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Dr. Lavine:

I think so.  They’re still on the line.  So, they can do follow-ups if they like.  You showed a case where there was a patient that had a uvuloplasty and they were still falling asleep on the dental chair.  You talked about the HIV 43.  What is that?


Dr. Elliott:



Dr. Lavine:

They’re talking about HV or HIV 43.  So, I’m not sure exactly what the question was.  We’ll invite them to maybe do a follow-up for that as well.


Dr. Elliott:

Oh, that AHI.  Sorry, it was the AHI of 43.  That means he still had severe sleep apnea.  If you look at the scale of AHI is, that’s the apnea-hypopnea index.  He was still have residual apneas or residual obstructions, but he was quiet.  So, he thought he was cured, but he wasn’t.


Dr. Lavine:

You said anything over 30 is not good.  Correct?


Dr. Elliott:



Dr. Lavine:

Okay.  The foam wedge, how is it placed?  Is it place right-left, or is it on top of the bed higher than the foot?  Where exactly are you putting that wedge?


Dr. Elliott:

Well, there’s actually a couple of ways to do it.  The bed wedge. I think they’re made to be just put under the sheet, but we found that if you put it under the mattress, it’s a lot less noticeable, and it just gives you a little lift.  You can find it on Amazon.  It’s like $40, and if you have Amazon Prime like I do, you get free shipping.

There’s something called postural fluid shift that happens at night, and some people actually elevate the head of their bed on some elevators.  They’re made to elevate the entire bed, but if you just put them on the head of the bed, you actually sleep at a little bit of an angle.  You don’t get all stuffed up, and you’re throat doesn’t take on the fluid that can narrow the airway and cause snoring as well.  So, some people feel a lot more refreshed and less puffy when they do that, too.  So, there’s a few strategies.


Dr. Lavine:

Okay.  Again, just some technical questions.  How do you know that the mandible is forward enough if you don’t have an HST device before sending back for follow-up PSG?


Dr. Elliott:

You don’t, and that’s the tricky thing because I would go off the subject of symptoms such as snoring, feeling rested, that sort of thing.  Some people, though, sleep alone.  They don’t know if they’re snoring, and you’re kind of going blind.  Really, dental sleep medicine doesn’t have to be extensive to integrate.  It isn’t at all, and the home sleep study is probably one of the most important pieces.  I actually found a sleep study.  I only have one, and I lease it for about $350 a month for as many of the disposables as you want and the free software that comes with it. So, there’s many different ways to do it, and you can do it pretty inextensively.   I always do a titration check before I send them back to their physician.


Dr. Lavine:

Which HST device do you use in your own practice?


Dr. Elliott:

I actually use the Watermark because of the cost because I have a partner, and he doesn’t do sleep apnea.  So, I’m permitted a certain amount of budget, and we work within that.  He does the implant degree, and I do the sleep apnea.  So, that really agrees with my budget.  There’s other ways to do it, and can do medical for the titration.  So, if you are getting paid for them, then a lot of people use the Watch-PAT or the Braebon MediByte Junior.  So, there’s a lot out there that can be affordable, especially if you’re getting reimbursed for them.


Dr. Lavine:

Okay.  Speaking of equipment where do you purchase your bite gauges from?


Dr. Elliott:

You can get them in a lot of places.  I do own a George Gage as well as the Moses.  You have to get the Moses from Modern Dental Lab.  The George Gauge, I do order directly from SomnoMed, or you can just do a simple Google search and find it.  I have a container next to me, and they have them as well, but I order from SomnoMed.


Dr. Lavine:

What are the top appliances?  Any opinion on that?


Dr. Elliott:

My assistant is kind of my guinea pig when we started, I made her one of everything. With the TAP, there are advantages to it, but you are locked in.  Some people get claustrophobic-feeling with it.  There are patients who do really well with it.  In fact, I work with the Air Force here, and that’s what all the dentists are trained in.  It’s just what works best for your patients and what works best in your hand, and other than SomnoMed, I don’t have a lot of chair side time or even the Moses.

There’s advantages to each appliance, but TAP, like I said, is really good if you have dental work that needs to be done.


Dr. Lavine:

Okay, a couple of questions here related to the same topic.  I’m not sure how comfortable you are talking about this, but is there a fee range that you are comfortable talking about that you normally charge these patients or the national average that you’ve seen?


Dr. Elliott:

These are great questions.


Dr. Lavine:

It’s very educated.


Dr. Elliott:

Yeah.  The difference between dental insurance and medical insurance is vast, and if dental insurance, we know it’s going to cost this much and we’ll get reimbursed this much and this patient owes this much.  In medical insurance, you can charge up to with the whole package with evaluation and radiograph, charge up to $6500, but medical insurance, you talk about out-of-pocket expenses.  You never really give a total.  Like when I got my knee surgery, I said, “How much is this going to cost?”  They look at you with a blank stare like, “I don’t know.”  It’s because there’s so many variables, and there’s adjustments and all sorts of things.  So, when you talk to patients about their appliance, you’re talking about out-of-pocket.

I did have a patient that I had to [01:23:37], and he spent $4000 in California for a $200 appliance.  I charge basically $2700 for discounted Medicared because we only get reimbursed a certain amount.  So, I think some insurance pay $5000 for the appliance. I’m not seeing those numbers here I Idaho.  I don’t know if we’re behind the times or if our insurances are behind the times.  It can range.


Dr. Lavine:

Are you talking about medical insurance?


Dr. Elliott:

I am.  I think that’s one of the biggest things, and it’s what prevents us from doing it, entering dental sleep medicine.  Medical insurance is really difficult to navigate, but once you get it, once Crystal was trained, things were stimulated.  It wasn’t until I started billing dental insurance that things took off.  I was doing two, three appliances a month, two and a half years ago, and I was having the patients try to bill and they would have to pay me the full amount.  Now, I’m doing 15 to 20 of them because we take a lot of that load from the patients and make it easier for them.  That’s the goal.  It’s just to help get people sleeping again.


Dr. Lavine:

Okay.  So, if somebody wanted to get started with this, obviously, the first step is to come to the course in Detroit.  What next?  What do they really need to be doing to start incorporating this into the practice?


Dr. Elliott:

I think the first step is to try treating your staff once you learn it and know how to do the impression and bit registration and communicate with the lab.  Treat your staff or even family and friends, but do not treat them without studies.  I think reaching out to a sleep physician and saying, “My dad, my hygienist is really struggling out with their sleep.  I’d like to work together with you,” and they really are open to I a lot of times.  They know that a lot of dentists can’t.  Because of medical insurance, it does have to be done by a dentist.  I know there was an ENT that was trying to do it, too, but oral appliances have to be done by a dentist in most cases with insurance companies.


Dr. Lavine:

Okay.  Where did you get your training?  I know you were in Canada.  Was this a formal type training?


Dr. Elliott:

I took an introductory course, and there’s always so much more new studies coming out.  So, the AADSM is always a great source.  That’s the American Academy of Dental Sleep Medicine, and they have a convention every year in the beginning of June.  So, I went to Boston last year.  I’ll be in Baltimore, again, this year, and that is a great resource to hear from the people that are doing the research.

We’re on the front line treating people whereas they learn from the people in the university by doing the studies.  It’s really great interacting and great information.


Dr. Lavine:

Okay.  Now, Erin, typically we finish in a couple of minutes.  We’ve got more than a couple of minutes’ worth of questions.  I’m obviously around for another 5, 10 minutes.  Can you stay for that as well, or do you have to go?


Dr. Elliott:

Yeah.  That sounds great.


Dr. Lavine:

Okay.  We’ve got a lot of great questions here.  If you do not do a sleep study after the delivery of the appliance, how sure are you that the OSA is treated?


Dr. Elliott:

You’re really not. The sleep physician that I work with, I really am politically correct because I like working with the medical community that’s why I’m really careful not to say oral appliances replace CPAPs or come to me and I’ll cure you of everything, but I do have a sleep physician who says that if they’re mild to moderate and they’re not snoring anymore and they feel good, he doesn’t require a follow-up PSG.  He may do a [01:28:07] just to make sure they’re not desaturating, and that’s if they have no co-morbidities or any problems.

I always do that follow-up study just for me sake.  Because we’re dentists, were the type that if you see a cavity, you want to take it all out.  You want to make sure it’s not going to break 100%.  In the medical world, it’s not so black and white.  So, I want to see an AHI of 5. That doesn’t always happen, but the patient has a better quality of life.  Even reducing your AHI by half or under 10 is going to maximize their life by years as well as make it a better life.  So, sometimes you have to start thinking like a doctor and not a dentist.


Dr. Lavine:

Now, you were talking how in your marketing, you’re careful not to put down the CPAP.  Is there any literature out there that compares the CPAP with dental appliances?


Dr. Elliott:

There are not a lot, but there are a couple overview articles that do compare difference studies.  They did find in one study that when treating mild to moderate sleep apnea with oral appliance that they were 85% successful.  So was the CPAP, but they found that the patients were way more accepting of the oral appliance and preferred it.  So, that’s what they say in the mild to moderate category.  That’s the only study comparing them.   The other one.  When they have a severe patient, it’s about 60% successful and a lot higher with CPAP.

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I’ve had two patients whose bites shifted, and I said, “Okay.  Well, we can just go back to your CPAP,” and they say, “No. I can live with this.  I don’t even notice.  It’s only because my dentist pointed it out to me. I didn’t even know.”  So, a lot of times, the patient isn’t even aware of it.  I think it’s funny that every time the patient leaves the delivery appointment, they’re always saying, “I hope this works.” Then, they come back for their one or two week appointment, based on our schedule because we do have some sleep apnea days that we dedicate straight to sleep apnea.

At that appointment, we ask them, “When you wore it, how did you feel?”  They look at us the same, and they say, “Well, I wore it every night.  Was I not supposed to?” I’m like, “Perfect. That’s great,” because we just don’t want them to feel that it’s not going to work for them if they didn’t wear it a couple of times.  So, we show them how to advance it.  We don’t show them how to advance it at the delivery appointment because we want them to get used to it.  By advancing it, we can from there.  If they feel great, sometimes we keep them there. I ask them to advance it until the pillar hurts.  We do have patients that still snore, and we talk about Breathe Right Strips or Nasal Pumps and things like that.

Then, we do a one month follow-up, and this is where it gets really fun because they’re feeling good.  They’re rolling along, and we start thinking about doing a sleep study at that point.  It takes about three months for that to shrink down for the muscles to get toned again.  When they’re getting constantly beat up and battered, the tissue is really edematous and swollen.  So, at the three month mark where they’ve been allowed to advance it enough, they’ve gotten over the side effects.  If they had any TMJ pain, they’re over that.

So, we do a titration home sleep test.  I actually didn’t own a home sleep study for a long time because of money, and I finally did that one because they are finally coming down in price.  It’s easier to use.  I had sent a patient back for his home sleep study because he feels great, and his wife was as happy as he could be.  So, I sent him back for sleep position.  He did not advance it at all, and his AHI was almost the same.  So, I’m always sure to screen them before I send them back. I don’t use my home sleep study as a screener before treatment or use it to diagnose.  I might use it for the titration, and then, we refer them for PSG.  Honestly, I’ve only have three patients do that, but I really tried to get them to do that.

So, we’re getting towards the end here.  The most important thing about doing this is that it’s so energizing.  I love getting hugs after I change people’s smiles, but I love getting hugs from patients after they think I’ve save their lives.  I just want to read you this testimonial really quick:

Sleep apnea, not anymore!  I feel compelled to add my experience to those testimonials already submitted.  This has been truly a life altering experience for me.  After being diagnosed with sleep apnea several years ago, I tried to adapt to the CPAP torture regimen.  After repeated attempts with several masks and watching me wife’s hair blowing around lying next to me in bed, I finally gave up and jut accepted the fact that it wasn’t for me.  So bet it.

Then, last year, I was introduced to an oral appliance by Dr. Elliott and her fine staff.  Now, many months have passed and both my wife and I are two happy campers! No more waking up tired, no more falling asleep in the middle of the day, no more snoring… Oh my God!  My wife has decided that she will no longer be looking for a new husband, as she has found that she can sleep without waiting for me to start breathing again!  It has been a life altering experience I never expected.  This simple appliance is the greatest thing since the sliced bread!

That is why I’m so passionate about it because I want to teach others how to help millions of people that are undiagnosed and people that we can help that their primary care physicians aren’t catching.  So, I’m doing to hand this over, and we can answer some of your questions.


Dr. Lavine:

Thank you.  That was fantastic.  There’s two things that I always look at to decide if a webinar was successful or not. Number one is do we have a lot of questions, and yours does not have a lot of questions.  The people are so interested in what you’re talking about.  They’re not typing them in. we only have four or five questions, but I certainly would encourage people to ask questions now if they think about them.  Secondarily, how was the attendance compared to when we first started?  We actually have about 50 more people than we did at the beginning of the webinar. So, you definitely kept everyone’s attention.  I appreciate that.

I think one of the things you alluded to in the presentation is the fact that the webinar gets people excited and interested in it.  It wasn’t something designed to make people experts in sleep apnea and treatment.  Of course, it also doesn’t mean that you have to go and get an MD either.  You do courses online. I know you’re doing one with the folks at Golden Dental Solutions in the next month or so, and I’ve asked Kurt Loder.

Many of you have heard of Cur Lawler when we talked about Physics Forceps.  I’m going to turn it over to him to talk about Erin’s course and a special offer for everyone on tonight’s course.  So, Curt, the floor is yours, and tell us what you’ve got to say.


Curt Lawler:

Lorne, I appreciate it.  Dr. Elliott, great presentation.  I really enjoyed it, and I hope everybody else on the line did also.  Like Lorne mentioned, in Golden Dental Solutions, we truly believe that in order for a course to be truly effective and translated into skills implemented in your practices on an immediate basis, it must have a hands-on component.  A lot of our courses are live patients courses that we do at the University of Detroit-Mercy School of Dentistry here in Detroit.  The reason we do that is because it allows you to practice on live patients, and it’s also a great facility where you actually get a true hands-on experience outside of the classroom.

So, we’re doing a course with Dr. Elliott on February 15th and 16th here in Detroit, and we’d like to offer the attendees of the webinar a discount with a promotional code of SLEEP, which expires on January 18th.  To learn more about this course with Dr. Elliott that’s being put on by our company Golden Dental Solutions, you can visit, and if you click on where I have the arrows indicated here on the slide for the Dental Sleep Medicine section or the alarm clock section that says HELP, that will take you to a different section of the website that goes through, in detail, more information about the course, on the amount of CE credits, the course fee, the general outline of the course.

Again, I just wanted to emphasize that this course is going to be really unique in that in day two of the course, we are going to be spending a portion of the day down in the clinic floor at the University where we’ll be going with Dr. Elliott in detail taking of impressions, bite capturing for dental sleep medicine.  We’re going to talk about all kinds of different appliances, bite capturing and impression methods.

We’re note tied to a specific product.  We’re going to talk about many different brands and provide information for doctors to learn.  So, again, if you want to learn more about this course and take the opportunity to register online, you can give us a call at our office with the phone number indicated on the screen, which is 877-987-2284, or if you click on the section of the website here, I will take you to the dental sleep medicine portion of Golden Dental Solutions.  You can click on registration, sign up online, give us a call.  We’re more than happy to answer any more of your questions.

So, at this point, I’ll turn it back over to Lorne and Erin to go over the questions that you may have submitted during the webinar.  Thanks again.  I hope you join us in Detroit.


Dr. Lavine:

Thanks, Curt.   I guess one of the questions is for you:  I already signed up for the course because Dr. Elliott is awesome.  Can I still get the $100 credit?  I think Erin should give him the credit for that.  That’s a very nice comment.


Curt Lawler:

Yeah.  No problem.  Just give us a call.


Dr. Lavine:

Okay.  I will send you the list of attendees so you’ll know who that was.  The other thing is that I know some people were curious.  Some people came in late.  I just want to remind everyone I did record this entire webinar.  You’ll all be sent a link in the next day or two so you can listen to it at your convenience.

Erin, we’ve got a lot of questions. Are you ready?


Dr. Elliott:

I am.


Dr. Lavine:

Okay.  We’re going to try to get through as many as we can.  I’m going to read them as I see them.  For Medicare prescription form in addition to the EO487 insertion form, do you list each of the visits?


Dr. Elliott:

For the Medicare, you actually aren’t allowed to.  We’re considered a DME company.  That stands for durable medical equipment so they look at us as if we’re a CPAP supplier versus the physician.  So, we have to bundle our codes.  Medicare reimbursement includes the evaluation.  It includes any radiographs.  It includes the appliance, and it includes all the visits up to 90 days.

Sometimes, you can actually charge out for repairs or maybe some follow-up appointments after 90 days, but I honestly haven’t done that.  You can’t even charge out for the home sleep test or titration study.  I hope that answered the question.

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So, usually the patients are motivated to wear it to stop the snoring, and they realize how much better they feel, too.  So, there are different types, and those include a tongue retaining device that’s the grandfather, the place where we started, the non-custom boil and bite that you see on the internet or the infomercials.  This is PureSleep® that you can buy online, buy one get one free right now for $59.95, but you can see you boil it, bite into it, and you can actually adjust it a little bit.

Non-adjustable but custom-made.  This was made for a patient who was a friend of a dentist.  He said he tried it to make him something to help him.  It’s basically a couple of mouth guards together.  This is the Tap-3, it is now, as of December 26th, approved by Medicare to use.  This is good for patients that are going to need a lot of dental work because you can use a material that’s white, and when you heat it up, it turns clear.  You can place it in the patient’s mouth and re-align it.

This is the Medicare-approved Herbst.  Most of the appliances, at one point, were actually approved by Medicare, and as of November 1st, the Herbst was pretty much the only appliance that was.  Someone decided that the hinge was needed and that the rubber band’s elastic hooks were needed as well.  So, you advance it by turning the screw over here, and then you can advance the mandible forward.  Again, just like when you to CDR training, when you need to get into the airway, you move the mandible forward.  So, that’s how we’re treating our patients.

Moses is a common appliance that’s used.  A lot of dentists like it because it is comfortable.  Because of its anterior opening, the tongue actually postures forward, and they think that’s actually better airway opening because you’re unconsciously pulling that tongue forward at night.  There’s no way to hook them together, but this is a fixed retainer on the top that glides into the appliance on the bottom.  By turning the screw, you can pull the mandible forward more.

What I think is interesting by the Narval is that it is created by ResMed.  ResMed is the world’s largest CPAP manufacturer and dealer, and so many DME suppliers are actually against oral appliances.  They say they don’t work, that anyone who turns in their CPAP are making a big mistake, but now that ResMed makes an appliance, and they’ve told the DME suppliers that, they go, “Hm, wait a second.  Maybe there is a place for oral appliances.”   It’s a flexible material, and it’s actually really strong, and you can change the lengths of these hooks to pull the mandible forward, too.  It’s [56:44] milled.

Now, a real common one is the Somnodent.  This is probably the one I use the most because it’s comfortable for the patients.  I use the flexible material, and then, I add elastic hooks that the patients can actually hold it together if they want to.  If their jaw drops open and they get a dry mouth, the elastics actually help close it together, and it’s small enough to get a lip seal.  This is called the dorsal fin pulling feature, and I believe there’s another one that uses this technology.  By advancing the screw, you pull this forward, and the fin couples with it and moves forward as well.  These are actually really comfortable.  The patients think they look like vampire teeth, but they stay right off along the cheek, and can’t even notice it.

Now, this is my dad, and that’s my little sister.  This is her 30th birthday party. It’s not a trophy life, but I want to tell you his story real quick.  He is a dentist, but he practices in another town.  We went to a course together, and in part of a course, we did a home sleep study.  I just knew that I didn’t want to share a hotel room with him because he snores so bad, but I’m cheap so I ultimately did. It wasn’t a very good sleep.  He ended up having moderate sleep apnea, AHI of 25.3, and you can see that he snored even when he was on his side.  That’s what all these lines mean.  Again, once you learn this stuff, you’ll be able to read this problem.  All these blue lines are these RERAs or those arousals. So, he was not getting continuous sleep at all.   The scariest part was his heart rate. It was a maximum of 137, and you can see how tachycardic it was all night long.  His heart was working overtime when it was supposed to be resting.

Now, the second night, he wore his appliance. When he had sent in the impression and bite registration, he arbitrarily set the bite registration.  We didn’t know how to do it correctly at the time, and that night it went down to a 14.8.  As you can see, though, his heart was actually resting.  So, there were a lot of blue lines and a lot of snoring, but he was resting already.  He has [59:15] so we pulled him forward and titrated him.  Now, he’s at a 5.1 and as quiet as can be.  My mom actually thought he was dead the first time it worked because she had never heard him quiet, and looking back, I see all the signs and symptoms he had with the acid reflux and the gag reflex. Everything I look for in my patients was happening in my family.

So, what do I look for in my patients? A good place to start, this is actually my partner.  He’s class II clincher, bruxor, headaches, everything you can think of.  So, we actually treated him as well as my hygienist’s husband as well as my assistant’s husband.  So, you can see that’s an easy way to start, and it’s an easy way to get fans.  Of course, with patients that you see, the easiest ones are the ones who have been diagnosed.  So, even adding, “Have you had a sleep study?  Have you been diagnosed with sleep apnea?” is a good place to start because they’re already not getting treated. Of course, you want to get all the training before you start to.

Your relationship with the medical community.  This is something that has really helped take off the dental sleep medicine part of my practice.  Like I said, I fell asleep with dental sleep medicine, but I still get to do my general dentistry, too, which is what I love.  This is something, too, that can be done in a small town, and I’ve figured out a lot of the systems and the communicating and the marketing to help you do that.

The external marketing, too. I’m really careful not to say, “I want to replace the CPAP,” because I work really closely with the medical community. I don’t want to say that oral appliances are the best thing ever and it’s going to replace the CPAP that you’re using, but we have a lot hunters and fishermen and campers and outdoorsmen, and this is an easy ad just to show that you can use your CPAP at home but take the oral appliance with you.  I also market to snorers and write the articles and all those sorts of things.

So, the American Academy of Sleep Medicine really opened this up for us.  What they decided is “oral appliances are indicated for use in patients with mild to moderate obstructive sleep apneas.”  They found that in patients with mild to moderate OSA, oral appliances are just as effective as CPAP, and they have a better acceptance rate.  So, it’s really beneficial to us that even the physicians say that.  The problem is trying to get every physician in our town to agree to that. I’m lucky in this area that I do, and I’ve had the chance to educate them and show them how it works and show them that I don’t want to take over.  CPAP is still the gold standard because oral appliances have a limited use in severe OSA and patients who have a high BMI.

So, before we do anything, we need a sleep study, and the presence or absence of OSA must be determined.  That is probably the hardest part.  That’s why starting with people who just snore is a difficult place to start, but I’ll tell you what.  They are so thankful to you that you helped them do something that they’re own doctor couldn’t help them do.  Do not make a snore guard for a patient unless you know that they are just a snorer.

You need to be serious about training yourself because there are a lot of nuances.  There’s a lot of things that you need to learn as far as medical insurance and background as to what sleep medicine is and to dental medicine.  There’s a lot of information out there.  It’s hard to sift through.  I get an e-mail every day from someone wanting to do my marketing for me. They want me to spend all this money on them, and they’ll guarantee me a successful dental sleep medicine practice.  I just think there’s easy solutions to that, and I would like to teach you that.

With the consult, are they diagnosed or not?  We show them different samples.  We go over the informed consent.  It’s really important to have a risk-benefit and alternative treatment. We go over what obstructive sleep apnea is, their treatment options, and we go over their sleep study.  Before they walk in the door, Crystal has already called their medical insurance.  We have a call intake form and an insurance verification form, and we have this information before they even walk in the door.  When we go over the sleep study, what’s weird is they never heard of any of that stuff before.

It’s so fun to educate them and show them what can be done for them.  We do an exam o the TMJ airway, teach them perio, go over side effects which can be light changes, teeth shifting, TMJ pain, but not as common as you might think.  Some people charge for the consult.  Some people do free.  I actually do it for free.  I did start out by charging, but it’s easier to do it for free.

A lot of times that consult appointment turns into impression appointment.  At that time, I do a full exam and send letters to the doctors.  It’s really important to keep the doctors informed, and it’s also a great marketing tool because the doctors know what you’re doing following through and treating their patients right.  That’s all they care about.  They send us fax, and they know their patients will be taken care of, followed through from beginning to end.

So, first impression.  You need polyvinyl [01:05:11] impressions, or you could do a putty with a watch technique and the bit registration.  There are four or five different ways to do it.  I do [01:04:24] Gauge, sometimes the Moses bite.  So, there are different tricks to that as well, and we use blue mint to set it up and send it to the lab.

In the delivery appointment, we go over the informed consent again and go over instructions.  Keep it away from the dogs.  Keep it away from the heat as well as morning exercises.  Your jaw will feel different in the morning because the fluid-fills up in the joint, and just be even chewing on a piece of gum or giving a morning repositioner or an aligner, the bite goes back.

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It’s amazing to see in the petite women I see how many have had their premolars removed.  If their petite women, usually their airway’s petite, too.  This are his lower teeth, and you can see how V-shaped that is.  If you notice, too, this is him open.  His tongue falls right back.

Gag reflex. That’s our body’s way of keeping obstructions out of our throat.  I have a couple of patients that are actually treated with CPAP, but every time I see their name on the schedule and I see x-rays, I say a little prayer for my hygienist because it’s really tough for them to get through that.  Anytime I see a gagger, it raises a red flag.  It’s not saying that they definitely have it, or they are diagnosed with it or anything.  It’s just that all these clues can tell us something, and, again, we’re looking at airways all the time.

This is a nice airway.  This is something we can see in adult patients as well as kid patients.  Now, in our kid patients, when we I talk to the parents, I’ll talk to them about if they are 6 or 7 and still wetting the bed, if they have bags under their eyes, they’re called shiners.  They fall asleep really easy because a lot of kids that are sleep deprived fall asleep really easy, but I’ll ask them, “Do they have restless sleep?  Do they move around a lot?  Are the sheets crumpled up in the bottom of the bed in the morning?” That’s telling me that they sleep about 8 or 9 hours, but they’re not getting good sleep.  Because kids’ nervous systems are not matured yet, it’s like when I give my two kids Benadryl®.  One gets higher and one gets real drowsy.

Because the nervous system isn’t really developed yet, when kids get tired, they can get wired.  So, they are finding that ADD and ADHD are related to sleep.  Again, in kids, the first thing we look at is airway.  When I ask the parents to talk to their pediatricians, I tell them that we’re not looking at sore throats.  We’re looking at the fact that they can’t breathe through their nose, and it’s affecting their sleep.

So, it’s really important when we talk about treatment options that there are more things than just CPAP or oral appliances.  Sleep hygiene is really easy.  That’s something to coach your patients on, going to bed at a normal time, getting up at a normal time.  If they’re shift workers, try to keep them on that same schedule, keeping electronics out of the bedroom, keeping TVs out of the bedroom.  If you do wake up, don’t go watch TV or get into your computer.  Just do some nice quiet reading.  These are all things that help get good quality sleep so we are well-rested in the morning.

We need 7.7 hours and 40% of the American population gets 5 hours or less.  In addition, the use of electronics and video games has caused a lot of us to be night owls.  I still go to bed at 9.  In addition, if you are having trouble sleeping, going to sleep in a quiet room, dark room, even a little bit of light can affect our sleep and Circadian rhythm and melatonin release.  One way to stimulate melatonin is to take a hot bath and get into a cold bed.

Lifestyle modifications.  That includes exercising regularly but not too close to bedtime, no smoking, no alcohol.  Alcohol actually relaxes the soft tissue so much that it can cause even more crowding of the airway, and some people even say they snore only when they drink.  That’s because it relaxes the smooth muscle of the throat.

Positional therapy.  Some patients only have closing off or obstruction when they’re on their back.  So, keeping them on their side would be a good solution.  The problem is getting patients to actually do it. We coach patients on it all the time, but they rarely follow through.  One strategy is to install [45:29] on the back of their t-shirt and keep them off their back.  I know a Canadian that actually use hockey puck and places them on a hose and places them right on his kidney.  A bed wedge is really easy to use and successful.  It’s really easy to use.  It’s just a foam, wedge that you can place under your mattress to keep it on a slope so that you can sleep on your side.

Of course, we have surgery.  It’s really important to have an ENT that you can work with, an oral surgeon that you can work with that get it.  Again, with the children, we’re not looking for sore throat, strep throat.  I want tonsils or adenoids out if it’s causing airway obstruction, and having an ENT that works with you is great.  A lot of times, they want to work with you, too.  They want somewhere to send their patients who aren’t surgical candidates. Of course, we have CPAP and oral appliances.

We’re going to get into surgery in a little bit here.  Nasal obstructions.  There’s a couple of ways to treat that.  This is a deviated septum as well as a big turbine, and you can actually get these fixed and allow you to breathe through your nose again.  This is radiofrequency, energy that is delivered beneath the surface of the turbine.  The treated tissue is heated to coagulate, and over the next three to six weeks, the tissue shrinks.

So, a lot of times, we’re hesitant to send our patients for surgery, but there are some in-office procedures that can be done to help, especially since oral appliances don’t always affect the nasal area.  We do need to sometimes treat that area as well.

There’s tonsillectomy.  This is a common procedure.  It’s not so common anymore because what we’re realizing is that obstructions aren’t in the soft palate and uvula area.  This is most commonly referred to as UPPP.  We don’t use uvupalatopharyngoplasty. This is a patient that just came in a few weeks ago.  This is post-surgery, but with this patient here, you can see quite a bit of his soft palate and uvula are gone.  In fact, he does have trouble swallowing in that area now.  So, he said that he’s cured of sleep apnea.  I said, “What does your follow-up sleep study say.”  He said, “Oh, I never had one.” He figured since he doesn’t snore anymore, he’s fine, but every time he comes in, he falls asleep on my chair.  So, I said, “Well, let’s just do a screening for you.  Let’s work with someone so we can just see what’s going on.”  He ended up having an AHI of 43, and he said he was cured.  So, it doesn’t always work.

A tongue resection and hyoid suspension is another common procedure, and it’s where they place a screw in the mandible attached to sutures and wrapped around the myeloid bone to stabilize it.   It doesn’t always pull the muscles tight, but it helps prevent the collapse during the sleep at night.  A tongue resection, of course, is you’re just taking out a section of the tongue, too.

This is a patient of mine that was actually getting treated by a dentist in Seattle when she moved here, and she had an oral appliance.  She extracted a few of the teeth that I had worked on, and I was upset by it.  So, I sent her to an orthodontist, and he basically sent her back to me and said, “Breathing at night is more important than a few shifted teeth.”  That’s when I finally realized that I had to get out of my dental mentality and look at the patient and treat them as a medical patient.

So, she actually ended up going and getting a [48:27], and that’s where they take a block of bone right where the muscles of the tongue and throat attach, pull it out, twist it 90 degrees, and put it back in.  Because she was petite, this worked out really well for her, and she did do a follow-up study.

Maxilomandibular advancement.  This is the most successful treatment, usually works out 90% because we are taking the maxilla and mandible and moving it forward 10 millimeters.  So, by doing that, you’re not only stabilizing the hyoid bone and all the muscles attached to it but also creating more space for that airway.  You can see, it’s moving the nasal area forward, too.  This is actually a local patient.  Of course, the 100% solution is just to bypass the airway altogether.

Now, CPAP is continuous positive airway pressure.  It doesn’t give the patient oxygen.  It doesn’t supplement oxygen.  It doesn’t make their blood richer and full of oxygen.  It just flows enough air out to move the soft tissue out of the way.  So, the more blockages there are, the higher the pressure’s going to be. I don’t know if you’ve ever tried one or tried one on, but it is a really weird experience. For patients who are really sick and really severe, it’s really easy for them to use because they feel so much better.  It is a gold standard because it does work, but the compliance is really low.  I’m glad you guys saw a better picture of me because this is what I took in my sleep study.

The compliance is low, but it is getting better.  When I asked my local sleep physician where his compliance was, he told me it was high 80s, and then you see numbers in studies that say 40%.  So, there’s a huge range, and there’s also a really liberal definition of what compliance is.  A successfully treated patient is someone who wears a CPAP four nights a week and, of those nights, four hours a night.  So, they say that’s enough treatment to get to lower their chance of co-morbidities, but in my opinion it seems like a really liberal definition because that is not a whole lot of sleep.

Most of the patients actually wear their appliance all night, and when I ask them about their use, they’re embarrassed to admit that they take it out at 5:30 in the morning and sleep until 6.   I say, “That’s okay.  I think you got some good treatment there.”  It is getting better because they have different masks.  Some of the chronic complaints are claustrophobia.  “The mask leaks air into my eyes and causes irritation,” or it can cause irritation on the bridge of the nose or they take it off and they don’t know why.  A lot of times they can work around that with dry mouths with the use of humidifiers.  They do help.  It does limit your sleep positions so that bugs a lot of people sometimes, but there are even masks now where you can sleep on your side.

Of course, the reason we’re all here now, where we fit into the piece of the puzzle, is by treating with oral appliances.  So, we prevent the collapse but also improve the muscle tone, and it’s counter-intuitive because you think that by pulling that mandible forward, we’re opening up the airway in the anterior and posterior way, but the way the pharyngeal constrictors is that they open the airway laterally.  In addition, by pulling that mandible forward, the pterygomandibular raphe, it tightens up the palatine aponeuroses, which is all the tissue of the soft palate, and by tightening that, you actually prevent the vibration and prevent the snoring.

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Dentist, Dr. Vinograd
The best dentist San Diego has available to it is a holistic dentist with decades of experience satisfying his patients, keeping them comfortable and looking after their overall health too. Should you be one of his patients?


Getting To Know Dr. Vinograd

Dr. Daniel Vinograd has a DDS degree from USC and a dental certificate from Universidad Technlogica de Mexico. He also has a degree in holistic medicine. More recently, he has received a BCLAD from San Diego State University.

All of Dr. Vinograd’s extensive education is aimed at helping people. Although he has chosen holistic dentistry and biocompatible dentistry as his profession, his patients will tell you that he helps them in many way that extend far beyond dentistry. He works with patients on the connection between dental health and overall health and makes sure his patients are well informed about how to keep their mouths and their bodies functioning at an optimal level.

Today, Dr. Vinograd offers his patients more than 30 years experience, most as the go-to dentist San Diego depends on for both dental care and overall life enhancement strategies.


So Much More To Dr. Vinograd

But there’s more to Dr. Vinograd than you might imagine. In fact, there are aspects of his life that even some of his patients don’t know.

For example, he is an associate professor of dentistry at the University of Southern California. That’s right: his alma mater thinks so much of Dr. Vinograd and his skills that they allow him to teach for them. That says something about him and his commitment to his profession.

But Dr. Vinograd also works to help those less fortunate than himself. That’s why he’s participated in several dental mission trips within the United States and abroad.

If Dr. Daniel Vinograd sees a way he can help, he does what he can. And as the dentist San Diego residents confidently depend on, he can put his commitment to work for you if you allow him to become your San Diego dentist.


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Did you know that most toothpastes at grocery and discount stores contain chemicals you shouldn’t put in your mouth? That’s why many big-name toothpastes are hazardous to your health.

When you’re attempting to choose the best toothpaste for your family, choose a brand that has your best interests at heart — or make your own toothpaste. Whatever you do, avoid these substances that are common in many brands of toothpaste:

  • Triclosan, a chemical that may be contaminated with the pesticide doxin. It can disturb your hormonal balance.
  • BHT or Butylated Hydroxytoluene, a substance that’s toxic to your immune and reproductive systems. You might be allergic to it also.
  • Sodium Fluoride or fluoride in any form. It’s in almost all toothpastes, but it has been shown to have developmental and reproductive toxicity.
  • PEG-12, a toxin that may be contaminated with ethylene oxide.
  • FD&C Blue, which can be toxic as it accumulates in your body.
  • DEA or Diethanolamine, a foaming agent that can lead to cancer and can disrupt hormones.

You also want to avoid toothpastes with SLS or Propylene Glycol. There’s no reason to choose a toothpaste with Sodium Saccharin, Carrageean, Manganese Gluconate or Sorbitol either.

To find the best toothpaste for you and your family, avoid the well-known big-name brands and choose a brand that’s labeled as organic or natural or sold in a health food store. But that’s no guarantee you’re getting a safe toothpaste. Read the label carefully, looking for the ingredients mentioned above that aren’t recommended. If a complete ingredients list isn’t available, don’t buy the product.

Many people are making homemade toothpaste these days because finding a fluoride-free toothpaste that also doesn’t contain any of the ingredients listed above is difficult.

Because substances are so easily absorbed through your mouth, it makes sense to take real care about what you put in it.

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So, in our practice, if we had an average of patient roll of 2,000, 20% of the population has obstructive sleep apnea, and 80% to 90% are undiagnosed.  It’s really because the physicians don’t have time to look for it, and they really have very little training just because in medical school they’re covering so much more.  Maybe it’s half a day.  Maybe it’s three hours of lecture in medical school that talks about sleep apnea.

Now, with that many undiagnosed, there’s even more people who have been diagnosed and are untreated.  They’re not using their CPAP, they just couldn’t tolerate it, or they did surgery and it didn’t quite work.  So, a lot of dentists make snore-guards.  There were a million snore-guards manufactured last year, and that can be a dangerous territory if we don’t have a baseline.  If we make someone quite but they’re still having apnic events, we don’t know it because there’s no follow-through.  So, we really need to make sure that we get diagnosis first or screening and make a snore-guard for someone when they only, truly are snoring.

We are in the front lines, and the reason why I say that is because we are.  We spend more time with our patients.  We know them.  We know their wives.  We know their kids.  We sometimes spend more than an hour with them, and we look at airways all day long, and I really trained my staff and my hygienists to look at these things, too.  In fact, just before I went on this webinar, they knocked on my door to see if I could do a sleep apnea consult.  So, it’s everywhere you look.

Now, this is a patient that I’ve seen from day one in my practice.  I’ve been practicing for about 10 years, and I love it when Richard comes in.  We like to two-step down the hallway.  I’ve been bugging him for years.  Once I got my training, he was one of the first people that popped into my head as having a red flag for sleep apnea, but he was a little bit unwilling to hear it.  He said he has other problems.  He has high blood pressure and diabetes, and he’s tired all the time.  He’s been talking with a nasal voice.  This is actually really a good picture of him because he has lost weight since he’s been treated.

I finally got him to a point where he was willing to talk to a sleep physician.  He told me he was tired of being tired, and he went to talk to him.  I said, “You may not be a candidate for oral appliance, but we want you to get help.”  He went to the sleep physician.  He had a CPAP put on the night of his sleep test, and he was been sleeping wonderful ever since.  I actually get gifts from him every time I see him.

Now, Shawn, I’ve been treating his daughters and his family forever, and Shawn doesn’t fit that profile.  Remember, it says obese, elderly.  He is male.  He’s 45 years old even though he has gray hair.  He’s a pharmaceutical rep, and he saw my sign out in the waiting room about snoring.  He said, “You know, I started to have to sleep in the other room, and I noticed that every time I get on the plane, I fall asleep right away.  I didn’t use to do that.”  He thought it was because he was just getting old, and when I looked in his mouth, I saw a lot of the things that went unnoticed before when I wasn’t trained to look for it.

We got him tested.  He was actually able to do a home sleep test because he didn’t have a lot of the other sleep issues going on, and he had moderate sleep apnea.  We treated him with an oral appliance, and he takes it with him when he travels.  He doesn’t have to carry that CPAP machine, and he feels awesome.  His wife, of course, is the happiest camper of them all.

So, I do some external marketing as well as working with the physicians, and one day, Cindy saw my ad in the paper.  She came because she had a lot of insomnia, and her physician was treating her.  She had been treated for insomnia with a sleeping aid and depression with an antidepressant.  She is actually a RN that works in our Pan Handle district so she knows a little bit about health, and she came because she doesn’t snore.  She has to sleep in a recliner because every time she goes to sleep, she gets a panic attack.  Of course, her doctor wanted to give her a Valium® for that.

Come to find out, it was her airway narrowing and her body’s way of treating or trying to open up that airway.  She would get these panicky type feelings.  So, she has been for a year only two nights without her appliance, and that same feeling came back.  So, she can’t live without it.

Now, when we’re screening patients, some doctors have come up with different screening tools, one of them being STOP-BANG.  The anesthesiologists use this prior to surgery so when they’re putting a patient under and their airway’s relaxed, they can identify people they may have problems with.  The S stands for snore, and the T is for tired.  Are you tired during your day?  O, obstruction.  Have you noticed yourself stopped breathing, or has your spouse or anyone noticed you stopped breathing?  Do you have high blood pressure?  If you answered two out of four on the top part, you have a really high correlation to having sleep apnea.

On the second part, depending on how many you answer positive to, you have a chance for having sleep apnea.  In the BANG part, B is BMI.  A is age.  N is neck, and G is gender.  This is something really important to put in our history.  I know dentists that add that to their paperwork to screen virtually every patient.

This is the Epworth Sleepiness Scale.  This is the standard scale used.  There’s probably 10 out there, but these are the two most common ones.  Now, this tests how sleepy you are in certain situations.  Now, if you answer eight or more, that usually means that you are overtired.  I think I actually have a 17.  I haven’t seen the end of a rented movie in probably five years.  I just think it’s because I get up too early, but when a patient complains of being tired and they only have a score of 6 or 7, it’s worth going through the questionnaire with them because we did have a patient one time.  She was so tired, and that’s what she was complaining about.  When I went through it, she was like, “Well, I don’t own a TV.”  So, she had put a 0 there.  So, for some of these questions, you do need to discuss with the patient to get a better idea.

So, when we’re looking at a patient, as far as dentists being in the front line, we have their health history.  We have their medication lists.  We take their blood pressure.  There’s so many things that we do to help treat the whole patient, and there’s a lot of clues in the mouth, one of them being a large tongue.  Now, this is Otis, and he actually has an AHI of 86.  He was referred to me because no matter how hard he tried he couldn’t keep a sleep app on.  He said he put it on, and the next thing he knew it was off on the side of the bed.

With his tongue, you can see that it’s folder in the middle.  He doesn’t have enough space for the amount of room allowed.  You can see he’s not overweight too bad.  He’s normal looking, but there’s enough anatomical structures that were causing an obstruction.  Scalloped tongue.  We see these quite often, too, especially when you’re trying to do a crown on number two, and the tongue still gets in the way.  That’s another good indication that they may have an obstruction.  Scalloped tongue tells us that there’s too much tongue than the room allowed.  Again, it actually causes indentations.  So, you can see different degrees of that.

This is Otis’s throat, and you can see how beat up that uvula is.  So, it’s no wonder he has sleep apnea.  His tonsils aren’t big, but his uvula is a battered uvula as it’s that swollen.  In addition, his pharyngeal grade is also high, too, and that’s the width of that airway there.  You can see the pillars or the walls encroach upon that airway.

Now, this is a good indication.  When my husband and I play “Who Has Sleep Apnea?” in the airport, this is one of the telltale signs.  This is Cindy on the right that I told you about.  She has an inferiorly placed hyoid bone, and this is what we should look like.  That is a nice crico-hyoid space.

Overbite.  Overbite tells us that the mandible is pushed back, that it’s trapped back there.  Along with the mandible is the attachment to the tongue in the throat.  So, if the mandible is held back, so are those muscles and the airway.

Acid reflux. I know acid reflux doesn’t always present heartburn.  A lot of times we can question the patients.  A lot of times you’ve seen those areas that are eroded, and this is a pretty severe example here.  I think, as dentists, we can see it first.  When we ask the patients about it, it could be the acidic food that they eat. I know in the Pacific Northwest, we have a lot of fruit and smoothie drinkers and health nuts.  So, I do see this front tooth, but when I question patients about it, they, “No, I’m fine.  I don’t have heartburn.”

It doesn’t always show up as heartburn. I was diagnosed with it after I had chronic cough for two months.  Anytime I went out in the cold or if I exercised, I would cough and cough and cough because the acid had affected the vocal chords and irritated them.  In addition, you can have constant clearing of the throat.  If you know someone that has that or they say they have allergies all year long in that post-nasal drip, it begs a question to ask about acid reflux.  One way to test it is to do Prilosec OTC® once a day, and if it helps their post-nasal drip, then, that’s a clue that it was acid reflux.

Again, I talked to you about bruxing, and that’s a sign.  That’s a way our brain tells us to kick start our breathing again.  There’s severe cases where we see this every day, and by doing a night-guard, you are actually crowding that space, crowding the tongue.  So, that’s a question to ask before you make a night-guard for someone.  Do they have other signs and symptoms such as if they are possibly snoring or possibly have sleep apnea?

Clenching.  It’s a way for our body to posture that mandible forward and open up the airway and pull that tongue forward.  Mouth-breathing.  This is common, and we, as dentists, see it because the patient’s gingiva is all red and their mouth is hanging open.  The plaque just dries on the front teeth.  We see it a lot on kids.  Sometimes they outgrow it.  Sometimes they don’t, but that tongue pressure is important to form the palate.  So, early intervention in kids is important.  We don’t treat them all the time with CPAP.  Most of the time, it’s getting their tonsils out and adenoids out and expanding the palate is a good way to prevent them from being adult apnics.  Of course, we see it in adults, too.

With a vaulted palate, it tells us that as a kid, they didn’t breathe right.  Maybe they breathe right now, but if you think about a vaulted palate, it actually pinches on the nasal component.  So, it narrows that passageway even more.  This is a patient of mine.  You can’t get a good appreciation for how high his palate really is in this picture. If you notice, growing up he couldn’t afford braces so if you notice, in order to prevent that crowding, they pulled the premolars to try to help these teeth into that.  If you pull the premolars right into the space where they’re actually growing the most, you actually prevent the mandible from growing forward, too.  That’s another way that crowds the airway.

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Now, hyperapnia, if you remember, is a buildup of CO2, and CO2 is actually what causes our brain to breathe.  It’s the reaction our brain has to CO2 rather than oxygen that tells our body to breathe.  So, once we realize that, our brain sends an activator, a little squirt of adrenaline.  That is the smooth muscle contractor that gets the airway open again.  So, we can grab a few breaths, relax again, and go to sleep.  Then, the whole system starts over again, and you wonder why we’re tired.

This is a video of a man having an apnic event.  As you can see, he’s trying to breathe, trying to breathe.  He’s quite because he has an obstruction in airflow, and he still continues to try to breathe.  You can do it, buddy.  Now, I guarantee you, if you try to do that even being awake, it would be difficult to hold your breath that long.

It’s like holding your breath at the bottom of the swimming pool. Your body’s going to do anything to try to get the air.  So, sometimes we gasp or our legs kick or we grind our teeth together, whatever it takes to get that diaphragm moving again, and it’s almost worse than holding your breath underwater because if you see, he started getting the obstruction right at the end of the breath, at the end of the expiration.  So, it’s like trying to release all the air out of your lungs and then holding your breath for that long.  You can see why most people don’t wake up refreshed.

The typical signs and symptoms of obstructive sleep apnea are of course obesity.  We have a huge obesity problem in America, and we see the census every year changing.  We have more categories of obesity, which is really scary for our health care.  Then, with snoring, that is basically pre-empting it.  That is usually the chief complaint that brings people in.  Most of the time when people come in for a consult it’s because their wife or husband forced them, and a lot of times it isn’t the daytime sleepiness.  The chief complaint is snoring.

In fragmented or light sleep, a lot of people say they have a lot of trouble sleeping or say they have insomnias.  A lot of times it can be related to sleep apnea, and the most tell-tale sign really is when a wife or husband tells us that they have to nudge their spouses again to start breathing, that they get scared something’s going to happen to them when they sleep.

Again, our memory and learning take place during REM sleep, and if we never reach that, we’re going to have poor memory, morning headaches from oxygen depletion.  A lot of time when people complain to us about headaches, we think TMJ.  It kind of begs the question to ask them about their sleep, and, of course, if someone’s grumpy, their family’s not going to like being around them.

The nocturnal enuresis is basically the safety word for getting up and using the restroom often in the night.  The reason I included that is I never realized how common it was until I started talking to my patients about it.  We actually treated my hygienist’s husband. She tells me all the time how much lower their water bill is because he always thought he had a bad prostate and had to get up four or five times a night, but he little squirt of adrenaline that your pituitary gland allows the release of actually can get our bladder moving, too.

So, why do we want to treat it?  Like Dr. Lavine said, there’s a lot of health consequences, and, especially as dentists, we are a lot more than just people who cut on enamel rods. With treating perio, we see that there’s a link between the oral cavity and the whole body.  So, we see 80% of nocturnal stroke victims have untreated obstructive sleep apnea.  Heart attacks.  You have a 30% higher chance of having a heart attack.  Dementia.  When they tested people in the Alzheimer’s Board, they found out that 90% of them had untreated obstructive sleep apnea. Acid reflux.

Hypertension, especially with patients whose hypertension is not controlled even with medication, 83% of the patients have obstructive sleep apnea.  Cancer.  I should you that new release, that study that they’re three times more likely to die, and, of course, it’s related to obesity.  I think that’s a vicious cycle because when you’re tired and not feeling good, you’re not going to want to get up and go to the gym.  In addition, the sleep cycle is where those appetite suppressant hormones are released and our hunger hormones are released.  So, if we’re not getting the proper regulation, I just don’t think that we’re motivated to eat right.

Diabetes.  Again, sleep is when those hormones a regulated.  You’re two and a half times more likely to have diabetes if you have obstructive sleep apnea.  With auto accidents, drowsy drivers are just as dangerous as drunk drivers.  In fact, they found that the crashes that drowsy drivers get in are five times more serious and more fatal.

Of course, if we’re not sleeping, we’re not doing good, and the only reason why I included this one is even my six year old knows that Cialis® is for daily use.  I think that I don’t talk to my patients a lot of about this and they don’t really admit it, but it has a huge effect.  The lack of oxygen in our bodies have a huge effect on this area. It’s something that we don’t talk about, but it’s obviously out there because I hear a commercial or see a commercial probably five times a day.

Death. This is Reggie White.  His wife is actually a spokesperson for sleep apnea now, trying to get low income people get diagnosed as well as treated.  If you remember, he died in his sleep.  They never say that a patient died from sleep apnea.  It’s usually heart failure or natural causes, but dying at 50 of heart failure is not really natural in my opinion.  Sleep is where we’re supposed to be resting, not dying.

So, how do we get diagnosed?  That’s the first step.  It must be made by a sleep physician, and we do that by getting a sleep study.  The most common is PSG or polysomnograph in which you go to a sleep lab, and they’re actually really comfortable.  I have one that is in a hospital and one that is a sleep lab.  It’s a little bit like a hotel.  You have TV and the amenities at home, and you’re allowed to bring your own pillow.

This is what we do.  There’s a lot of wires, but they test for a lot of things.  There are wires to your heart for ECG and wires attached to your head for REM, which is rapid eye movement.  Brain waves as well as channels on your chin to test for bruxing as well as on your legs to test for restless leg syndrome or periodic limb movements, which are leg kicks, which are common with apnea as well.  Then, of course, there are nasal flow, pulse oxygen. They can test more than just sleep apnea because there are many sleep disorders.

It is technician-assisted.  This is actually my dental sleep coordinator right here.  She makes the best coordinator because she actually has sleep apnea herself and really can’t sleep without her oral implants.  So, she is great with the patients and really advises them.  So, the technician sets it up, and, in my opinion, it’s a nice night away from home.  I actually had one as well, and I thought, “This is great, and my husband’s not pestering me to move around.”

Then, they print out a report. I know this looks confusing and it looks like a bunch of squiggles, but when you enter dental sleep medicine world, you’ll see that you’ll be able to see what this means and interpret it for your patients.  This is a typical sleep apnea patient.  Here is his chin movement.  So, bruxing can be associated with obstructive sleep apnea as well.

In addition, there are home sleep tests that are becoming more and more common because more patients aren’t wanting to go to a sleep lab.  They’re more resistant to seeking treatment.  More and more physicians are open to home sleep testing.  In addition, if there are no other co-morbidities and no other sleep disorders, obstructive sleep apnea is what they have, then, the physicians can do a home sleep study.

This is one type.  The type IV just means that there are two channels that are measured, and I’ll talk about that in a moment.  Type II is basically a PSG at home.  There is no technician, but there’s still those leads and wires.  Type III is what you see here.  There’s a respiratory valve as well as a reader and nasal canula to study oxygen flow.  This is another type where he just wears it on the head, and it can test position, airflow, pulse, and the oxygen saturation.  It does rely on the patient’s place, and sometimes, they can’t get it right.  I know my in-laws were visiting, and they did a home sleep test.  I had explained it to them but still had to help them.

Okay, this is the type IV I was talking about, and only two channels are read.  Patients, when I ask them if they snore or if they possibly have sleep apnea, I can see a lot of the signs, they say, “Oh, I was tested, and I don’t have it.” Well, I asked them what kind of test they had, and usually, they said they wore something on their finger.  It’s really common for primary care physicians to send their patient home with this just to test them, but it’s not really going to show you if you have mild or moderate sleep apnea.  It’s mostly if you have severe desaturations during your sleep.  So, it’s really going to show you severe sleep apnea but not the mild and moderate.  So, I don’t really consider it a good screening tool, but a lot of physicians use it because it’s cheap and easy.

Now, when you talk to physicians, we’re entering their world.  It’s dental sleep medicine so we have to put on our doctor hats for a little bit, and in doing that, we talked in AHI.  That’s how you determine how severe or mild someone’s sleep apnea is, and that stands for apnea-hypopnea index.   The apnea-hypopnea index is where you take the amount of apneas, where there stop breathing for 10 seconds or more, and add in the hypopneas, where there is the narrowing of the airway and their oxygen desaturates by 4%.  Then, you divide it by the amount of hours slept.  So, that gives us a number and a scale so that we can now how bad somebody is.  I’ve had a patient as high as 128, and he was a [26:04].  So, that was pretty severe.

Now, the RDI.  That’s another thing that people will talk about, and that’s the respiratory disturbance index.  That’s where they add in the RERAs.  RERAs stands for respiratory effort related arousal in which you are aroused to a higher stage of sleep, but there is no oxygen desaturation.  So, sleep cycle’s still getting disturbed and interrupted.  I had a patient who had an AHI of 7 but an RDI of 20.  They were very tire.  So, we were able to get medical insurance to cover them.  Now, typically, this is what doctors will see.  Someone who’s overweight, old, male, and has a large, thick neck, those are the ones that usually get diagnosed, but there are many who go undiagnosed.

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see the video:

Dr. Lavine:

Well, we’re going to go ahead and get started.  Welcome, everyone.  This is Lorne Lavine.  Most of you know me as the digital dentist.  I wanted to welcome you all to tonight’s webinar.  As of this morning, we have almost 450 people that were registered for the webinar. I think it really the interest in this topic, and a good chunk of you are already here.  I’m only going to spend a couple of minutes talking so that we make sure that Dr. Elliott could speak as long as she’d like.  We also want to make sure that we leave time for any questions.

All of you, on your screen, should have a little “Go to Webinar” control panel.  Go ahead and type in your questions as you think about them.  Depending on where we’re at in the presentation, we may not be able to get to them until the very end, but as you think about them, just go ahead and type them in.  I’ll do my best to make sure we get to all those questions before the evening’s done.  By the next week, you should all get a number of things.  When log out tonight, indicate if you would like Dr. Elliott to follow up with you or whether you want me to follow up with you.  That will just be a short, little two-question survey there.  Also, many of you know what I do record these webinars. So, within a day or two, you are going to get an e-mail with a link where you can download the entire presentation.  So, don’t worry if you have to take a phone call or the kids are screaming.  We’re going to give you the whole presentation to listen to when you’d like.

I also want to thank our sponsor tonight, Golden Dental Solutions.  They have graciously agreed to provide an hour and a half of continuing education credits for everyone.  Many of you are probably familiar with Golden Dental because we’ve done a lot of webinars with them in the past, the Physics Forceps and other products.  They’re going to be coming on later tonight, and they’ll offer a special deal for everyone as well.

So, many of you already know me.  I am known as the Digital Dentist.  I did practice as a periodontist for 10 years.  What I’ve been doing for the last few years is to present webinars that are topics of interest even if they’re not necessarily in my area of expertise, which is technology.  Really, the goal of these courses is to provide concepts that I think are interesting and stimulating, maybe a little controversial but hopefully beneficial, and I think we’re going to hit on all those topics tonight.

As dentists, we are constantly looking for ways that we can improve our practices, looking at new things that we can do, and this is really the focus of webinars I’ve done over the last year or so.  Many of you have been on some of my previous webinars where we talked about Physics Forceps where general dentists are now handling tough extractions or Six-month Smiles where dentists are now doing short term ortho.  I think sleep apnea, sleep medicine really falls into that area because dentists can definitely play a role.

As many of you probably know, if left untreated, it can cause all kinds of problems, heart failure, stroke, high blood pressure, diabetes.  So, I really think this is a great tool, a great service we can provide our patients as long as we have the training and the knowledge to be able to do that.

Now, as much as I’d love to talk about sleep apnea until the cows come home, the fact is I don’t know much about it.  My role, really, is a as a moderator tonight.  It’s interesting that as a speaker, as a consultant, I’m out there a lot, and I talk to a lot of other dentists, other consultants.  So, we get to hear when there are new rising stars in our field, and Dr. Elliott, I hear about her for a few months.  I had the pleasure of meeting her at a social event at the Greater New York Meeting back in the end of November.

I was just so impressed with the passion that she brings to this topic and how she has helped so many of her patients with it, and I said to her that this would be a great webinar topic.  She graciously agreed to come on.  She is a practicing general dentist with a private practice.  She’s in Post Falls, Idaho.  She does a lot of things other than sleep apnea.  She practices general dentistry, cosmetic dentistry, ortho, but, definitely, sleep apnea is where she’s becoming a real expert.  She’s an active member of the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine.

She’s authored several articles on dental sleep medicine, including her latest article which was in the October issue of Dental Economics.  It was called “Take the Time to Check for Sleep Apnea”.  She is considered a national expert in this growing field of dentistry, and she’s lectured extensively, educating dentists on how to incorporate sleep dentistry medicine into their practices.

So, without further ado, I’m going to turn the microphone and the screen over to her, and welcome Erin.  It’s a pleasure to have you tonight, and we’re really looking forward to the presentation.


Dr. Elliott:

Thank you, Dr. Lavine.  I’m looking forward to sharing with everybody the passion I have for not only helping my patients but in helping other dentists help their patients as well.  Like you said, I practice in Post Falls, Idaho, which actually has a population of 27,000.  So, like many of you, I don’t practice in a big metropolis with thousands and thousands of patients around.  Our county actually has about 125,000, and two [05:11] physicians that I work with very closely, and it didn’t happen overnight.

It’s something that I started about three and a half years ago, and, since then, have really taken it as a whole other part of my practice.  Within Post Falls Family Dental, I have Sleep Better Northwest and a dental sleep medicine coordinator that actually handles a lot of the administrative staff as well as the follow-up appointments while I’m still practicing general dentistry.  In fact, today I did occlusions on a four year old and an extraction on a 60 year old using the Physics Forceps, and I just do everything to help serve the families in the county.


Dr. Lavine:

We’re not seeing your screen, yet, Erin.  So, I don’t know if you’ve clicked the button yet.


Dr. Elliott:

Oh, okay.  Alright.


Dr. Lavine:

The presentation always goes better when we can see the screen.  There we go.  Perfect.


Dr. Elliott:

Sorry about that.  There’s my practice in Post Falls.  So, recently, we’ve seen in the news.  This was actually when I traveled to the Greater New York Meeting.  On the way there, I took Delta, and there was an article in the inflight magazine about sleep.  On the way home, I took Alaska, and there was an article about sleep.  It affects a lot of Americans because, really, we don’t get enough sleep with all the electronics we use and caffeinated beverages and sleep aids.  There’s so much that we’re missing in our sleep.

Now, even in the news, every week I see different press releases about obstructive sleep apnea and the effects it has on our health.  This one just came out this summer in which patients are more likely to die from cancer, and it really affects a lot of us.  It’s really important because there are four stages to our sleep.  That includes deep sleep and REM sleep that we know about where we dream.  If it is interrupted, we don’t get the restful sleep we need, and with already surviving on so little sleep, we aren’t getting the hormone regulation.  Our body’s not resting. Our cells aren’t regenerating and healing, and it has a hug economic impact as far as untreated sleep apnics using twice the amount of health care dollar.

So, there are about 84 different sleep disorders, and the once that the dentists concentrate on, of course, are sleep disorder breathing category.  Other categories include sleep walking, sleep talking, something called REM behavior disorder.  My patient actually just got diagnosed disorder in which she was acting out her dreams.  So, fortunately, she’s safe and her husband’s safe.  She was actually going after him in her dreams.

With the snoring, we all know about snoring, and it’s not really a joke.  We all know we like to joke about it.  Upper airway resistance syndrome is when patients are snoring, and they’re consistently getting interrupted because of the snoring, whether it be an arousal from their life or an arousal from a deep sleep into a lighter stage of sleep.  These are people that wake up unrested.  Central sleep apnea is a category of sleep apnea that’s actually pretty rare.  That’s when our brain tells us not to breathe.  So, we have two different types of sleep apnea that we deal with, and obstructive is the one the dentist can treat because there’s an actual physical blockage affecting our sleep pattern.

We’re going into snoring. I guess, recently, due to my cold, I have been snoring more lately, and my husband sent this to me on our Facebook account with love.  He has resorted to this occasionally, the pillow technique, and like I said, we see it on the cartoons, in articles, in the news.  A lot of the population snores, but many people tell me they don’t snore.  When I talk to their wives or husbands, I hear the real truth.  Most of the time when I ask if somebody snores, they say, “No, I don’t.  I sleep just fine.  I don’t snore, but my wife tells me I do.”

I thought it was interesting that a lot of the custom built homes that are being built actually going to have two separate master bedrooms, and that’s already started in Europe.  They’re called snore rooms.  So, it has become a pretty common thing, and snoring occurs when there is a narrowing of the airway and vibration of the soft tissue.  That can be in the nasal component or the back of the throat.

As we sleep, there can be a continuum of snoring, especially as we age or start gaining weight.  As we age, we lose muscle tone.  So, our normal sleeping becomes a non-sleepy snore, and, like I said, that upper airway resistance is when we’re interrupted enough that we don’t get enough sleep.  We become a sleepy snorer, and eventually obstructive sleep apnea is diagnosed.

Obstructive sleep apnea is where there’s repetitive episodes of apnea, insufficient airflow or without rest, and the difference between obstructive sleep apnea and central sleep apnea is actually when there’s ventilatory effort.  It’s when we’re trying to breathe, but we can’t because there’s blockage.

So, as you can see, when we lay down supine on our back, we normally maintain an airway with the soft palette and uvula allowing us to breathe.  Now, with snoring, there’s a partial obstruction of the airway, and the nasal cavity and the soft tissue there could be vibrating.  There could be a narrowing there or the soft tissue and uvula area.  Then, apnea occurs.  Obstructive sleep apnea occurs when there is a complete blockage, and our oxygen desaturates.

So, as we become increasingly obstructed, that is called hypopnea.  Hypopnea means that basically there’s a little kink in the hose. The airway is narrowed enough that our oxygen desaturates 4% or more.  Now, with apnea, we have a complete obstruction for 10 seconds or more, and our oxygen desaturates.  So, we get into this continuum, this pattern where we fall sometimes pretty easily.  Sometimes it takes us a while. As our muscle relaxes, the soft tissue relaxes.  The tissue vibrates, and the tissue actually relaxes.  Snoring is the vibration.  Then, it narrows enough to the point it collapses, and we have an apnea.

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The next best thing is aquahexine mouthwash, and I think this is actually a superb product that Virbac have got.  I think it’s horribly underutilized in practice.  Chlorhexidine is a very unstable molecule, but it’s got a really good property, which means it will actually bind to the tooth surface, on to the tongue, and it can last up to 12 hours in the mouth and have an antibacterial effect.  So, it is a good product.

I think we should be using it, following all dental treatments in animals that are teething, following extractions, for example.   A lot of people reach for antibiotics rather than something like aquahexine mouthwash which is all you would need.  I use it preoperatively and before I start getting into polishing to reduce my bacterial aerosol.  I use it postoperatively so once I finish scaling and polishing, I just flush out the mouth.  I use it in things where I’m going to be doing oral surgery.  You can’t always prep the area like you could if you were doing abdominal surgery, so I use chlorhexidine to get the mouth as clean as possible after jaw fractures or during lump removals or gingiva and things.

I think it’s absolutely invaluable in cases of chronic gingivostomatitis or in these really young cats where they get a juvenile gingivitis or an eruption gingivitis.  Often, you can get it well under control if the client’s using a good quality chlorhexidine product from an early age.

There are a whole range of products out there with dental claims, and I think you should be really, really careful with what you recommend.  Some of these on the screen, I do recommend.  I do recommend dental diets.  I think they are good, but I think the client has to be aware of the limitations.  As I said, when a tooth sinks into the kibble, the whole crown is going to be effectively cleaned, but the gingival margin is where your disease process is occurring.  The plaque there is not going to be affected.

So, when you’re reading any published studies that are related to any of these products, always look at what do you change at the gingival margin, and dental trials should separate out the gingival margin and the coronal margin.  The coronal margin is the tip of the tooth.  I’m not that bothered if there was calculus reduction or plaque reduction on the tip of the tooth.  What I’m really worried about is was there a change at the gingival margin because that’s where it’s going to have an impact on the animal’s health.

I would strongly encourage you, if you get drug reps coming around or if you get somebody recommending a dental product, that you actually ask what the claims are and look at the published studies because, at the end of the day, a lot of these products are costly.  Clients think they’re doing the right thing by adding an additive to the diet where perhaps there’s not a lot of science to support the product.

I think I’ve probably discussed this, and I’ve said it myself.  Once again, when you’re looking at these trials, what do the results mean?  What I’d just like to mention here is the Veterinary Oral Health Council.  When you look the claims, for example [01:01:04] has got the VOHC seal of approval.  Immediately you think, well that’s good because that’s going to have a health benefit, but all that indicates is that there is a claim that it’s going to reduce plaque accumulation.  It’s going to reduce calculus accumulation.  The VOHC doesn’t say that this is going to be of a health benefit to your pet.  So, when you are looking at these trials, really do look at it.  What does this mean for my pet?  Is it a product worth using?

So, when is plaque control adequate.  Basically, it is adequate when there is no gingivitis.  You know, a dog like this, I would start tooth brushing and see how you get on.

The last thing I’m just going to finish with are just the management of two cases.  The first is a five year old pug.  It’s in for a routing dental treatment.  There is no home care.  I’ve put routine dental because that’s one thing that absolutely drives me mad.  Routine dental, we use it all the time or a lot of vets use it all the time.  What does dental mean?  It means nothing to the client.  They don’t come in for cardiacs.   They don’t come in for dermals.  So, why are they coming in for dentals? We should always be using the phrase, “They come in for dental treatment,” because immediately, the client starts thinking along a different line.

So, there’s no homecare, but the clients are willing to try postoperatiely.  So, this is what we find under and anesthetic.  This is the lower molar.  You can see that there’s an overlap between the fourth premolar and the first molar.  We’ve got a probing depth in that area.  We’ve also got a probing depth on the lower canine, and you can see a very heavy calculus accumulation.

So, if we go back to important teeth, functional teeth, what is the owner going to be able to do?  Immediately, following scaling and polishing and radiographs, I would be considering extracting this tooth, purely because you’re going to be getting an area of plaque stagnation where the client is going to find it very difficult to brush in between those teeth and to keep it clean.  On this tooth, on the lower canine, there is a 5 millimeter periodontal probing depth.  Now, in a pug, 5 millimeters is probably borderline whether I would extract it or not.

On the other side, which you can’t see, is we had a deep probing depth between the incisor and the canine.  So, I would always extract the incisor because you don’t want an area of plaque accumulation.  I would clean that thoroughly, but then you can actually discuss with the client why you’ve kept the tooth in (the lower canine is such an important functional tooth), why they need to toothbrush, and how they can toothbrush.

The next case is a seven year old Maltese terrier.  The owners do meticulous home care.  They brush twice daily, and they do use a chlorhexidine mouthwash.  He also uses little teepee brushes to clean between the furcation.   So, this is what we’ve got with this little dog.  X-rays show that we’ve got some bone loss between the molar and the fourth premolar.

Once again, I would be tempted to extract this tooth.  We do have the 3 millimeter dental probing depth here, but because the client is brushing and because he’s got a good boney attachment, the rest of the tooth, which I can see radiographically, I wouldn’t consider extracting that lower molar.

On the top, you can see the third premolar.  We’ve got an area of bone loss over here.  We’ve got an area of bone loss over here, but given how well the client is tooth brushing, I would opt to keep those in for now purely because he is tooth brushing so well.  The last molar, unfortunately, you can see a [01:05:00] where you get bone destruction around the root of that tooth.  So, my radiographs are showing me that this is affected.  It really has got almost the equivalent of a peri-apical abscess.  So, that tooth would need to be extracted, but it’s showing you how a combination of radiographs, periodontal probing, and knowing what your client is going to be able to do postoperatively.  It’s going to help you with your decision making.

So, I think that’s all I’ve got to say.  It’s just, hopefully, a different way of think about periodontal disease and just remembering that it’s not just about smelly breath.  It’s not a cosmetic procedure that you’re doing.  You’re actually doing something to try and help these animals.

Thanks, Lisa.  Buh bye.

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