"Joint Conference Dental Sleep / Oral Appliances for Obstructive Sleep Apnea" Leopoldo Correa (01/12/2022)

January 18, 2022

ID7359

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00:00Bars sponsored by the Yale CME and and.
00:07Coordinated with multiple multiple
00:09sleep programs now started off with
00:12two and now we have 6 and stronger,
00:14the better and so happy New Year.
00:16Welcome to yet another session and
00:18I just wanted to take a couple of
00:20minutes and just maybe summarize
00:21what we were able to achieve in
00:23the last couple of years and.
00:26And before I hand it over to Doctor
00:28Grover to introduce Doctor Korea
00:29for today's wonderful talk. And so.
00:33Just as a little bit of bookkeeping.
00:37So since our inception in the fall of 2019,
00:41we've had about 1100 or almost
00:431200 attendees in these sessions,
00:46and so it's been one of the better
00:49attending sessions for for the Yale
00:51Pulmonary critical care fields,
00:53and hopefully the same for Beth Israel,
00:55Brigham, Mass General Tufts,
00:57and BU both Medical Center and it's been
01:01actually a wonderful resource for education.
01:04We've had experts in the fields talk on a
01:06variety of different topics or anything.
01:08Drums, circuiting,
01:09clocks in your development interactions
01:11to impact of COVID on the sleep
01:13centers might be due for another
01:15session of those and looking at
01:17sleep deficiency and chronic pain
01:18drug therapy for sleep apnea,
01:20Alzheimer's and sleep disruption,
01:23wearable wars and and looking at sleep
01:26assessment using wearable devices
01:28and looking at early environmental
01:29exposures and sleep program are
01:31just some of the topics that have
01:33been addressed by wonderful faculty
01:34and so we're grateful for that.
01:36And thank you all who attend these on.
01:39Every first Wednesday of the month
01:41and we are looking forward to many
01:43more of these wonderful talks and so
01:45thank you everybody and I wanted to
01:46say a special thanks to you know my
01:49colleagues at these various institutions,
01:50Dr Heckman, Dr Grover Javaheri Epstein,
01:53and Auerbach and also say great thanks
01:56to Debbie Lovejoy who helps organize and
01:59coordinate these sessions month after month.
02:02And so thank you Debbie.
02:03And so we have another great session
02:05planned for today and that further do you?
02:06I'm going to hand the mic over
02:09to Doctor Grover from Tufts.
02:11And we'll go from there.
02:15Thank you Andre.
02:17It is my pleasure to introduce
02:19my esteemed colleague Dr.
02:21Leopoldo Correa today,
02:22so just to give a quick
02:25introduction of Doctor Korea,
02:27he is an associate professor and director
02:30of Division of Craniofacial Pain at
02:34Tufts University School of Dental Medicine.
02:37He's the director of Dental Sleep
02:39Medicine programs at Tufts University,
02:41School of Dental Medicine,
02:42and is a diplomat of American Board of Dental
02:45Sleep and received his Masters in Science.
02:48At Tufts University, so Doctor Korea,
02:51he is committed to academic medicine and
02:54learning and as well as clinical practice.
02:58He has worked as a faculty at Tufts
03:01University in the Craniofacial
03:02Pain Center for more than 15 years.
03:06And he teaches dental Sleep Medicine to
03:08the pre and post graduate programs at
03:11Tufts University and has participated
03:14as a speaker in many countries,
03:16including United States,
03:18Europe, Asia and Latin America.
03:20He goes out to different countries to teach,
03:23and I know with COVID it's been hasn't
03:27been a little issue for all of us.
03:30He has been a valuable part of our
03:32Sleep Medicine Fellowship program
03:33here at Tufts Medical Center,
03:35where we both of our programs collaborate
03:38and teaching dental Sleep Medicine fellows.
03:41In addition to teaching for our
03:43sleep fellow with his program and
03:46our program combined.
03:49So he I just want to say thank you Doctor
03:53career for today's talk and I look
03:56forward to listening and and just you know,
03:59thank you for coming in today.
04:02Thank you. Thank you so much.
04:04Very welcome everyone.
04:05So just allow me a few
04:07seconds to share my screen.
04:16Alright, so it's it's really a
04:19pleasure to participate in this
04:21series of Sleep Medicine lectures,
04:24so I got the invitation on a few
04:26months ago and then you know,
04:27it's I was thinking about the topic.
04:29So what topic would be the ideal
04:32one for the for the audience?
04:34So what I'm going to present
04:37is basically the the standard.
04:40Protocol that we follow in regarding
04:43oral appliance oral appliance therapy.
04:45So we have some information to to share.
04:49And certainly we can take questions.
04:53I believe that Gruber,
04:54we can take questions towards
04:55the the end of the presentation,
04:57so we will allow enough time to you
05:00know to spend time with the participants
05:03and go over different questions.
05:05So this is my contact information.
05:07So my clinic or clinic is located
05:10at South University Dental School,
05:12literally next to tough Medical Center.
05:15Over the last several years.
05:17So we have really strengthened
05:19the collaboration.
05:20Between the Center for Sleep
05:22Medicine at Tufts and our center
05:25here at the dental school,
05:27along with some other sleep
05:29centers in the Boston area.
05:32So there is no conflict
05:34of interest to disclose,
05:35and this is like oh,
05:37this is light so everybody can request
05:40they see me and I believe that the
05:43information will be posted on the
05:44chat as we go along with the presentation.
05:47Just give me one second.
05:52So we're going to.
05:53We're going to discuss.
05:55We're going to talk about the you know,
05:57oral appliance therapy for a stroke slip up.
06:00Yeah. So then things had been a no been
06:05slowly getting into the field of sleep.
06:08The last the last few
06:10years they had been done.
06:12A significant increase of dent is
06:14getting in the field of Sleep Medicine.
06:17So we understand that oral
06:20appliances is a treatment modality.
06:22For patient with apnea,
06:24some indication some patients who failed
06:27the use of the C PAP and some other
06:30specific indication for this day to be.
06:32As I said, you know,
06:33we're aware there are some use
06:36and limitation for these devices,
06:39so we will try to cover as much
06:42as possible this information
06:43during the next 4045 minutes.
06:46So I think I'm,
06:49you know I was.
06:50I was pretty much putting together
06:53the the information and I think
06:55it's important for a physician.
06:57For for sleep is Ishan.
06:59For everybody attended this these
07:02seminars to understand the protocol that
07:05dentist follow for this for this purpose,
07:08too often the oral appliance
07:10therapy for Libya.
07:11So we're going to go over
07:14each of these steps.
07:15And of course we will cover.
07:16We will extend.
07:18The information regarding oral
07:20appliance designed the purpose
07:22they use efficacy and so on.
07:25So the dentist offering
07:27this option this therapy.
07:29So basically what we do.
07:33We started with the screening so
07:36we screen our dental patients with
07:39utilize different questionnaires
07:41to implement this first step.
07:44So let's start with this one.
07:45So screening and clinical history.
07:48So we understand that the goal for this
07:51initial step is to assess the symptoms.
07:53So the symptoms that we commonly see
07:56in patients with sleep disorders.
07:58So these symptoms are gonna be divided.
08:00Of course,
08:01in night time,
08:02and they transit also include
08:04this as part of the the regular
08:07clinical history and all the
08:09documentation that we are that we
08:12implement to order interpretations.
08:14So in addition to.
08:15Then information so we utilize
08:17the standard validated screening
08:20questionnaires they won for
08:22sleepiness and the one validated to
08:25assess patient with sleep apnea.
08:28I believe everybody is familiar
08:30with these two,
08:32so along with the screening questionnaire,
08:35the Stop Band and the Edward
08:38Sleepiness Scale,
08:39we expand into the standard section for
08:43the clinical history in take a medication.
08:46Medical history and and different things
08:48that are standard for this purpose.
08:51And they were the reason in presenting this.
08:53So we are in a course in
08:55educational institutions.
08:56So we have resident with the fellows
08:59that come to our Center for a training,
09:02so they learn all these all these steps.
09:06So as part of the clinical history we do
09:09the assessment for high risk patients.
09:12And of course,
09:13we evaluate the risk factors
09:15and something that we developed
09:16with my fellows recently.
09:19One second in the moving.
09:28Are they at in the? Images for sale.
09:38Sorry about that. Let me try
09:40to fix. It's not moving.
09:49Sure. Switch.
10:11Sorry, I think I believe
10:12I need to restart the.
10:15Sensation the computer.
10:17My apologies, let me try something.
10:19I'll be back in 5 seconds.
10:23Alright, no problem.
10:26Zuma technical issues to the rescue as usual.
10:29So while we have doctor
10:31Korea restart his computer,
10:33I just want to remind you that
10:35you can get CME credit for the
10:37seminar and so please check box.
10:41To put in the code of 28446,
10:46you can text it to the
10:48Yale CME number, which is
10:512034429435. And if you don't have a
10:55yelsey any cloud or account set up,
10:57you would have to set that up
10:59before receiving credit for this.
11:00So hopefully we're back in business.
11:04Take it away.
11:08Is it working now?
11:09Doctor Korea, yes, yes it's working.
11:12No idea what happened.
11:14First time we have.
11:16Anyhow, so thank you.
11:18I apologize for that for the interruption.
11:20So what I was saying is that you know
11:23combination of all these screening tools.
11:25The sleepiness scale this dog band along with
11:27all the medical history and medications.
11:30So along with my fellows and residents.
11:33So we developed.
11:34This is a one page screening tool,
11:37so it's mainly utilized for my residents
11:40and fellows to discuss the the cases
11:43with faculty and we include all
11:46this information regarding symptoms.
11:48Risk factors some kind of facial evaluation,
11:52and we include the the assessment
11:54of this thought banner,
11:56the airport at the end,
11:58so it's something that we utilize
11:59in the in the daily basis.
12:01So now my point with this first step
12:03of screening clinical history is that
12:06of course dentist need to understand
12:08that this is only the beginning.
12:10This initial part initial component
12:12to do the assessment for the patient
12:15and the next step of course is
12:17to to move forward.
12:19With a referral and diagnosis and
12:22this is there actually is extremely
12:25important because this is when and
12:28where we need the collaboration
12:29with all of you with the sleep
12:32center with the sleep sessions,
12:34the medical component.
12:35So at this point we are in the
12:38stable referral patients for
12:41further assessment and diagnosis,
12:43so the referral.
12:45It's basically the when we start
12:47the collaboration.
12:49This collaborative approach with
12:51the with the medical,
12:53the medical team used to to to do the
12:56further assessment to the patient and
12:59get the the diagnosis is the patient.
13:02The candidate for oral appliance?
13:04Maybe, maybe not.
13:05Maybe the patient has severe
13:07obstructive sleep apnea and they must
13:10start with with other therapy social,
13:12so this is the the point that
13:14we're trying to.
13:16Implement during our courses
13:18all the different lectures that
13:20we offer to practicing dentists
13:23or or students here is this.
13:25The importance of this collaborative
13:27approach with the medical field,
13:30dental and medical field.
13:32So from the screening and diagnosis.
13:37So now we are moving into the
13:39step of initiating therapy,
13:41initiating therapy with oral appliance.
13:43So let's say the patient with diagnosis.
13:46So it's a patient based on the
13:48SLEEP study results is a candidate
13:51for for oral appliance.
13:52So the steps that dentist follow for
13:57this initiation of therapy number one
13:59is the referral from the sleep physician,
14:02basically.
14:02You sleep physician recommended the oral
14:05appliance copy of the Diagnostic Sleep study.
14:09Basically any clinical
14:10note from other providers.
14:12So we implement the clinical history.
14:14A more expanded clinical history
14:16and examination developed the
14:17treatment plan and of course the
14:19informed consent for therapy.
14:21So we understand that oral appliance therapy,
14:24along with some other team modalities
14:27they had some potential side effects,
14:29so it's important to disclose all
14:31this information with the patient.
14:33So now the patient is back,
14:35so the patient is back to the
14:37dental clinic back
14:38from the sleep center.
14:39The diagnosis is a, you know,
14:41based on the SLEEP study,
14:42so it's the candidate for LA Pliance.
14:44So the dentist at this point it will expand.
14:492A comprehensive examination and what
14:51is involved in this comprehensive
14:54examination from the dental standpoint?
14:57Well, in addition to the standards section,
15:00the standard clinical history and
15:02examination of course be include the
15:05assessment of certain baselines, BMI,
15:08blood pressure, neck circumference,
15:10and of course, as a dentist.
15:12So we look at them out.
15:14So when the patient opened them out,
15:16so the areas that we look at is.
15:18This soft palate, the uvula,
15:20the president of tonsils,
15:22size of the tongue size of
15:24the maxilla and mandible.
15:25So basically following or identifying
15:28certain anatomical features that
15:31it will help us at the dentist to
15:35understand the you know before moving
15:37into the next step of oral appliance.
15:40Designed is the patient had some
15:43comical features that will you know
15:45that that will help to to improve.
15:49The treatment outcome with our appliance.
15:52So in addition to the oropharyngeal
15:55examination,
15:56so the assessment examination
15:58of the masticatory muscles,
16:00the muscles of the face,
16:01the head and the neck is extremely important,
16:04along with the temporomandibular
16:06joint so the oral appliance therapy.
16:10I mean the main effect is to advance the
16:12mandible to move the mandible forward
16:14for several hours so when the mandible
16:17is forward certainly is going to.
16:19Nothing is gonna have some direct
16:22effect over the muscles of the face,
16:24the temporomandibular joint.
16:26So we take this step as a baseline used
16:30to identify any potential pre-existing
16:32TMD symptoms that may contribute to
16:36some discomfort with the oral plans.
16:40So we evaluate the temporomandibular joint.
16:43And after completion of this step
16:46of the comprehensive examination,
16:48so then we move into the oral
16:51appliance selection.
16:52So what oral appliance will be
16:55indicated for that particular patient
16:58and the way we select the the whether
17:01we choose this oral appliance is
17:04basically based on the anatomy of
17:06the dictations or offering your
17:09structure or the size of the mouth.
17:12The size of the maxilla.
17:14So by choosing the appropriate oral
17:17appliance, basically we tend 2.
17:21They may focus is to improve comfort,
17:24to provide comfort,
17:25and by providing the comfort
17:27of using the oral appliance.
17:29Certainly compliance or adherence
17:31will be better.
17:33So according to different studies,
17:36different, systematic review.
17:38So there is no any specific particular
17:43oral appliance that will that will
17:46help all patients with the structure is
17:49certainly the oral appliance designed.
17:52What we're looking at is to provide comfort,
17:55good retention based on the anatomy
17:57based on the identation motivations.
18:00The efficacy of this oral devices certainly
18:04are based on individual characteristics,
18:08so patient characteristics.
18:09So what is the severity of the condition
18:12and other things that we will review
18:14in a few minutes so used to expand
18:17into this oral appliance design?
18:19And everybody probably are curious of,
18:22you know.
18:23Now these oral appliance look like
18:26so this oral appliances.
18:27They have a basic component.
18:29They have a specific mechanism based
18:32on the manufacturer based on the
18:35the company that provides devices.
18:38So they recently there was a
18:41development of these nomenclature for
18:44oral appliance design based on the
18:47attachment based on the the mechanism
18:50that allows the mandible forward.
18:53So the first one is the
18:56bilateral compression.
18:56Basically the description
18:57is listed here on the slide.
19:00This is a short video on the way
19:02you know the way this specific
19:04appliance look like.
19:05The way seated on the on the patient's mouth,
19:09so the next appliance.
19:11It's called the ballata retraction,
19:13and this definition you know these
19:16names nomenclature of the devices are
19:18pretty much in a way to understand the
19:23way the the the mechanism produce the
19:26the the the advancement of the model.
19:29So in this case we can see that the
19:32component is attached from the superior
19:34until you're part of the plate to
19:37the lower posterior part of the of the plate.
19:40This is another short video showing.
19:42The the mostly adjustment that are done
19:45in the office in the dental office,
19:48or sometimes patients tend to
19:50perform this adjustment at home.
19:52So we go over some instructions and so on.
19:55So this is the bilateral traction.
19:58So the next design is the midline traction,
20:01and again,
20:02so is basically the way the position
20:06decide the dimension of the the
20:08mechanism that will provide the
20:11advancement of the mandible.
20:13This is another.
20:15Visualization of this Midland traction so we
20:18can see the components in the interior part.
20:21So by looking through all
20:23these different designs,
20:24So what are we doing here?
20:25Well, I mean we're trying to match the
20:28the best option for certain patients.
20:31Size of the mouth,
20:33size of the audit on the
20:34condition of the tip,
20:36and so on.
20:37And all these devices actually is
20:40very important to mention that
20:43all these devices are adjustable,
20:46adjustable or titration.
20:47It means that during the
20:50time that the patient.
20:51Initiate treatment and come back
20:53for follow UPS so we can perform
20:56all these different adjustment
20:58on the mechanism should continue
21:01moving the mandible forward.
21:03We do not initiate the therapy
21:06with the maximum protrusion or
21:08demandable because of course
21:10that may cause some discomfort.
21:12Some symptoms of the temporomandibular joint,
21:15so we take all these steps
21:17gradually so we started with some
21:19degree of protrusion and then we
21:22perform the adjustment.
21:23During the follow up appointments,
21:25so the last one,
21:27this design is the bilateral
21:30interlocking and we can see that
21:32you know this particular design.
21:34It has more option for a judgment
21:37options on the lower plate on by
21:39replacing these little films or the
21:42option of adjustment in the area
21:44of the the screw on the upper plate
21:47so he wears we're showing both the
21:50both option for the titration.
21:52So all these devices.
21:54They fall under the this
21:56standard nomenclature,
21:57so now the lease of oral appliances
22:01commercially available is
22:03extensive. It's very long,
22:05it's approximately close to 100
22:08different designs over there.
22:10However, when we you know for the
22:13purpose of teaching and and for the
22:15purpose of for residents and practicing
22:18dentists to understand this concept,
22:21so be lonely. So 100.
22:23Appliances have commercial available.
22:25All those appliances.
22:27They fall on their these four categories,
22:31so the bilateral traction,
22:34midline, traction,
22:36bilateral compression and
22:39bilateral interlocking.
22:42So taking one step one step back
22:45so we know that you know dentists
22:48are getting involved in the
22:50field they've been involved in
22:51the field for for a long time,
22:53but when we look into this as light,
22:55we can see that dental Sleep Medicine
22:58or oral appliances they they've
23:00been around for a long a long time.
23:02So the first report of an or
23:05utilization of an oral appliance
23:07to improve the oropharyngeal
23:10collapsibility is back from 1923.
23:13That was the first one who reported
23:15the use of these devices and over
23:18the last several years they had been
23:21different milestones regarding the
23:23advancement of this of this therapy.
23:26Of course,
23:27I mean research different studies
23:29showing the efficacy of the device had
23:31been stronger over the last few years,
23:34and that is the reason why these
23:36feel the feel of dental dental
23:38sleep is is moving forward is based
23:41on the the evidence that we are.
23:43That we are developing for the
23:47utilization of these devices.
23:49So now moving forward.
23:51So what is the purpose of this therapy?
23:53I mean very straightforward, right so?
23:57That, like any other therapy for a structure,
23:59is sleep apnea.
24:00We're looking to improve symptoms.
24:02We're looking to decrease the
24:05respiratory event. Improve our oxygen.
24:10However,
24:10the oral appliance is the oral
24:14appliance therapy.
24:15At this point,
24:17it has some specific indications so
24:20oral appliances according to the you know,
24:24the evidence and the studies
24:26done regarding efficacy.
24:28Stratifying the severity of the
24:30condition patient with mild,
24:32moderate or severe obstructive sleep apnea.
24:35So all this study has shown that
24:38oral appliances are more effective.
24:40In patients with mild to moderate
24:42sleep apnea, however,
24:44there are some patients with
24:47severe sleep apnea.
24:48That they respond favorable.
24:50They respond well to oral appliance
24:53therapy and what is that?
24:55And of course I mean it will require like a
24:58more extensive session, but it's based on,
25:02you know, patient characteristics.
25:04So we have over the last several years.
25:07So we have identified.
25:10Showed that our better responders
25:12to oral appliances.
25:13However, we do not offer.
25:16We do not provide.
25:18We do not fit oral appliances
25:21as the first line of treatment
25:24on patient with severe strep.
25:26So the current guidelines.
25:28The commendations for this therapy
25:31clearly indicate that patient
25:33with severe structure sleep apnea,
25:35the first line of therapy is the
25:37use of the C pad or bad therapy.
25:39If at some point the patient fail,
25:42they cannot tolerate the bite,
25:44they slip up,
25:46they don't comply with the with
25:48the C PAP therapy.
25:49Of course,
25:50the physician this the
25:52physician may recommend
25:53the the the use of oral appliance,
25:56and we do all this, of course with the.
25:59Very close communication with the with
26:01the Sleep Center and with the sleep
26:04physicians that is referring the patient.
26:07So another purpose,
26:09another use of these devices.
26:13Is as an agent therapy so commonly
26:17known as the combination therapy.
26:19So there are some patients that
26:22definitely will need the the the
26:25pub therapy as the first option and
26:27you know for some reason they cannot
26:30tolerate the device and the oral
26:32appliance certainly is not giving is not
26:35providing the resolution of symptoms,
26:37the resolution of respiratory events,
26:41so we have.
26:43The option to to provide this combination
26:46therapy so the patient utilized the C PAP
26:49and the oral appliance at the same time.
26:52So what is the purpose of this?
26:54Well, we understand that,
26:56let's say in a patient with severe
26:59sleep up the oral appliance by itself
27:02it will not be able to manage all
27:06the OR resolve the severity.
27:09We may reduce it by 50% or
27:12something like that.
27:14So the way is going to help the way this
27:18combination therapy between oral appliances.
27:21According to different studies.
27:23So what it does it does,
27:25it helps to reduce the air
27:27pressure from the C pad,
27:29making the therapy more
27:30comfortable for the patient.
27:32The patient will be able to tolerate
27:34better the lower pressure of the C PAP,
27:37and along with the oral appliance,
27:39so the oral appliances reducing the severity.
27:42So therefore the path or the air
27:44pressure pressure in those thing
27:46has to be in a high high level.
27:49So as we mentioned so indicated,
27:51for might moderate can be indicated as the
27:54first line of therapy according to the
27:56to the coding guidelines and recommendations.
28:00And there's some patient with civility, but.
28:02So on the bottom of this slide so.
28:07You know we mentioned about
28:09qualified dental personnel,
28:10qualified entities,
28:11So what does that mean?
28:13So it's an important question.
28:15That is, lift station and sleep center.
28:18As you know when they are looking to
28:21refer patient for oral appliance therapy,
28:24they need to.
28:25They want to know you know what dentists
28:28have the credential of the qualification
28:30for these two offer this option.
28:33I mean it's it's very straightforward.
28:34So then things who decide to get involved in.
28:38He's in this field.
28:41So.
28:42They need to go through and
28:45extended training understanding of.
28:46Of course the concept of Sleep
28:48Medicine or structurally.
28:50But yeah,
28:51you know in addition to the understanding
28:53of course of the the components
28:56of the oral appliance design,
28:58titration and different protocols that
29:00we follow on this on these cases.
29:03So we look into the function of the devices,
29:06so we are.
29:08Looking into this nice systematic review.
29:12So basically this.
29:15This report shows the possible mechanism
29:19that the oral appliances make over
29:22the upper airway and and the autos.
29:25Here they describe three main mechanisms,
29:28so advancement of the mandible
29:30with the oral appliance.
29:32You know it has to move this global
29:35muscles to enlarge the airway.
29:37So it helps to provide some
29:40degree of tension extending
29:42tension across the the South Pole.
29:45And lastly, it seems to maintain,
29:49you know, by having this forward
29:51position of the mandible.
29:52So it tends to modify the higher bond.
29:55They hired bond position.
29:57So combination of these three
29:59possible mechanism it helps to
30:02maintain the patent see over the the
30:05on the airway so at least reduce.
30:08The the obstruction or eliminate
30:10completely the the the respiratory events.
30:14And then I mean we go back into
30:17the early studies about the
30:19mandible advancing the mandible.
30:22So it's basically those dependent.
30:25So this this study.
30:27Done by the group in Japan,
30:30doctor Sona and Doctor Caddo so it
30:34demonstrate that they stratified
30:35there was some state wise
30:38advanced mental demandable at 2,
30:40four and six millimeters,
30:42and they reported how the
30:44advancement of this demandable.
30:46Though it improved the oxygen oxygen
30:49saturation and it was one of the you know,
30:52early studies regarding the
30:55demonstrating the the defect.
30:57Last Monday will advancement over
31:00the struction of the of the airway,
31:03and there are some other.
31:05Other studies from this group in the
31:08in in Australia Professor Ecker and
31:11and and other collaborators, 2018.
31:13So there was this nice publication
31:16about no reporting the way this
31:19movement at Boston Demandable.
31:22He has already anatomy of the
31:24of the upper airway muscles.
31:27Basically,
31:27it tends to tense or increase
31:31the the airway size.
31:33You know it tends to maintain.
31:35Or increase the size on the
31:36area of the soft palate.
31:38Remove the the way so they don't forward,
31:41and so on.
31:42In addition to that,
31:44they also report that another
31:46possible mechanism it tends to the
31:49advancement of the mandible in May
31:51stimulate some local reflects and overall,
31:54so this is a mechanical,
31:57mechanical way to maintain the
32:00airway open during during the sleep.
32:04Now when we look into these
32:06two therapies and and and,
32:08this is very important to
32:11to explain and understand.
32:13So dentist so we understand
32:16that CPAP is highly effective.
32:20You know is normally provided the
32:23first line of therapy however,
32:26so there are a group of patients.
32:28There is an important percentage
32:31of patients who unfortunately
32:32will not be able to.
32:34Tolerate the therapy and then you know.
32:37So we need to look for alternative.
32:39We need to look for different options.
32:41Oral appliances is one of the alternatives
32:44to the to the sipad failures.
32:47So C Pap and Orla plans.
32:50So here pretty much explained efficacy
32:54and effectiveness of these two
32:56three modalities and we know that C.
33:00Pap of course will provide a higher.
33:04Results, But then when we
33:07get into the adherence,
33:09the compliance of 1 therapy versus
33:12the other so we can see that
33:15according to a different report,
33:18different studies.
33:19So we see that the compliance
33:22one therapy versus the other
33:25is is significantly different.
33:27So if you can see them focusing.
33:31It's how you don't see PAP compliance
33:33is lower compared to oral appliances
33:35and this is where we need to assess.
33:38We need to determine you know
33:40what are the characteristic of
33:42this particular patient visit.
33:43Patient will be able to tolerate
33:47or reception a good candidate
33:50for oral appliance therapy.
33:52Or maybe it could be a patient that will
33:55benefit from combination combination
33:57of these two two options, certainly.
34:00He gets some.
34:01He can sleep, but he gets deeper Lee.
34:05This meant about patient characteristics,
34:07patient assessment.
34:09So before we initiate.
34:12That update with oral appliances and we tend
34:14to evaluate all these factors and you know,
34:17try to maintain a very strong
34:20communication and collaboration.
34:22Of course,
34:23with the the Sleep Center they sleep session.
34:28So oral appliance just to
34:30conclude this this this part.
34:32This step of the the protocol.
34:34So oral appliance designed is extremely
34:38important is important to understand
34:40the mechanism and still notice.
34:43So we are not talking about brand names.
34:45So there is a long list of
34:48commercial available devices.
34:49Although devices for fall on there.
34:53Four particular categories
34:54and again the main point.
34:58From the dental.
34:59From the dentist to implement.
35:01To apply this oral appliances is to
35:04have a good understanding of the you
35:07know the Physiology, the mechanism,
35:09the function of the airway,
35:12patient selection, you know,
35:14severity so so many characters.
35:17So many things that we look
35:19before we initiate this therapy.
35:22But let's say you know at this point,
35:24so we completed the screening.
35:27The examination. Diagnosis with stab Lish.
35:30The communication with sleep physician.
35:33So now it's time for the next step
35:36will be to, you know, to determine.
35:40The initial position of the mandible,
35:43the initial position that we're going
35:45to fabricate the oral appliance.
35:48Commonly known as a buyer registration,
35:51so this picture shows the bar
35:53registration with one of our patients
35:55and then when we look into the evidence.
35:57So what the evidence shows?
35:59What the you know literature shows.
36:02So the initial mandibular position,
36:04you know,
36:05the position that we that we're
36:07going to start therapy and structure
36:10and the patient so to determine
36:13that initial position,
36:15we're going to evaluate much these steps.
36:18We review earlier during the examination,
36:21dentition muscles,
36:22temporomandibular joint severity of
36:25the obstructive sleep apnea and so on.
36:29So just to give you an idea,
36:31the range of initial position
36:33initial protrusion that we implement
36:36as the initial step.
36:38He goes from 25 to 75% position that
36:43is comfortable and therapeutica
36:45in a therapeutic range.
36:47Is is a long range 25 to 75.
36:50So, however,
36:51going to determine if it's 2550 or 75,
36:55well condition of the muscles,
36:57condition of the temporomandibular
36:59joint is a patient with mild,
37:01moderate or severe obstructive sleep apnea,
37:03so they will need some increase of a
37:08protrusion depending on those those factors.
37:11So after we finish the by registration
37:14or determine the the initial settings.
37:17So now the appliances
37:18fabricated and we proceed.
37:20With the seating of the oral
37:22appliance and we look into three,
37:23these three factors, comfort,
37:26retention, good retention of the device,
37:28of course, and we verify some of the
37:32the occlusal the occlusal contacts.
37:34So from the initial position,
37:38the initial mandibular position,
37:40now we need to move into the
37:44therapeutic mandibular position.
37:46So the therapeutic mandibular position
37:48is the mandibular position that
37:51will provide the best resolution
37:53for symptoms regarding snoring,
37:55daytime sleepiness, quality of sleep,
37:59and of course,
38:00we need to measure the respiratory events.
38:02So reduction of.
38:05Hypopnea index as a measurement of
38:08success and increase of oxygen saturation.
38:11So this device is the way that we will
38:14achieve the therapeutic position is by
38:17performing the adjustment that I show
38:20on the video as on the previous slide.
38:23So that's why all these devices
38:25they have this particular mechanism
38:28that will help to to achieve this.
38:32This particular position and.
38:34The specific therapeutic position
38:36certainly is going to be different
38:39from patient to patient.
38:41It could be a 5075%.
38:43So achieving this terrible team
38:46and the rural position is done
38:49during the follow up appointments.
38:51So we provide the oral appliance.
38:54And we communicate with the patient.
38:57We explain the importance of
39:00coming back for follow ups.
39:03So the adjustment of this device is again,
39:05it can be done at the by the patient
39:07with a very strong explanation
39:09on how to do that at home,
39:11or preferable is done in the dental
39:14dental clinic in the dental office.
39:17So in this way,
39:19during the follow up appointments
39:21regarding the patient will come back
39:23every three weeks once a month.
39:25So during the follow up appointments
39:28we do the assessment.
39:30Any changes on this sleepiness
39:32it snoring quality with sleep,
39:35different things that we implement on
39:37the on the questionnaires and that
39:40will help to determine the need for
39:43additional adjustment on the device.
39:45So it's very important for me
39:47to mention that at this point,
39:49even if the patient report that they are,
39:53you know, feeling fantastic,
39:55they were called feeling refreshed.
39:56They don't feel sleepy anymore that.
39:59Is not sufficient.
40:00That is only the subjective assessment.
40:03The subjective report from the patient.
40:06So we need to refer the patient
40:09back to the sleep center.
40:11Refer the patient back to
40:13the sleep physician.
40:15And request the additional is
40:17sleep study so it follow up sleep.
40:21Study with the oral appliance in place.
40:25And again this is a protocol that we have.
40:27We follow. The sleep centers are.
40:32Familiar when the patient
40:33returns for additional sleep.
40:35Test with oral appliance.
40:37The main purpose is to compare
40:39the baseline and the follow
40:41up with the oral appliance.
40:43After completion of adjustment,
40:45other devices and going back to the
40:49you know patient characteristics.
40:51Patient selection.
40:53Not every patient will respond
40:56to oral appliance therapy.
40:57There are different factors,
40:59and of course there are different.
41:01Studies there are some evidence
41:04showing some group patient that
41:06responds that have a better response
41:09to oral appliance therapy and what
41:12are those predictors of success?
41:14I mean, we look into the literature,
41:17so there are different predictors
41:19of treatment response predictor for
41:21oral appliance treatment response.
41:24And this is based on what we
41:25included in this additional form
41:27that we are developed with with
41:29my fellow my risk students.
41:31No, it's based on the sum
41:33anthropomorphics factors.
41:34You know Asian.
41:35There be my next conference
41:38or pharyngeal dimension.
41:41Sunset,
41:41follow metric analysis and very important.
41:44What is the condition of the the
41:47severity of the condition of
41:49the patient with my motor severe
41:51and also very important too.
41:54To include the predictor of indication,
41:57have pre-existing TMD temporomandibular
42:00joint disorder symptoms so those patients
42:05with temporomandibular joint symptoms,
42:07so those are the patients that
42:09we need to be extremely cautious.
42:11Careful with the initiation of
42:13therapy so this patient will require.
42:16In this specific appliance design,
42:19some particular adjustments on
42:21the oral appliance to minimize
42:23or to avoid worsening the TMP
42:26as the first place with certain
42:30modifications of the oral appliance.
42:32So we may may be able to help in some
42:35patients with this trick sistant,
42:37DMD and, of course, side effects.
42:39As I mentioned in the beginning
42:41of the presentation,
42:42side effects are going to occur
42:45at some point.
42:46It doesn't indicate doesn't
42:49represent like you know,
42:50something that the patient needs to
42:52stop wearing the device right away.
42:54So there are different options,
42:56different things that we do to
42:59minimize or to manage these side
43:01effects as we have listed in here.
43:04And of course for the purpose
43:06of today's presentation.
43:07So pretty much we're just listing
43:09the common side effects that we
43:11see in in patient regarding to the
43:14occlusion temporomandibular joint muscles.
43:17And and different things.
43:19So this is another form and I presented
43:22different form because this is,
43:24you know, it's very helpful for us.
43:26It's very helpful for residents
43:28and I'm fellows to understand
43:30the progression of treatment
43:32or the development of symptoms.
43:35So this is discomfort scale
43:37that dictation fill out in every
43:39single appointment.
43:40So it's very helpful to you know
43:44to assess if the patient develops
43:47any symptoms related to the.
43:49Or the common areas that we see here.
43:52So the protocol used to conclude the
43:56protocols from the dental therapy
43:59oral appliance therapy as we went
44:02through all the different steps.
44:03So the important component is the follow ups.
44:09So the dentist months request
44:12must explain to the patient the
44:15importance of returning.
44:16For this follow up appointments.
44:18And of course the documentation
44:20and information that we get.
44:22From these from these visits.
44:26So after we complete all
44:28the adjustments on the oral
44:30appliance at the division,
44:33returns to the Sleep Center
44:34or to the sleep physician.
44:36We verified that the treatment is,
44:39you know, is effective.
44:40The of the index or the
44:42symptoms are resolved.
44:44So in collaboration and
44:45communication with his sleep,
44:47sleep physician or the sleep center.
44:49So we stab Lish, the long term management.
44:52So the long term management
44:55from the dental standpoint,
44:56so it includes seeing the patient initially
45:00at six months and eventually once a year.
45:03And what do we do during those
45:06long term follow-up appointment?
45:07Well, I mean,
45:09we verify the condition of the oral
45:11appliance and we get an update on the
45:15medical history medication body weight,
45:17something that may compromise
45:20the the the the.
45:22Outcome efficacy of the of
45:24the oral appliance if needed,
45:27so the patient may.
45:28You know,
45:29we may refer the patient for
45:31additional consultation and updated
45:33the SLEEP study after several years.
45:35But depending on all those,
45:37all those factors that we see over overtime.
45:41So I will say that so pretty much what we
45:44went through for the last 40 minutes or so,
45:48it was the 10 steps.
45:50So I developed this.
45:5310 sections short presentations.
45:56It's pretty much straight forward.
45:59Do you have a good understanding
46:02of what dentist you know can?
46:07The way they entries though, developed this.
46:09This treatment offered this treatment to
46:11to the patient starting from screening.
46:15I'm finishing with the long term management,
46:20so all these steps are.
46:23And this is, you know,
46:24one of my last my last life.
46:26So all these steps has to be done
46:29in a in a collaborative approach.
46:33Every time that you know I
46:35teach my students my we teach.
46:37Practicing dentist wants to, you know,
46:39know more about these difficult dental sleep.
46:43So we emphasize.
46:45That the collaborative approach,
46:47the communication,
46:48the collaboration,
46:49the you know talking,
46:51discussing individual cases
46:53with this lift station is one of
46:57the most most important steps.
47:00Understanding where are the limitations
47:03where our limitations and where
47:06is the need for this collaboration
47:09from the medical standpoint,
47:10we understand that sometimes it's not easy
47:13to to know where to send the patient,
47:16but at least from this presentation,
47:20one of my goals is,
47:21you know,
47:22for for physicians to to understand
47:24the steps that are needed,
47:26they need for training for the
47:28dentist to be trained.
47:30In the field of Sleep Medicine,
47:33understanding the condition
47:35understanding the different oral
47:37appliance design and most important,
47:39understanding the patient, patient selection.
47:43Patient selection is one of the key
47:46factors for a good treatment outcome,
47:48and I always think that you
47:51know between the collaboration,
47:53collaboration and strong collaboration
47:55between academic institutions.
47:56As we can see in this fascinated.
48:00Keep conferences different
48:01institutions working together develop
48:03this series of lectures with very
48:06important so this collaboration
48:08is needed when Academy institution
48:11between professional associations.
48:13By doing that by doing this
48:15property approach so it really is
48:16going to take the feel of a Sleep
48:19Medicine or taking the feel
48:20of a Sleep Medicine and the
48:22feel of dental Sleep Medicine.
48:25Forward so we need to continue supporting,
48:29communicating, collaborating,
48:30and continue to grow this field globally.
48:34So contact information and a
48:38reminder about the information that
48:41you need to plan your CECE credit,
48:45so I appreciate your attention.
48:47I I thank you so much for this this
48:49this important invitation it's it's
48:52really an honor to participate.
48:54In these in this series of lectures,
48:57and certainly I look forward to
49:00communicating with with all of you
49:03with some of you any questions,
49:06any additional information that
49:08you would like to know about our
49:11training here at UF Dental Tufts
49:13University Dental School,
49:15so feel free to contact me.
49:17So email the office address or by telephone.
49:21So I'm here and available for all of you.
49:24Thank you,
49:25thank you so much Doctor Gruber for
49:26the Nice introduction and thank you
49:28for the interactive entire team.
49:30Thank you doctor Correa.
49:32It was such an insightful talk.
49:35So I'm going to just read
49:37some of the questions to you,
49:38but I just had my own question.
49:40I know we have sent.
49:43What are your thoughts on?
49:45Patients who are using hypoglossal
49:48nerve stimulators as a.
49:50Way of treatment of OSA.
49:53I know we have collaborated
49:54on some of those patients.
49:56What are, you know,
49:57in terms of using which sort
49:58of device would you use for
50:00that set of patients and.
50:02I know there aren't many studies out there,
50:05enough data to support combination,
50:08but I think we would something to consider.
50:11What are your thoughts on
50:12combination of hypoglossal nerve
50:14stimulator and the oral devices?
50:15Yeah, thank you for this very important
50:19question and my answer to this question.
50:23I would say it is is an emerging
50:26therapy so certainly will fall on the
50:30combination combination therapy so.
50:33You understand that patient
50:35characteristic patient selection
50:37for simulation and oral appliances.
50:40They have some specific inclusion criteria,
50:42but but we can see,
50:44at least on the global patient,
50:46that we are that we are currently
50:48collaborating and developing some
50:50of the the combination therapy so.
50:53But we can see is that,
50:55at least on some of these patients,
50:57overtime after the they get the
51:00the hypoglossal nerve implanted.
51:02Let's say they gained significant
51:06body weight.
51:07So the body weight increase,
51:08the BMI increase, probably the
51:11response to the hypoglossal nerve.
51:13It's not. It's not the same.
51:16So the way we have been able
51:19to help this patient is.
51:21Incorporating the oral appliance
51:23so with the oral appliance is
51:26able to reduce the severity.
51:28Let's say the hi from 15 to 3050 to 20,
51:32so that will help in certain way
51:37to to tolerate for this settings of
51:39the hypoglossal nerve to be in a
51:42different in a different stage for
51:44the patient to to tolerate 1 device.
51:47Understanding that if we want
51:49to switch completely.
51:51Oral appliance,
51:52so probably will not be the the the the.
51:56The patient is not a candidate to
51:58start with with oral appliance,
52:00but doing this combination therapy
52:03certainly it opens to a new
52:07treatment modality.
52:09Because few years ago when we
52:12talk about combination therapy,
52:14the first thing that we can do our
52:16money was sipat and oral appliance
52:19and now we have a more expanded.
52:22Remember that it is so oral appliance,
52:24positional therapy or appliance and emerging.
52:29They would have netted stimulation.
52:31Now, having said that,
52:34so for the physicians and for for
52:37the rest of the group understand.
52:40So when we look into the function,
52:42the the the mechanism of the,
52:44you know the term being through
52:47during the hypoglossal nerve therapy.
52:49So in this patients are going
52:52to receive an oral appliance.
52:55The oral appliance designed it
52:57has to be modified to accommodate.
53:02The effect of the Deaton protrusion.
53:06So currently when we look into
53:09the the picture that we presented
53:11for the oral appliance design,
53:13none of those appliances are
53:17designed with the interior space
53:20for the for this purpose.
53:23In fact, one design it will not.
53:26It will not allow that protrusion,
53:29but he has the component
53:31on the interior area.
53:32So this is where you know the dentist
53:34needs to understand the concept,
53:36the collaboration and make these
53:39modifications on the oral appliance.
53:41Well, first of all,
53:42selecting the oral appliance that will
53:44allow this modification to allow to
53:47you know for this specific purpose.
53:49So yeah, I'm sorry it was a.
53:51It was a long answer,
53:52but my point.
53:54Is that it is a fascinating treatment,
53:56modalities and emergent combination therapy?
53:59I would say so we have a few.
54:04Common cases, comma patients and in
54:07process of of developing this therapy
54:10and I would say that within the next few
54:12months and hopefully in the next sleep
54:15meeting so we will have the the the
54:18option to present some of these results.
54:21And you know for physicians and
54:23dentists to be more aware of this
54:25potential treatment treatment modality
54:27for those patients. Thank you.
54:32I'll just go through some of the questions
54:34we received today from Doctor Stewart men.
54:37How important is is the consideration
54:40of anterior posterior displacement
54:42in addition to degree of protrusion.
54:45For which patients,
54:46what percentage of maximal protrusion
54:48is most commonly required to get
54:51a good therapeutic results?
54:52How do you earn BMI in deciding
54:54whether to try and all the clients?
54:56Yeah, yes, certainly.
54:57So thank you for the
54:59question and very important,
55:00very important comment.
55:02So when we look into the the evidence.
55:06So the evidence currently shows that,
55:09for example, patient with severe
55:11or shop there is sleep apnea.
55:13So what is it therapeutic?
55:16Monday would have position that
55:18will help the majority of this
55:21particular group patients.
55:22According to the you know
55:24some systematic reviews,
55:25so there is is a minimum of 75%
55:29of maximum protrusion in patients
55:31with severe obstructive sleep apnea
55:33and the other group you know.
55:35According to some studies,
55:36so it ranged from 25 to 50%, you know.
55:40Unfortunately these numbers is percentage.
55:43It will not apply.
55:45It will not be.
55:48It will not apply to all all these patients,
55:51so BMI is a factor. Of course,
55:55high BMI you will have a lower response
55:58to oral appliance therapy, age,
56:01gender accordingly, female gender.
56:04It tends to have a response to oral
56:06appliance, so these are some of the
56:08predictors that have been like had some
56:13preliminary information about this.
56:16Dichters of treatment response
56:18predictor of oral appliance success.
56:21So we imagine their severity of OSA
56:25measuring by by the Asia and uncertainly.
56:30You recall this slide showing
56:34the therapeutic position.
56:36So he goes from 25 to 75 assassination
56:40position and then the therapy or
56:44the final position certainly can
56:46go from 50 to 75% and it's going
56:49to be unfortunate at this point.
56:52So it's it's going to be different
56:54stadiums for for each patient.
56:57So patient characteristics,
57:00tour examination,
57:02understanding of the anatomical.
57:05Anatomical features the craniofacial
57:09or offering real areas so putting
57:13together all that information.
57:15They will give us a better idea
57:17of the potential predictors or
57:20treatment treatment response
57:21for each individual appliance.
57:24The Polish individual patient,
57:26the oral appliance design.
57:28Is important, however,
57:30the oral appliance,
57:32the particular oral appliance it will not.
57:36Provide the the efficacy is the
57:39understanding that we implement
57:41that we apply from the other
57:43factors that patient selection and
57:46all the clinic facial structures.
57:49Thank you.
57:51Another question, what are your
57:52thoughts on actively titrating an oral
57:55appliance during polysomnography?
57:56I know our sleep center does not
57:59do that but I know you do ask
58:02patients to do titration at home
58:04right? So if I understand correctly so the
58:08question is about titration and the sleep
58:11center door during the police on the ground.
58:15Versus titration of the oral appliance at
58:18patients home by by the patient itself.
58:21So for many years you know they were
58:24the there was a development of this.
58:27Devices they call it diagnostic spinning,
58:31much like trying to identify the patient.
58:36Trying to select patient though,
58:37for for for a oral appliance.
58:40By advancing the mandible with a remote
58:43control device utilizing polysomnogram.
58:45So that was one option and several
58:49studies were done by trying to
58:51validate that the technique.
58:54Now the other technique it was
58:57also titration and the sleep lab.
59:01But the titration,
59:02the adjustment of the oral appliance.
59:04It was done by the Sleep technician
59:07and mainly these these reports.
59:10It was mainly for the purpose
59:12of that particular study.
59:13So when they stand that for the you know,
59:17legal standpoint,
59:18training standpoint,
59:19not all these sleep centers will
59:21be able to to provide this.
59:23This service for this sleep technician
59:26to to do the adjustment for the
59:28Den for the patient itself to the
59:30adjustment or denial of the sleeper.
59:32Or they deliver study so it really comes
59:34into play different different variables.
59:37Like waking up,
59:39waking the patient up too many
59:41times 20 night and not being able
59:43to do the proper recording of
59:45the of the police underground.
59:47So different things.
59:48So I would say you know you sorry
59:50not I will skip long answers,
59:52but the short answer is they have
59:55been some validation, some protocols,
59:57some reports about in lab, in in,
01:00:01in laboratory and sleep laboratory,
01:00:03titration,
01:00:03oral appliances and of course
01:00:05I mean as you control.
01:00:08Is you control the the the the technique,
01:00:11you know it's a policy under running
01:00:13board patient is there that litigation is
01:00:15there so the mandible is moving forward?
01:00:18But of course I mean the the
01:00:20outcome probably is is very good
01:00:22for the purpose of the app.
01:00:24This study, study, design and study results.
01:00:27But again in in real real scenario real life
01:00:32so it may may be a little bit more complex.
01:00:34But yeah,
01:00:35there are studies.
01:00:36There are protocols that
01:00:37have been implemented.
01:00:39Many has been done for for the
01:00:41purpose of those particular research.
01:00:46Is steps.
01:00:50Thank you, Doctor Dioguardi
01:00:52has some comments as well.
01:00:55Yes, agreed calculation
01:00:56would be ideal with the PSG.
01:00:59But it might be difficult to do without
01:01:02disturbing the patient at night.
01:01:04I don't see any more questions in the chat,
01:01:06and doctor Andrea Andre has left
01:01:09and he then our next session
01:01:11will be on the February 2nd.
01:01:14Those who would be joining.
01:01:17Thank you again Doctor career
01:01:19for coming in today and look
01:01:21forward to working with you
01:01:22in place for thank you. Thank you all
01:01:24and have a wonderful wonderful year
01:01:26beginning of the year the next time.
01:01:29Thank you.