AGD 2017 Las Vegas

Dental Sleep Medicine 2017

What’s New? - part 1

Steve Carstensen DDS FAGDDiplomate, American Board of Dental Sleep Medicine

Premier Sleep Associates, Bellevue, WA

DisclosuresCommercial companies may have contributed

to the meeting organizers to support this presentation

I receive no financial benefit for sales of any product or service mentioned in this talk

I use (and pay for) many of these products in my private practice

I am Editor-in-Chief of Dental Sleep Practice Magazine

Oximetry as P-OSA Screener

Álvarez D, Alonso-Álvarez ML, Gutiérrez-Tobal GC, Crespo A, Kheirandish-Gozal L, Hornero R, Gozal D, Terán-Santos J, Del Campo F. Automated screening of children with obstructive sleep apnea using nocturnal oximetry: an alternative to respiratory polygraphy in unattended settings. J Clin Sleep Med. 2017;13(5):693–702.

50 children with PSG studies

Home Sleep Recorders

Oximetry Studied Separately

With Cutoff of 1event/hr, 85.5% accuracy with Oximetry

MAD vs. Positional Therapy

Sleep Med. 2017 Jun;34:109-117. doi: 10.1016/j.sleep.2017.01.024. Epub 2017 Mar 27.A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea.Benoist L1, de Ruiter M2, de Lange J2, de Vries N3.

81 patients RCT AHI >5 <30

PT Group: AHI 13 went to 7

OA Group: AHI 11.7 to 9.1Adherence was Same

Conclusion: Equally Effective

Functional Appliances

Int J Pediatr Otorhinolaryngol. 2017 Jun;97:170-180. doi: 10.1016/j.ijporl.2017.04.009. Epub 2017 Apr 10. Changes in airway dimensions following functional appliances in growing patients with skeletal class II malocclusion: A systematic review and meta-analysis. Xiang M1, Hu B1, Liu Y1, Sun J1, Song J2.

Seven Studies

177 Treated, 153 controls

Conclusion: Use of FA in growing patients can enlarge the oropharynx and may decrease risk of future OSA

Commercial Vehicle OperatorsAASM recommendations to the Federal Motor Carrier Safety Administration

OSA Common in drivers

Screeners (BMI) are available

CPAP is effective

CPAP is economically viableME’s have guidelines

Gurubhagavatula I, Sullivan S, Meoli A, Patil S, Olson R, Berneking M, Watson NF. Management of obstructive sleep apnea in commercial motor vehicle operators: recommendations of the AASM Sleep and Transportation Safety Awareness Task Force. J Clin Sleep Med. 2017;13(5):745–758.

OSAS Treatment in Non-Obese PatientsMay be as common as obesity-related OSA

Less severe symptoms

Lower perception of problemsHigher Sleepiness Score

Lower arousal threshold = less PAP use

More Drugs or OAT may yield greater therapeutic successGray EL, McKenzie DK, Eckert DJ. Obstructive sleep apnea without obesity is common and difficult to treat: evidence for a distinct pathophysiological phenotype. J Clin Sleep Med. 2017;13(1):81–88.

Melatonin

Erland LA, Saxena PK. Melatonin natural health products and supplements: presence of serotonin and significant variability of melatonin content. J Clin Sleep Med. 2017;13(2):275–281.

Canadian OTC Melatonin

Lot-to-Lot variation to 465%

Content: -83% - +478% of label

8 of 31 samples contained Serotonin: 1 - 75 micrograms

Custom vs. OTC MAD25 patients with AHI 13.3 ESS 11

OTC CustomEffective 24% 64%

Failures 36% 4%

Nights per Week 3 7

Patient Preference 4% 84%

Cerebral Microbleeds

45 male, 30 female

PSG + MRI

AHI > 15 = OR 4.5

Koo DL, Kim JY, Lim JS, Kwon HM, Nam H. Cerebral microbleeds on MRI in patients with obstructive sleep apnea. J Clin Sleep Med. 2017;13(1):65–72.

Cost of Treatment in France

Int J Technol Assess Health Care. 2016 Jan;32(1-2):37-45. doi: 10.1017/S0266462316000088. Epub 2016 Mar 9. COST-EFFECTIVENESS OF TREATMENTS FOR MILD-TO-MODERATE OBSTRUCTIVE SLEEP APNEA IN FRANCE. Poullié AI1, Cognet M2, Gauthier A3, Clementz M3, Druais S3, Späth HM4, Perrier L5, Scemama O1, Pichon CR1, Harousseau JL1

Patients with High CV risk: CPAP more cost-effective

Low CV risk: Dental Devices 7,710 EUR lifetime

CPAP: 13,754 EUR lifetime

Cost of acquiring OA in France is higher

Cost Effectiveness in Canada

Canadian Agency for Drugs and Technologies in Health: Continuous Positive Airway Pressure Compared with Oral Devices or Lifestyle Changes for the Treatment of Obstructive Sleep Apnea: A Review of the Clinical and Cost-effectiveness DATE: 22 December 2014

Patients list:1. Improved Health

2. Apnea elimination

3. Improved Sleep

4. Reduced Fatigue

5. Reduced Snoring

6. Bed Partner Benefits

CPAP is more costly

Oral Devices more Cost Effective

Requires <70% PAP use > 80% OA use

Does SB cause TMD?

86 TMD pain patients

46 controls

all female

PSG

Same: Inter-episode intervals SB episodes Total duration of SB episodes

K. Muzalev, F. Lobbezoo, M.N. Janal, K.G. Raphael; Inter-episode sleep bruxism intervals and myofascial face pain. Sleep 2017 zsx078. doi: 10.1093/sleep/zsx078

American Dental AssociationTask Force Recommendations for HOD 2017

1. Dentists are encouraged to screen for SRBD and refer for diagnosis

2. Screening includes children, although referral and treatments differ from adults

3. Oral appliance therapy is appropriate

4. Physicians prescribe OAT but dentists are responsible for evaluation, choosing,

and providing the service

5. Informed consent is required

6. Dentists treating SRBD with OAT should be capable of recognizing and

managing side effects

American Dental AssociationTask Force Recommendations for HOD 2017

7. Dentists should test patients using OAT for effectiveness, including use of home

sleep apnea monitors to obtain interim results for the purpose of OA titration

8. Surgery may be necessary

9. Dentists should continually update their knowledge and training

10. Dentists should maintain regular communication with patient’s other medical

providers

11. Follow-up testing by physicians should be done to confirm treatment efficacy

Pediatric Dentist Screening for OSA

Chiang HK, Reddy N, Carrico C, Best AM, Leszczyszyn DJ. The prevalence of pediatric dentists who screen for obstructive sleep apnea. Journal of Dental Sleep Medicine. 2017;4(1):5–10.

Steve Carstensen DDS

SeattleSleepEd@gmail.com

425 698 1732

Thank You For Attending AGD 2017!

Next: Cardiovascular Consequences of Obstructed Airway Sleep

Steve Carstensen DDS SeattleSleepEd@gmail.com