MSS/PCP

max titration? CSA exhausted oat options? OAT titrated to Procedure eliminate snoring, no no EDS, etc.

yes PAP

Effective Surgical Consult PCP/MSS concur titration OMFS successful? no yes ENT Bariatric yes yes

yes surgical procedure

pap or combination consented? Repeat sleep study oat/pap trials shows SDB adequately no continue? no treated no only eds remaining? no yes yes yes

detrimental changes Long-term follow-up found on follow-up? Collaboratively every 6–12 mo along Expedite follow-up visit explore options. with the PCP/MSS to MSS/PCP Go to start? 1. Dental/OA changes no yes 2. Medical changes in BP, EDS, snoring, weight, etc. Steps in red boxes CSA Central sleep apnea require physician EDS Excess daytime somnolence (MSS/PCP) input MSS Medical sleep specialist OA(T) Oral appliance (therapy) OSA Obstructive sleep apnea PAP Positive airway pressure (CPAP, BiPAP, etc.) PCP Primary care physician/cardiologist etc. SDB Sleep-disordered breathing UARS Upper airway respiratory syndrome figure 3. Treatment algorithm for dentists.

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concern for the presence of significant SDB. care practitioners to educate and engage pa- syndrome in U.S. communities. Sleep Breath 6(2):49-54, 2002. Knowledge of these signs and symp- tients. As a primary care screener and active 19. Young T, Evans L, et al, Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged toms should stimulate communication with participant in the identification and/or treat- men and women. Sleep 20(9):705-6, 1997. the patient’s PCP. It might be necessary for ment of SDB, the dentist can play an integral 20. Weaver TE, Grunstein RR, Adherence to continuous the dentist to educate the physician regard- role alongside the PCP and MSS. positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 5:173-8, 2008. ing SDB. If this is the case, tact and support 21. Manski RJ, Moeller JF, Maas WR, Dental services: an analysis of are essential to gently educate the PCP references utilization over 20 years. 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PUBLICATION California Dental Association SIZE 4.75” x 7.5” SCREEN 100 lpi WO # 136856 IO # 600590 NOTES B/W CPS.temp.CDA.2011.qxd:CPS.APRIL.CDA.2010.qxd 1/19/12 1:57 PM Page 1

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Also serving you: Robert Palumbo, Executive V. P. /Partner, Alice C. King, V.P., John Knipf (Neff) President Greg Beamer, V.P., Tina Ochoa, V.P., & Maria Silva, V.P. Classifieds cda journal, vol 40, n 2 º

office for rent — A state of the art offices for rent or lease periodontal office in Century City How to Place a available for rent to endodontist, Ortho- dental suite for lease — Located dontist or Pedodontist 2-3 days a week. ClassifiedA d in prime area in Newark, CA. 4 operato- Contact 310-614-1449. ries, each fully equipped with dental unit, The Journal has changed its classified X-ray, N2O2, central air, vacuum, amalgam dental suite for lease — Located in advertising policy for CDA members to separator, and full complement of dental Glendora, just 35 min from downtown Los place free classified ads online and instruments. There are 1 panoramic X-ray, Angeles, this Mediterranean style, six-suite publish in the Journal. Only CDA members 2 intra oral cameras, 1 Chemiclave, 1 office complex is dedicated to dental can place classified ads. Non-CDA members DIAGNOdent, 8 high speed handpieces, professionals. The ground floor corner Suite can place display ads. 10 forceps, etc. Sterilization room, dark 3 with views of the San Gabriel mountains room, plaster room, 2 bathrooms, storage is now available for lease. This 1,125 sq. ft. All classified ads must be submitted room, reception room, business office and suite has been completely remodeled to through cda.org/classifieds. Fill out the private office are furnished. Ideal offices meet the demands of the digital practice blank fields provided, including whether for recent grad, relocation or second office. and is comprised of four operatories, lab, the ad is to appear online only or online Please contact Dr. J. Au at 925-828-7455 or sterilization, break room, consultation and and in the Journal. Click “post” to submit [email protected]. your ad in its final form. The ad will be continues on 184 posted immediately on cda.org and will remain for 60 days.

Classified ads for publication in the Journal must be submitted by the fifth of every month, prior to the month of publication. Example: Jan. 5 at 5 p.m. is the deadline for the February issue of the Journal. If the fifth falls on a weekend or holiday, then the deadline will be 5 p.m. the following workday. After the deadline closes, classified ads for the Journal will not be accepted, altered or canceled. Deadlines are firm.

Classified advertisements available are: Equipment for Sale, Offices for Sale, Offices for Rent or Lease, Opportunities Available, Opportunities Wanted, and Practices for Sale.

For information on display advertising, please contact Corey Gerhard at 916- 554-5304 or [email protected].

CDA reserves the right to edit copy and does not assume liability for contents of classified advertising.

february 2012 183 feb. 12 classifieds

cda journal, vol 40, nº 2

classifieds, continued from 183 reception with an additional 400 sq. ft. of patients and staff, or build your clientele. storage. Conebeam available. Common For more information please email opportunities available mechanical services (vacuum, air, water, gas, [email protected] or call 714-664-0200. building maintenance) are included in the opportunity available — Looking association. Negotiable term lease available. office for rent or lease — for an experienced motivated dentist who Walking distance to town center. Additional Starting in January 2012, prime office can work part-time in a very nice friendly information, photos and virtual tour space of 1,600 sq. ft. at $2.35 sq. ft. in a environment dental office. Call 510-796-3333 available at dentaloffice4lease.wordpress. two-story Medical Dental Professional or email [email protected]. com. Email [email protected] or call Building, ideal for SPECIALISTS! Current 909-910-2365. tenants include two general dentists, opportunity available — Get out plastic surgeon, pediatrician, ophthalmol- of the crowded city make great money and office for rent or lease — Very ogist, gastroenterology, nephrology, get excellent additional training, working nice general dental office has 2 operatories pharmacy, etc. Call 213-386-8200 or with me in my rapidly growing offices. available for leaseback. Bring your own [email protected]. We do all areas of dentistry and pride ourselves on our outstanding gentle care. With over 100 new patients a month we are growing too fast to keep up. We are proving SINCE 1987 that taking excellent care of patients can Nor Cal GOLDEN STATE PRACTICE SALES sm bring great dividends. Come work with a Specializing In Northern & Central California Practice Sales & Consulting great team, with great equipment in our James M. Rodriguez, MA, DDS chartless office in the beautiful part of 44 Holiday Drive, P.O. Box 1057, Alamo, CA 94507 California. Experience is always helpful, DRE Licensed Broker # 957227 however, as long as you are willing to learn, v MARIN COUNTY - Coll. $332K, 3 ops, between Sausalito and San Rafael. a lot of experience is not necessary. Email SOLD [email protected] or call 530-533-8204. v PERIODONTAL - S.F. EAST BAY - Established 30 plus years. Well known and respected in dental community. Seller will stay on contractually opportunity available — Part-time for introduction to established referral base. associate dentist wanted for a high quality, v CENTRAL CONTRA COSTA - DANVILLE - Established family 2 doctor practice near Old Town Pasadena. practice priv/ins UCR, $1.2M collections, 4 operatories. SOLD Senior doctor will be decreasing days over v SOUTH LAKE TAHOE - For Lease. 5 ops. Not equipped. No upgrades or the next few years. Fridays to start. 6 ops, additions needed. Call for details. 2 hygienists per day. The mission of our v DUNSMUIR - SHASTA - Dental office bldg for sale. Call for referral. practice is to provide the highest quality of v CENTRAL VALLEY - 3 ops., collections $725K. PENDING care with kindness, compassion, humility, integrity, and respect for our patients and Practice Sales - Presale Complimentary Consultations and Valuation Estimates each other. Minimum 2 years experience. Practice Appraisals and Forensic Services - Independent Practitioner Programs Please submit resumes to vasrdh31@ Each Transaction Handled Personaly From Start To Finish aol.com or contact 626-796-8904. Buyer Consultant Service Available STRICT CONFIDENTIALITY OBSERVED opportunity available — We are 925-743-9682 looking for an orthodontist to work in our Integrity-Experience-Knowledge-Reputation Dublin office. We are flexible with the e-mail: [email protected] days. Email resume for consideration to [email protected]. continues on 188 NorCal_GoldenState_Template.indd 1 8/15/11 3:32 PM 184 february 2012  

                                                                                                                                                                                                                                                                                                                                    

       PROFESSIONAL PRACTICE TRANSITIONS

“DENTAL PRACTICE BROKERAGE” Making your transition a reality. For more information regarding the listings below: More information is available on our website regarding practices 9,6,7285:(%6,7($7 3UDFWLFH6DOHV0HUJHUV listed in other states, articles, :::3376$/(6&20 3DUWQHUVKLSV$SSUDLVDOV upcoming seminars and more. (Practice Opportunities) Patient Record Sales s %, $/2!$/ (),,3 For Sale-General Dentistry Practice. s '2!33 6!,,%9 For Sale-General Dentistry Practice. of an attractive Medical Dental office building. Gross receipts 2009 GR $790,758, adjusted net income of $312K. Intra-oral Gross Receipts $491K with an adjusted net income of were $676,000 with a $174K adjusted net income. Dentist is camera, pano, Softdent software, 4-equipped ops. 6-hygiene $130K. Overhead 73%. Office leased 1,555 sq ft. 4 equipped retiring after 39 years. 4 days of hygiene. Additional operatories days. Practice has been inSOLD its present location for past 18 years. operatories 5 available. Laser, Intra-Oral Camera, Cerac, & could be added to existing space. Great location.#14376. Owner retiring. Eaglesoft software. Owner would like to retire. #37108. s ,%-//2%(!.&/2$!2%! For Sale-General Dentistry s %, $/2!$/ (),,3 For Sale-General dentistry practice. s '2%!4%2#()#/ For Sale-General Dentistry Practice. Practice & Building. Owner has worked in this location since Gross Receipts of $834K with adj net of $389K, 53% overhead. Gross receipts in 2010 were $584K, with an adjusted net 1971. Gross Receipts were $378K with $139K adj. net income. Office has five equippedSOLD operatories in 1485 sq.ft. Pano, income of $152K. Approx 1,100 active patients. 4 There are 3 equipped operatories and 3 days of hygiene. Intra-oral Camera, Dentrix, 5 days of hygiene. Owner retiring. operatories, Pano, Intra-Oral Camera. Easy dental software. Purchase of the building is optional to the Buyer. 100% s &/,3/- For Sale-General Dentistry Practice. Gross Receipts Leased office 1,200 sq. ft. Owner is retiring. #14359. financing is available for both building and practice. Excellent in 2010 were $703K with an adjusted net income of $300K. 5 opportunity for new grad or satellite practice. #14375. days of hygiene and approx1500 active patients. Leased Office s '2%!4%2 3!. */3% !2%! For Sale-General is 2,000 sq ft with 4 equippedSOLD operatories-5 possible. Patient Endodontic Practice. 2009 Collections were $1,187MIL with s ,).$3!9 For Sale-General Dentistry Practice & building. Base software. Owner to retire. an adjusted net income of $696K. There are 4 ops in this Gross Receipts $330K with adjusted net income of $219K. nicely decoreated 1,400 sq ft office space. 4 microscopes. Owner has operated in present location for 27 years. Office space s &/,3/- For Sale-General Dentistry Practice. Gross Receipts Owner has been in same locationSOLD for 26 years with long-term 1,489 sq. ft., 3 operatories available (2 equipped), Intra-Oral in excess of 1.5M the past three years. Adjusted Net of $550K. employees. Owner is retiring but will continue to work 1 ½ to Camera, Soft-Dent software. 3-hygiene days a week. Owner 2,700 sq. ft. office with 7 ops, Digital, Dentrix, Intra-Oral 2 years through the transition with the buyer. retiring. #14363. Camera, Laser, 5+year oldSOLD equipment, 8 days hygiene. Beautiful office, great location. Owner retiring. #14336 s (!7!)) -!5) For Sale-General dentistry practice. s ,)6%2-/2% For Sale-General Dentistry Practice. 2009 Gross Receipts of $636K. Office has four equipped Collections were $688K with an adjusted net income of $287K. s &/5.4!).6!,,%9 For Sale-General Dentistry Practice. operatories in 1198 sq.ft. Pano, Laser, I.O. Camera, Fiber There are 4 ops in this nicely updated 1,082 sq. ft. office space. Gross Receipts $284,000 with only a 47% overhead. Practice Optics, 2 ½ days of hygiene. Owner retiring: Don’t miss this Dentrix software, 6-days/wkSOLD hygiene. Owner has been in same has been in its present location for the past 37 years. There are opportunity to live and work in paradise. #20101 location for 36 years with long-term employees. Owner is two equipped operatories in this 5 op office. E2 2000 software. retiring. #14326 Doctor is retiring. s (!97!2$ For Sale-General Dentistry Practice. This practice consists of 1,600 sq ft with 4 treatment rooms in an s ,/3!.'%,%3 For Sale-General Dentistry Practice.1,200 sq s &2%3./ For Sale-General Dentistry IV Sedation Practice. excellent location. 2010 Gross was $501,000 with a $228K ft 4ops, 29 yrs in present location. Gross Receipts $274K with (MERGER OPPORTUNITY) Owner would like to merge his adjusted net income. DentalSOLD Vision software, Average age of adjusted net income of $89K. Owner to retire. #14348 practice into another high quality general dentistry or IV equipment is 8 yrs. Approximately 1,200 active patients. sedation practice. The merger would be into Buyers office. s -!2).#/5.49 For Sale-General Dentistry Practice. This Seller would like to continue to work as either a partner or s )26).% #/34! -%3! For Sale-General Dentistry is a small 650 sq.ft. office with three treatment rooms. The associate after the merger. 2010 collections were $993K with a practice combined. Gross receipts combined $781K with practice has a very low overhead of only 48%. 2010 gross $422K adjusted net income. There are 7 days of hygiene. adjusted net of $396K. Both office spaces are leased with receipts were $179,000 with $90,000 adjusted net. Practice #14250. 4-5 ops in each. Both are 1,600 sq. ft. Irvine is equipped with includes Panoramic X-ray and Easy Dental Software. Refers out Intra-Oral Camera, Pano & Dentrix. Costa Mesa is equipped O.S., Perio., & Endo. Practice has been in its present location for s ',%.$!,% FACILITY SALE-General Dentistry Office Space with Laser, Intra-Oral Camera, Pano and Dentrix. #14355. 30 years. This is an ideal practice for the new grad or satellite & Leasehold Improvements Sale- Office located in a medical practice for the established dentist. Owner is retiring. #14370 plaza, 1760 sq. ft. 7 operatories, computerized equipment s ,!'5.! .)'5%, For Sale-General Dentistry Practice. approximately 5 years old. Two 5-year options available. #14373 2010 gross receipts were $503k. 4 operatories, Pan, s -/$%34/ 42!#9 34/#+4/.!2%! For Sale-Pediatric computerized with EZ dental software. 1,500 sq. ft. lease. 10 Practice. $677,000 in collections in 2010 with a $357,000 net s '2!336!,,%9 For Sale-General Dentistry Practice. GR of years in present location. Owner retiring. #14352 income. This 3-chair office is located in approximately 1,250 sq $307,590 (3 days/wk) with adjusted net income of $105K. 3 ft & has recently been remodeled. Patient Base software. Office Ops. refers out most/all Ortho. Perio, Endo, Surgery. Intra-Oral s ,!+% #/5.49 For Sale-General Dentistry Practice. equipped for NO2 & IV sedation. Practice has operated in its Camera, Diagnodent, EZ Dental Software. Good Location. Gross Receipts 904K with adjusted net $302K. Practice has present location for 20 years. Owner retiring. #14337. been in same location for past 23 yrs, and 25 yrs in previous location. 2,600 sq ft with 8 equipped treatment rooms. s .%70/24 "%!#( For Sale-General Dentistry Practice. s '2!336!,,%9 For Sale-General Dentistry Practice. GR Intral-Oral Camera, Pano, and Data Con software. Owner to Practice has operated at its present location since 1986. Located 545K 3 days/wk (4 avail). 3 hygiene days/week. 5 Ops (6 Avail) retire. #14338 in a highly affluent Newport Beach community. Three (3) 1,950 sq ft. Refers out most/all Ortho, Perio, Endo, Surgery. s ,!.#!34%2 For Sale-General Dentistry Practice. This 4 hygiene days per week. LeasedSOLD office space with 4 ops. in 1,450 Office has Laser, Intraoral Camera, Pano, & Dentrix Software. sq. ft. Pano & Practice Works software. #14354. Owner retiring. #14372. operatory office is located in 2,360 Sq Ft on the second floor

CALIFORNIA / NEVADA REGIONAL OFFICE HENRY SCHEIN PPT INC. Henry Schein PPT Inc., Real Estate Agents California Regional Coporate Office and Transitions Consultants DR. DENNIS HOOVER, Broker Office:(800) 519-3458 Office (209) 545-2491 'U7RP:DJQHU 1&DOLI Mario Molina (323) 974-4592 S. Calif. Fax (209) 545-0824 Email: [email protected] -LP(QJHO 6)%D\$UHD Thinh Tran (949) 533-8308 S. Calif. 6WRGGDUG5RDG6WH0RGHVWR&$ PROFESSIONAL PRACTICE TRANSITIONS

$R$ENNIS(OOVER 7ESTERN2EGIONAL-ANAGER $R4HOMAS7AGNER *IM%NGEL 4HINH4RAN -ARIO-OLINA #ORPORATE"ROKER 4RANSITIONS#ONSULTANT 4RANSITIONS#ONSULTANT 4RANSITIONS#ONSULTANT 4RANSITIONS#ONSULTANT #!2%,IC .62%,ICs.6"/,IC #!2%,IC #!2%,IC #!2%,IC #!2%,IC s ./24(%2.&2%3./For Sale-General Dentistry Practice. s 3!#2!-%.4/ For Sale-General Dentistry Practice. approximately 1,800 sq. ft. with 6 operatories. The building has This is a perfect starter or satellite practice. Excellent location in Gross Receipts $546K with adjusted net income of $159K. been recently re-roofed. Excellent opportunity for a startup North Fresno. Gross Receipts in 2010 were $173K. Office is 2,400 sq ft with 7 operatories. Practice has been practice or for the dentist that needs more space. Financing Approximately 450 active patients. 3 operatories. Dentrix operating in the same location for the past 50 years. Pano, available through various dental lenders. #14368 software. Leased office 1,200 sq. ft. Owner has been accepted to Softdent software. Owner to retire. #14374 an Endodontic Residency after starting practice 1 1/2 years ago. s 3!.4! #25: For Sale-General Dentistry practice. Gross s 3!#2!-%.4/2/3%6),,% For Sale-One of many Receipts $300K with a 57% overhead. Office is 1,140 sq. ft. 3 s ./24(%2.#!,)&/2.)!For Sale-Endodontic Practice. partners is retiring in this highly successful General Dentistry equipped operatories. Intra-OralSOLD Camera, Pano, Digital X-Rays, This Endodontic practice is located in an upscale professional Group Practice. Intra-Oral Camera, Digital Pano-Dexis, and Dentrix software. Practice has been in its present location office complex. The owners condominium occupies 1,770 sq ft, electronic charts, owner Financing. Call for further since 1980. Owner retiring. #14358. There are 4 equipped treatment rooms with an additional 5th information. #14334 room available. Gross Receipts were $638K with $239K s 3!.4! #25: For Sale-General Dentistry practice. This adjusted net income. Owner will stay for transition to introduce s 3!."%2.!2$)./For Sale-General Dentistry Practice. excellent practice is centrally located in a professional complex. buyer. Owner is retiring. #14251 GR $972K. Practice has been in its present location for the Office is approx. 1,885 sq. ft., 4 operatories with room for one past 35 years. Leased 4,500 sq ft of office space- 12 equipped additional. There are approx. 2000 active patients with 6 days of s ./24(%2. #!,)&/2.)! For Sale-Pediatric practice. operatories. Dentrix software, Pano and Cerac. Accepts hygiene per week. Practice Pano, Intra-Oral Camera and Easy Owner has operated in same location for 32 years. Approx 1,760 HMO. Multi-specialty practice. Owner to relocate. #14377 Dental software. Owner is retiring. Reasonable lease available. active pts, 1,160 sq ft, panoramic X-Ray, Dexis Digital and #14361 Dentrix software in this SOLD 5–chair office. 2009 Gross Receipts s 3!. $)%'/ For Sale-General Dentistry practice. Gross $713K with 48% overhead. Owner retiring. Call for Details. Receipts $414K. Practice has been operated by the same s 4/22!.#% For Sale-General Dentistry practice. This owner for the past 6 years. Leased 950 sq. ft. office with 3 excellent practice is centrally located in a professional complex. s /#%!.3)$% For Sale-Modern looking office. 4 op, office equipped operatories. Dentix software, Intra-Oral camera, Office is approx. 1,885 sq. ft., 4 operatories with room for one space and equipment only. Belmont chairs. Gendex x-ray Panoramic X-Ray. Owner to relocate. #14356. additional. There are approx.SOLD 2000 active patients with 6 days of system, intraoral camera, approx 1200 sq ft. Low overhead-Rent hygiene per week. Practice Pano, Intra-Oral Camera and Easy is $1,900/month, and it's a 5 year lease. Staff is available for s 3!. $)%'/ For Sale-General Dentistry Practice. 6 ops, Dental software. Owner is retiring. Reasonable lease available. rehire-front desk $15/hr, assistantSOLD 13/hr. Update all the computer Intra-Oral camera, Eagle Soft Software. Office square feet #14320 systems after purchasing the office in 07. Computers and 2,300 with 3 years remaining on lease. 2009 Gross Receipts monitors in every room. #14346 $1,448,520, with an adjustedSOLD net income of $545K. Doctor s 4/22!.#% For Sale - General Dentistry Practice. Gross would like to phase out then retire. #14331 Receipts $413K with an adjusted net income of $203K. 50% s 0,5-!3#/5.49 For Sale-3 equipped ops. Space available overhead. Practice has been in its present location for the past 25 for 4th op. 1,245 sf office in good location. Gross Receipts s 3!.4!"!2"!2! For Sale-General Dentistry Practice. years. The office has been tastefully remodeled. Office is 800+ $475K. Practice in present location over 50 years. Owner is This excellent practice’s 2009 gross Receipts $891K with sq. ft. with 3 equipped operatories. 4 -hygiene days per week. retiring. #14318 steady increase every year. Practice has 6 days of hygiene. Doctor is to retire. #14369 1,690 sq. ft., 5 ops, Laser, Intra-Oral Camera, Schick Digital s 2%./ For Sale-General Dentistry Practice and Dental X-Ray, Datacon software.SOLD Doctor has been practice in same s 42!#9For Sale-Equipment, furnishings, and leaseholds only. Building: 2009 Gross Receipts $517K with adjusted net income location for the past eleven years of his 31 years in Santa In the Central Valley. Fully equipped including 4 Belmont of $165K. 4 ½ hygiene days/week. 1, 800 sq. ft. with 6 equipped Barbara. Doctor is retiring. #14333 Accutrac chairs, 2 Midmark chairs, 6 DCI rear delivery units, 3 ops. (7 Avail). Dentrix software,SOLD Pano. Practice has been in its Gendex x-ray units, 1 SoridexdigitalSOLD x-ray processor, 1 Statim present location for 40 years. Owner retiring s 3!. ,5)3 /")30/ For Sale - Two Doctor General 5000, 1 Harvey autoclave. 2,800 Sq ft, 6 Ops. New lease Dentistry Practice. Gross receipts $1,537,142 for 2010 with available from landlord. #14335. s 2/#+,). For Sale-General Dentistry Practice. Gross an adjusted net income of $691K. The office has 2,331 sq. ft. Receipts $593K in 2010 with $240K adjusted net income. with 8 equipped operatories. Pano, E4D, and Dentrix s 6)3!,)!For Sale- General Dentistry Practice. Gross Receipts Office is 1,630 sq. ft., with 4 operatories equipped with fiber software. Practice startedSOLD in 1990 and has been in its present $616K with an adjusted net income of $ 321K. Office is 1,380 sq optics. Owner has been inSOLD present location for the past 13 years. location since 1998. Approx. 3000 active patients. Great ft with 3 equipped operatories,SOLD Intra-Oral Camera, Digital 3 1/2 days hygiene. Intra-Oral Camera, Dentrix software. Owner location with nice views. #14353. X-Rays, Mogo software, equipment & leaseholds look new. 5 to retire. years in present location. Owner to relocate. #14347 s 3!.4! #,!2! For Sale - BUILDING ONLY: This s 2/3%6),,% For Sale-General Dentistry Practice. Great building is located just west of Westfield Mall and Santana Location. 2009 GR $900K with adjusted net income of $300K. Row. The building has two units. One side is designed and 1,975 sq. ft. with 4 ops, 8 days hygiene/wk. Digital, Intra-Oral plumbed for dentistry and the other was a law office. There Camera, Dentrix, Trojan, fiberSOLD optics, P & C chairs - all less than is 3,776 sq. ft. of office space. The dental office is 5 years old. Owner is retiring. #14327 CALIFORNIA / NEVADA REGIONAL OFFICE

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opportunity available in simi opportunity available — A opportunity available — Looking valley — This is a wonderful opportu- growing private office with private for a sweet and energetic GP with nity for an associate who is interested in patients and PPOs only in Las Vegas is in experience working with children. committing to a full purchase later this need of an experienced GP full time. Preferred having oral conscious sedation year. Looking for someone who is profi- Great opportunity for those who want license. Full-time position. If interested cient in all phases of general dentistry, great compensation for now and have an contact Dr. Camila Borrero by email at including molar endo, with at least 5 years option to BUY in the future. The comput- [email protected]. of practice experience. You should be erized Dentrix office is extremely efficient professional in demeanor, empathetic, and for highly productive doctors that are opportunity available — Looking able to communicate with patients and self-motivated and have well rounded for Bilingual Spanish Dental Associate for staff. This is a well-established successful clinical skills. This is not a fast paced, high dental office in Huntington Park. Please practice in Simi Valley emphasizing quality volume, big corporation type of practice. email resume to [email protected]. dentistry and patient education. The office There is no pressure, you can make your has 6 operatories, Dexis X-ray, digital Pano own decision and be your own boss. The opportunity available — Dental and Eaglesoft practice software. There is owner wants to retire. Must have active Hygienist in Smith River. 2-days/wk. Rare no HMO or Medi-Cal. If you feel you are NV license and currently effective opportunity to work in a state-of-the-art the right person for this position, please malpractice insurance before working dental facility as part of a comprehensive email your resume to simidentalpractice@ interview. Please email your resumes to health care organization. We strive to

gmail.comFoundation_Sept_2011_Journal_halfpg.pdf or call 805-522-8330. [email protected] 1 8/16/11 4:38 PM or call 702-348-4462. continues on 190

The Foundation’s significant Creating smiles, achievements include its work in changing lives. community water flouridation, CAMBRA, the development of Thanks to generous donations to the Perinatal Oral Health Guidelines CDA Foundation, nearly 85,000 and the Student Loan Repayment C underserved Californians received Program, which awards grants to M oral health care in 2010, reflecting new dentists in exchange for a Y more than $12 million in services. commitment to provide services to CM The Foundation that started with underserved communities that are MY a single employee and a sole most in need. CY purpose celebrates its 10th

CMY anniversary of transforming lives

K across California.

Thank you to our supporters:

188 february 2012 “MATCHING THE RIGHT DENTIST TO THE RIGHT PRACTICE”

Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

3061 SAN JOSE DENTAL FACILITY Dental facility ideal for Pediatric or easily converted to GP. Located in desirable Evergreen area in a two-story, handicap accessible, high profile, medicalSOLD and professional building. Gross lease with utilities included expires July 2013 with 5 year option to renew. Modern, tastefully designed, approximately 1,321 square feet. Asking $95K.

3064 SAN JOSE GP Now available. Great turnkey opportunity. Beautiful 1,500 sq. ft. facility with 4 fully equipped ops. State-of-the-art fully networked office, Dentrix software, digital x-ray & recently purchased dental & office equipment. Avg. GR $328K+ with 4 doctor-days. Owner willing to Serving you: Mike Carroll & Pamela Gardiner help in transition. Asking $220K. 3068 MONTEREY COUNTY GP Practice on the Monterey Peninsula surrounded 3065 FREMONT GP by natural scenery in a well-established general Don't miss this opportunity. Spacious 1,150 sq. and cosmetic practice. Located in a desirable ft. office w/3 ops. No Capitation. 2010 GR commercial and residential mix neighborhood 169K+ w/just 2-2.5 doctor days. Perfect on a well traveled street surrounded by two opportunitySOLD to take this practice to the next upscale shopping areas. The 2,000 sq. ft. office level. Owner retiring. Asking $124K. is state-of-the-art w/digital x-ray and 6 modern and fully-equipped ops. Long term & loyal staff. 3057 SAN JOSE GP Approx. 1,500 active patients all fee-for-service. Priced to sell. Located in 2 story professional 3 year avg. GR $1.7M, 2011 GR on schedule for building w/3 fully-equipped ops. in 990 sq. ft. $1.8M. Avg. net profit $700K+. Asking office. Part of historic Rose Garden $1,374,000. neighborhood; 1 block from the Alameda, & near a wellSOLD travelled intersection. Seller 3049 SAN JOSE GP transitioning due to health reasons. FY 2010 GR Well-located, across from O'Connor Hospital, $415K. Asking Price $120K. general practice in 2,118 sq. ft.state-of-the-art facility w/ 3 fully-equipped ops. 2 pvt. offices (1 3069 NAPA VALLEY ENDO can be plumbed for 4th op.). This office is Endodontic practice now available in Napa beautifully designed and is stunning. In addition Valley. Gorgeous state-of-the-art 1,450 sq. ft. to his general practice, owner treats sleep apnea facility w/4 fully-equipped ops & microscope in patients. Owner selling just the general every op. Single story professional building. operative portion of the practice and is willing Well-established w/seasoned & loyal staff. Avg. Contact Us: to help for a smooth transition. Ideal for an GR over $1M past 3 years w/4.5 doctor days. Carroll & Company experienced dentist looking to merge an existing Excellent referral sources and upside 2055 Woodside Road, Ste 160 practice. Asking $195K. opportunity. Redwood City, CA 94061

3059 SANTA CRUZ COUNTY GP & BDG UPCOMING LISTINGS: Phone: Charming practice tucked among soaring 650.403.1010 redwoods in Santa Cruz County. Located in a 3070 SOUTH BAY OMFS single level professional building in the heart of Owner transition to retirement. Offering well Email: established practice and referral sources in a town. Well established and part of the small [email protected] community landscape. 2010 GR $595K+ w/3 highly desirable residential and commercial mix doctor days. All fee-for-service. Owner retiring neighborhood with great upside potential. Website: and willing toPENDING help for a smooth transition. This www.carrollandco.info is a great turn key practice and opportunity to 3071 SONOMA COUNTY GP own a hidden gem. Practice asking price $373K, Outstanding opportunity. Large, successful 6 op CA DRE #00777682 building is also available. GP. Approx. 1,500 loyal & stable patient base.

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classifieds, continued from 188 provide quality, comprehensive dental care work closely with a team of other dentists opportunity wanted — After over in a comfortable caring environment. Must and hygienists in providing culturally 20 successful years, I sold my upscale, have an AA degree or equivalent combina- sensitive, high quality and comprehensive private practice and I am looking to tion of education and experience from an health care services to the Indian Commu- relocate to CA. Let me email you my list accredited dental hygiene school and nity. Computer skills and ability to work of advanced CE courses I have attended, minimum of 1 year related experience. in fast paced environment required. as well as testimonials and photos from Must posses a CA Dental Hygienist license. Competitive wages and benefits. Salary is my previous patients. This will let you Salary is $22.67/hr and up DOE. Email $109,907/year and up DOE. Open until get to know a little about me, as well as [email protected] or call 707-825-4036. filled. Email [email protected] or call the high quality of restorative and 707-825-4036. cosmetic dentistry I can provide. I have opportunity available — Dentist in an excellent chair side manner, my Arcata, CA. United Indian Health Services opportunities wanted patients and staff really know I care. I (UIHS), a non-profit community clinic have my CA license, and can quickly be providing health care to American Indian opportunity wanted — In the wherever needed when the right people and their families, is seeking a FT Greater San Francisco Bay Area. Implant opportunity arises. I am looking for a Dentist to provide outpatient care. Surgery/Bone Grafting/Perio Surgery/3rd long-term relationship in a high quality, Located in beautiful Northern California, Molar Extractions/Surgical Extractions. patient centered office. Thank you! UIHS offers an opportunity for personal Email: [email protected] or call Please email [email protected] or call and professional growth. This position will 617-869-1442. 949-922-5987.

opportunity wanted — Experienced G.P. available for temporary vacation coverage, health emergencies, practice transitions, etc. Also interested in part-time permanent position. S.F. Bay Area, Northern California. Contact 925-757-1383 or 925-783-2815.

opportunity wanted — Periodon- tist/Implant Surgeon with extensive background in all phases of regenerative surgical treatment, implant placement, and substantial experience with implant restoration seeks part-time surgical position in a general or multi-specialty office looking for an old-fashioned work ethic, excellent chair-side communication skills, and a commitment to quality care. A graduate of the Misch Institute in both Surgery and Prosthetics, doctor Missing a Journal? has a successful track record in presentation and completion of large, com- All issues back to 1998 bined surgical/restorative cases as an are available at cda.org in-house provider for quality-minded restorative practices. References are No password required. available upon request. Email lvan930@ yahoo.com or call 707-695-7229.

continues on 90

Journal_archive_1-3_square.indd 1 1/23/12 7:23 AM 190 february 2012 Professional Practice Sales of The Great West

If you want your practice “For Sale”, we are not the rm for you. If you want your practice “SOLD”, contact us!

5999 “SOLD” PLEASANTON Adjacent to Hacienda Business Park. 2011 6013 “SOLD” LIVERMORE Not yet 4-years old, tracking $430,000+ in tracking $900,000. Strong profits. Digital radiography with collections 2011. Attractive 4-Op suite fully networked, employs computers in Ops. Great visibility. computer charting and digital radiography. 6003 “SOLD” PINOLE - HERCULES AREA 4-days of Hygiene. 90%+ effective 6014 “SOLD” SAN FRANCISCO Located in “Heart” of the Mission. Owner Recall. Produced $740,000 and collected $709,500. Low AR balance. does not speak Spanish. 2011 tracking $425,000+ with $185,000 in Endo referred. Profits on 3-day week. 3-Ops. Great opportunity for Successor who 6004 “SOLD” SAN JOSE’S SANTA TERESA AREA Asking slightly more shall devote more attention. Building has private garage for tenants. than what it would cost to replicate this office today. Digital & 6015 SONOMA COUNTY’S HEALDSBURG Vibrant economy and great paperless 3-Op suite. 2010 produced $385,000 with collections of small town atmosphere. Anchored by 4-day per week Hygiene $277,000 and Profits of $190,000+. Gorgeous facility. Lease allows schedule and great Office Manager. Revenues tracking $545,000 occupancy thru 9/30/2024. with Profits of $235,000 in 2011. 6008 MENDOCINO COAST - FORT BRAGG Nestled in desirable cultural 6017 CAMPBELL 2011 shall collect $600,000. Adec delivery systems, haven creates attractive lifestyle. 4-days of Hygiene. 2011's computer charting, digital radiography, Biolase Waterlase, collections totaled $725,000. Owner works 3-day week and states he Panorex. $380,000 invested here. Full price $350,000. could work more if desired. Computerized Ops and digital radiography. 6018 SAN JOSE’S CAMPBELL Senior partner in esteemed Group 6010 “SOLD” BERKELEY – ALTA BATES MEDICAL VILLAGE Attractive Practice is retiring. Produced $460,000 and collected $420,000 in revenues. Last 2-years Profits have averaged $225,000. 2011 2010 with Profits of $190,000+. Great opportunity to simply treat doing better! patients and go home as Administrator oversees all front-end operations. Full price $230,000. 6011 “SOLD” SAN JOSE – WEST OF I-280 Long established practice off Saratoga Avenue. Has averaged $400,000 per year in collections. 6020 "COMING UP" - PEDO PRACTICE - SACRAMENTO AREA Generates 3-Ops with 4th available in 1,000 sq. ft. suite. $500,000 per year. Beautiful office. Shall be available shortly. 6012 “SOLD” FREMONT Well established practice as evidenced by 6+ 6021 SANTA CRUZ Great central location. 44-hours of Hygiene per week days of Hygiene. Fantastic Recall System. Great location. Collects creates strong foundation. 2011 collected $415,000. Optional just shy of $900,000 per year. Total Available Profits in 2010 were purchase is Seller’s interest in building or Seller can extend long term $360,000. 5-Ops. Lease. For complete details on any of these opportunities, go to www.PPSsellsDDS.com Professional Practice Sales of The Great West Ray and Edna Irving (415) 899-8580 ~ (800) 422-2818 www.PPSsellsDDS.com Thinking on selling your practice? Call “PPS of The Great West” today. This shall be the best decision you make regarding this important change in your life!

“I listed with a competitor for 12 months. Had two people visit my “When I signed the Listing on June 1st, Ray stated he would have the practice sold by Labor Day. The sale was concluded on Sept 1st, two days before Labor Day. Wow!” step of my life.” “I will always remember your statement when I questioned your contract “It was a pleasure to work with PPS. I had to sell because of health being only four months. You stated: ‘If I can’t sell your practice in that time, you complications. Mr. Irving listed my practice on Jan 1st, we closed escrow on should get someone else.’ Well, you did with time to spare!” Feb 27th. It took him less than 60 days to complete the sale as promised.” “Before I called Ray, I had a listing with another prominent Broker. After eleven months without a sale, I called Ray. He sold it in about a month! Would I “When I decided to sell my ortho practice, I sought the services of a recommend Ray? Yes!” large company. Over the 12-month contract, I had one buyer visit. Word “In April, I asked Ray Irving to sell my practice. At the same time my friend

My regret was the time and money lost with the other guys.” My friend’s practice still hasn’t sold and he was putting his dreams on hold.”

provide the best service imaginable for this very important engagement.

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opportunity wanted — I am an experienced, licensed and insured, board-eligible Periodontist. I perform periodontal and implant surgeries in your office, including but not limited to sinus Paul Maimone augmentations, tissue grafting, bone Broker/Owner HAPPY VALENTINES DAY! grafting, osseous surgery, and implant placement. Performing these surgeries in BAKERSFIELD #21 - (10) op G.P. & Bldg. on a main St. (3) ops fully eqt’d. (3) ops part eqt’d your office will help you maintain better & (4) add. Plmbd. Store front. Collects ~$500K/yr. Cash/Ins/PPO/< l % Denti-Cal. NEW. control of your treatment plans, be more COVINA #2 - (4) op comput. G.P. (3) ops eqt’d/ 4th plmbd. 2011 Gross Collect ~ $220K on a 2 comfortable for your patients who are day wk. Mixed patient base. REDUCED AGAIN already accustomed to your office, and COVINA #3 - (3) op compt. G.P. Cash/Ins/PPO. Gross Collect $242K+ on an easy (3) day wk. Located in a small prof/medical/dental bldg. w off street parking. Seller retiring. NEW help make 2012 more profitable than 2011! GLENDALE #6 - (5) op state of the art comput. G.P. 4 ops eqt’d, 5th op plumbed. Digital x-ray Email [email protected] or call & networked. Mixed pt base. In a free stand bldg. Annual Gross Collect.~ $500K. 949-287-6641. GLENDORA - (3) op comput. G.P. Cash/Ins/PPO very small % Denti-Cal pt. base. Very low overhead office with a very high % net. 2011 Gross Collect $296K+. Seller moving. NEW L.A. (SILVERLAKE - ATWATER) – (3) op G.P. located in the trendy Silverlake-Atwater area. dental practices for sale (28) years of Goodwill. Cash/Ins/PPO. Gross Collect $140K p.t. Retail Store front. NEW th NEWPORT BEACH - (5) op comput. G.P. 4 ops eqt’d/5 plmbd. In a prof. bldg. on the Marina. looking to purchase a practice Cash/Ins/PPO small % cap. Dentrix & Shick. Collects $400K+ on a (2) day wk. NEW No. COUNTY SAN DIEGO - (4) op comput G.P. in a shop ctr. w excell exposure & signage. — I have over 15 years experience in Cash/Ins/PPO/HMO pts. Dentrix s/w, & digital. Gross Collections $900K+/yr. PENDING general dentistry. I studied at USC School OXNARD #5 - (4) op comput G.P. Can purchase w or w/o single use free stand. bldg. Mixed pt of Dentistry and attended the postgradu- base. 2011 Gross Collect ~ $447K. Locate on a heavily traveled main road. REDUCED RESEDA #6 - (3) op comput G.P. located in a well know, easily accessible prof. bldg. ate prosthetic residency program. I am Cash/Ins/PPO pts. Annual Gross Collections ~ $150K on a p.t. schedule. REDUCED looking to buy a dental practice from SANTA BARBARA #2/GOLETA - (4) op computerized G.P. located in a garden style prof. Retired/relocating dentist in San Jose/ bldg. w St. frontage. (3) ops eqt’d/4th plumbed. Cash/Ins/PPO pt. base. (4) days of hygiene/wk., approx. (20) new pts/mos. Pano eqt’d. Collects. $400K+/yr. on a (4) day wk. REDUCED Santa Clara area. Please email hani_jamie@ SANTA BARBARA #3 - (3) op comput. G.P. in a prof/med/dental bldg. Cash/Ins/PPO. 8-10 new hotmail.com or call 530-640-2324. pts/mos Gross Collect. $250K+ on a (4) day wk. Digital x-ray. Seller retiring. REDUCED So. TULARE COUNTY No. of BAKERSFIELD – (6) op comput. G.P. in a shop. ctr. w practice for sale in southbay exposure/visibility/signage. Cash/Ins/PPO/Denti-Cal pts. Annual Gross Collect. $500K+. NEW UPLAND #3 - (5) op comput G.P. & Speciality Pract. in a free stand bldg. Gross Collect $525K- — Located on major busy street. Heavy $625K/yr. Digital x-ray. Excell opp. for G.P. who likes to do Endo. BACK ON MARKET traffic. 4 ops, 3 fully equipped. 1,100 sq. VACAVILLE – (3) op compt. G.P. turnkey w charts. Shunted 5 mos. Great start up op. SOLD ft. Gross $365K. 4days/week. Please UPCOMING PRACTICES: Camarillo, Corona, Covina, Irvine, Long Beach, Montebello, Panorama City, Pasadena, SFV, San Diego, Thousand Oaks, Torrance, & West L.A. call 310-488-8142 or send an email to D&M SERVICES: [email protected].  Practice Sales & Appraisals  Practice Search & Matching Services  Practice & Equipment Financing  Locate & Negotiate Dental Lease Space practice wanted — Looking for a  Expert Witness Court Testimony  Medical/Dental Bldg. Sales & Leasing practice for sale in the West Los Angeles  Pre - Death and Disability Planning  Pre - Sale Planning Area. General Dentistry practice from a P.O. Box #6681, WOODLAND HILLS, CA. 91365 retiring doctor or long established Toll Free 866.425.1877 Outside So. CA or 818.591.1401 Fax: 818.591.1998 www.dmpractice.com CA DRE Broker License # 01172430 practice. Please call 310-922-1366 or email [email protected]. CA Representative for the National Association of Practice Brokers (NAPB)

192 february 2012

cda journal, vol 40, nº 2

advertiser index

A. Lee Maddox, A Professional Law Corporation maddoxpracticegroup.com 140

American Academy of Dental Sleep Medicine aadsm.org 150

Aspen Dental Management aspendental.com 181

California Center for Advanced Dental Studies ccads.org 167

California Complete Dental Laboratories completedentallab.com 158

California Practice Sales calpracticesales.net 182

CariFree carifree.com 105

Carroll & Company Practice Sales carrollandco.net 189

CDA Membership cda.org/member 102–103

CDA Practice Support Center cdacompass.com 110–111

D&M Practice Sales and Leasing dmpractice.com 192

Golden State Practice Sales 925-743-9682 184

Implant Direct implantdirect.com 129

Lee Skarin and Associates, Inc. leeskarinandassociates.com 193

OCO Biomedical ocobiomedical.com 130

Professional Practice Sales of the Great West 415-899-8580 191

Professional Practice Transitions pptsales.com 186–187

Select Practice Services, Inc. betterobin.com 199

Snoring Isn’t Sexy snoringisntsexy.com 128

The Dentists Insurance Company tdicsolutions.com 98, 106

TOLD Partners, Inc. told.com 183

Ultradent Products ultradent.com 200

Western Practice Sales/John M. Cahill Associates westernpracticesales.com 139, 165, 185

for advertising information, please contact corey gerhard at 916-554-5304.

194 february 2012

feb. 12 dr. bob

cda journal, vol 40, nº 2

dr. bob, continued from 197 on, scanning the nutritional facts can of 510.3 hectoliters had a “serving size” eats like a meal”), the sodium content is take up to an extra 10 minutes per item. about that of a thimble. It doesn’t re- listed as 790 mg. The company compan- This has the full approval of market ally help to note that “no MSG added” ionably assumes that the contents will gurus; a slow-moving shopper always frequently means added to what was be shared by another soup lover and spends more than a person with a list already there. that each diner will get his fair amount and a schedule. As an individual who can cheerfully of 790 mg of sodium. If I am glutton- Disclosing the chemicals in their put away a family-sized bag of potato ous enough to eat the whole can myself, product must have been a bother to chips during a single evening, I am 1,580 mg of sodium serves me right, food manufacturers. To soften the chopfallen to learn that the serving size they imply. I eat it anyway. What kind of impact of discovering you were about of my own personal 18-oz. bag is listed a person eats only a half can of soup? to chose an item with enough sugar, as “about seven chips” with a sodium Obviously, the nation is hell-bent on say, to satisfy your daily allowance for total of 2,070 mg for the whole bag! escaping its own Sodium and Gomorrah. three months, they skillfully and legally Who can eat seven chips and quit? My only advice is to keep moving and printed in 4-point font the fact that this Surveying a favorite can of Camp- try not to look back. We don’t need any one single package with a net weight bell’s Chunky soup (“The soup that more salt.

Progress. It’s what happens when 25,000 dentists work together. CDA is where you connect with the best and brightest dentistry has to offer, have a stronger voice in government and access everything from education to practice support. And together, we move the profession forward.

Gyan Parmar, DDS Member since 2002

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feb. 12 dr. bob

cda journal, vol 40, nº 2

dr. bob, continued from 198 the pepper. The present brouhaha with Lot correctly discerned recommended upper threshold of salt to sodium has caused it to be banished to 2 grams per day in 2013 and to 1.5 grams the rear of a kitchen cupboard back by that whatever happens per day for everyone by 2020. What this an ancient flour sifter. is translated to teaspoons is anybody’s We — all of us, except me — eat too in Sodom and Gomorrah guess. Mine is a smidgin or a pinch. much salt. The USDA says so. Dr. Mehmet It is difficult to fathom, but many Oz concurs as he enthralls an audience of should stay there. years ago, people who felt their food women rapturously awaiting a summons needed a condiment were required to to don a white lab coat and participate in sprinkle salt on their food themselves. elaborate but simple demonstrations of governing the heaving of magnificent This tedious task has been almost the dangers of OD’ing on sodium. bosoms, sneaked a peek back and was completely assumed by thoughtful About 4,000 years ago, a biblical char- immediately turned into a pillar of salt. processed food purveyors. A fast meal acter named Lot fled with his wife from One disregards angels at his own ex- is a happy meal, particularly if there is the equivalent of Las Vegas located in a pense! It was for this reason the Morton a small polycarbonate reward with no couple of cities on a plain in the Valley of Salt Company (“When it rains, it pours”) moving parts involved. Siddim just south of the Dead Sea. A big dropped the idea of using this pillar for Commercially processed food com- piece of celestially inspired history was the company logo 6,000 years later. prising a high percentage of our diet is about to happen and it seemed propi- For reasons that defy analysis, turning now conveniently loaded with more salt tious to get out of Dodge before it began. a person into a chunk of salt seems, in than Mrs. Lot’s pillar. Having eliminated They were accompanied on their retrospect, a little much, especially when the dreaded transfat and replaced it with exodus by a gaggle of so-called “deliver- dealt by an angel. The standard toad dietary fiber that is probably as good for ing angels” who were flying shotgun on metamorphosis would have been just as you as it sounds, manufacturers are on a the fleeing Lots. The angels were quite effective. Confiscating her credit card for a roll, providing enough nutritional facts, explicit in warning Lot not to look back month would have worked even better. percentage of daily requirements and ca- at the cataclysmic destruction about to Salt in the form of sodium chloride loric content to challenge the combined be wrought unto the sin cities of Sodom is an essential nutrient for humans and intellects of Stephen Hawking and the and Gomorrah because … well, “just animals where it performs many scien- late Jack LaLanne. don’t do it,” they chorused. tific functions including killing you if But wait! Growing numbers of alert Lot correctly discerned that what- you take too much. Don’t do that. shoppers, Blu-ray devices welded to an ever happens in Sodom and Gomorrah In order to determine how much is ear as they consult with unseen advisors, should stay there. That is why the Las just right for you, the benevolent Food are seen in markets searching for that Vegas Chamber of Commerce maintains and Drug Administration in 2010 joined one little isolated section of the aisle a 24-hour watch for angels swooping the American Heart Association in rec- dimly labeled “Diet.” Pricing is not their down to discourage impoverished visi- ommending that a healthy adult needs goal. They know by now that leaving tors trudging homeward from looking to reduce his consumption of sodium to something out of a product is frequently back at their money. less than 2.3 grams of sodium per day. dearer than putting it in. Witness “re- Equipped with a deep instinct for The American public has never cottoned duced fat,” “sugar free, “low sodium,” or self-preservation, Lot echoed this com- to the metric system, believing it to be palming off uncooked fish as “sushi.” mand to his wife. a mystical mish-mash conceived by a In an effort to give the public a fair “For Heaven’s sake, Mrs. Lot,” he decadent cult, possibly the Druids after shake when trying to work out what barked (back in those days, women a night of heavy mead consumption. food items — other than produce and didn’t have names, nor could they vote Since we couldn’t recognize a gram from meat — are comprised of, a federal or drive cars), “Don’t look back!” a gramophone, the daily requirement requirement to list the nutritional facts Big mistake! One does not command has been dumbed down to a teaspoon, a on the package became a law a few one’s spouse not to do something. His common tool seen around the house. years ago. Rather than just pop a can nameless wife, her magnificent bosom Don’t inscribe this in granite be- of something into the basket and move heaving in accordance with the laws cause the AHA is planning to reduce the continues on 195

february 2012 197 Dr. Bob cda journal, vol 40, nº 2

Salt: There’s Na-thing Like It

There is a serious concern going on especially fish? How long before Al Gore The present brouhaha with in this country today amongst nutri- points the finger at sodium vapor lights? tionists that, oddly enough, has nothing Sodium’s chemical abbreviation is Na. sodium has caused it to be to do with the Middle East or keeping First published by Jön Jakob Berzelius banished to the rear of a up with the Kardashians. The problem in his system of atomic symbols, Na was is so serious that the federal govern- initially thought to be the opposite of kitchen cupboard back by ment has been forced to intervene, the Russian word for “yes” (da) and is forming committees to study solutions still widely used in the Western world in an ancient flour sifter. and agencies and bureaus to issue the form of “nah,” meaning “I don’t think guidelines and regulations. That this so.” Unfortunately, the original symbol has never worked before only under- has now been almost entirely forgotten lines how serious it is. in the excitement of tracking Lady Gaga’s , Robert E. The culprit — the fly in the soup wardrobe, reappearing but briefly via Horseman, of America’s pathetic nutrition — is some irritating trivia contestant on Jeop- DDS dietary sodium, an element so common ardy. That’s how serious the problem is. that the ocean, which occupies 70 per- In my house, we referred to con- illustration cent of the world’s surface, is full of it. sumer sodium as salt. It was formerly by dan hubig How long before scientists realize that housed in a little shaker right beside salt water is not good for living things, continues on 197

198 february 2012 When you want your practice sales DONE RIGHT.

Salt: There’s Dr. Robin’s upcoming speaking engagements. Na-thing Like It Call us for more details.

January 19th, 2012 - Southern California Oral/Facial Study Club; Tarzana; Dental Practice Act.

March 4th, 2012 - Loma Linda University, Loma Linda; Dental Practice Act.

May 3rd, 2012 - California Dental Association, Anaheim Session; Dental Practice Act.

December 2nd, 2012 - Loma Linda University, Loma Linda; Dental Practice Act.

BetteRobin,DDS, JD DENTIST ATTORNEY BROKER Loma Linda Dental 83 Southwestern Law 95

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