In this issue - The American Academy of Dental Sleep Medicine

Dialogue 

American Academy of Dental Sleep Medicine 

2510 North Frontage Road 

Darien, IL 60561-1511 

www.aadsm.org 

FINAL 

ISSUE 

See page 5 

for details. 

ISSUE 4 | 2013 

In this issue: 

AADSM Through the 

Years 

PR Campaign 

Expands to Raise 

More Awareness 

Patient Requiring Quick 

& Effective Treatment for 

Severe OSA

ISSUE 4 | 2013 3 

Table of Contents 

President’s Message........................................ 4 

Editor’s Notes................................................ 5 

AADSM Through the Years........................6-7 

PR Campaign Update................................... 8 

Suggested Reading: Sleep Medicine Care Under 

One Roof: A Proposed Model for Integrating 

Dentistry and Medicine..........................10-19 

Case Presentation: Patient Requiring Quick 

and Effective Treatment for Severe Obstructive 

Sleep Apnea............................................20-22 

Manager’s Desk: What Questions Will My Referring 

Physicians Ask Me?..................................... 24 

New Members........................................26-27 

AADSM Sponsors....................................... 29 

Copyright Clause 

Dialogue is published quarterly by the American Academy of Dental Sleep Medicine 

2510 North Frontage Road, Darien, IL 60561 

Phone: (630) 737-9705 

Fax: (630) 737-9790 

Email: dialogue@aadsm.org 

Web site: http://www.aadsm.org 

President 

B. Gail Demko, DMD 

Editor-in-Chief 

Kathleen M. Bennett, DDS 

© 2013, American Academy of Dental Sleep Medicine 

Disclaimer: No part of this publication may be reproduced without the permission of the American Academy of Dental Sleep Medicine 

(AADSM). 

The statements and opinions contained in editorials and articles in this magazine are solely those of the authors and not of the AADSM 

or of its officers, members or employees. Statements contained in advertisements for products or services are the responsibility of the 

advertisers alone, including descriptions of effectiveness, quality or safety. The Editor and Managing Editor of Dialogue, the AADSM and 

its officers, members and employees disclaim all responsibility for any injury to persons or property resulting from any ideas, products or 

services referred to in articles or advertisements in this publication. 

Further, the statements and opinions contained in editorials, articles and advertisements in this magazine are solely those of the authors 

and not of the American Academy of Sleep Medicine (AASM), which is the managing agent of the AADSM, or of the AASM’s officers, 

members or employees.

4 

ISSUE 4 | 2013 

President’s Message 

B. Gail Demko, DMD 

Diplomate, ABDSM 

AADSM President 

This final issue of Dialogue provides a unique vantage point that 

allows us to look back on our organization’s history while also 

looking forward to the opportunities that await 

us. Established in 1991, the American Academy 

of Dental Sleep Medicine is only a couple years 

away from celebrating its silver anniversary as 

the only non-profit professional society that is 

dedicated exclusively to the practice of dental 

sleep medicine. 

The success of our organization can be 

attributed in large part to the unwavering 

dedication and commitment of those leaders 

who have devoted their time and expertise to 

the AADSM, including the gentlemen who 

were our founding members: Rob Rogers, 

Arthur Strauss, Peter George, Alan Lowe and 

Mike Alvarez. The photo collage in this issue 

gives a brief glimpse of some of the individuals 

who have served the AADSM through the 

years, and there are many more colleagues who 

helped pave the way for us. I am indebted to 

each AADSM president who came before me, 

and I am grateful to everyone who currently 

volunteers as an AADSM Board, task force or 

committee member. 

Certainly the success of the AADSM also can 

be ascribed to the loyalty and devotion of our 

membership. Today the AADSM has more 

than 3,000 members, which must have been 

unfathomable to our small group of founders 

more than two decades ago. The truism that 

there is strength in numbers is applicable to any 

professional society, and it is particularly relevant to the AADSM, 

which has led the way in gaining respect for oral appliance 

therapy among both the dental and medical communities. While 

a variety of pathways may lead us to an interest in dental sleep 

medicine, we all share a passion for reducing the burden of 

snoring and sleep apnea. It is important for us to remain united 

through our AADSM membership as together we strive to 

advance the dentist’s role in the treatment of sleep-disordered 

breathing. 

Earlier this year 

the AADSM took 

another important 

step forward 

to gain greater 

recognition for 

oral appliance 

therapy by 

developing an 

empiric definition 

of an effective 

oral appliance for 

the treatment of 

sleep-disordered 

breathing. 

Earlier this year the AADSM took another important step 

forward to gain greater recognition for oral appliance therapy by 

developing an empiric definition of an effective oral appliance 

for the treatment of sleep-disordered breathing. In February 

2013 the AADSM brought together leaders in the profession for 

a consensus conference to establish a standardized benchmark 

for both research and clinical practice. 

Sincerely, 

I am pleased to announce that both the 

definition of an effective oral appliance and 

the comprehensive report that explains the 

rationale behind it have been approved by the 

AADSM Board of Directors and accepted 

for publication in the inaugural issue of the 

online Journal of Dental Sleep Medicine, which will 

replace Dialogue as the official publication of the 

AADSM in 2014. Members who would like to 

preview these papers can visit the “Accepted 

Papers” section of the JDSM website at www. 

jdsm.org, where both manuscripts are available 

for download. 

I am excited about this significant development, 

which is another landmark for our field. It is our 

hope that this definition will foster consistency 

in clinical practice, allow research results to 

be compared more easily, provide guidance 

for insurers, and serve as a guidepost for the 

innovators who develop the next generation of 

oral appliances. 

These are exciting days for dentists who are 

involved in treating sleep-disordered breathing, 

and the future for the AADSM is bright. I 

thank you for your support and involvement as 

an AADSM member, and I look forward to all 

that we will accomplish together in 2014. 

B. Gail Demko, DMD, D. ABDSM

ISSUE 4 | 2013 5 

Editor’s Notes 

Kathleen M. Bennett, DDS 

Diplomate, ABDSM 

Editor-in-Chief 

Over the years the AADSM’s official membership 

publication has gone through numerous 

changes that have reflected the growth of 

our organization. In the fall of 2000 the 

AADSM’s Report was rebranded as Dialogue, 

and eventually the newsletter became a fullscale 

magazine. For more than a decade, 

Dialogue has provided an avenue for new 

members to learn more about oral appliance 

therapy and for veterans to share their 

expertise. 

Now our publication is about to transform 

again, this time into the Journal of Dental 

Sleep Medicine (JDSM). This peer-reviewed, 

online journal will be launched by the 

AADSM in 2014, providing you with the 

best research in dental sleep medicine in 

a clinically useful format. As an AADSM 

member you will receive a complimentary 

subscription to JDSM, allowing you to 

be a part of this exciting new stage in the 

development of dental sleep medicine. 

For this final issue of Dialogue, I thought 

that it would be appropriate to take a look 

back at some of the AADSM members and 

leaders who have appeared in the magazine 

through the years. This retrospective photo 

collage is just a small glimpse of the many 

members who have contributed their time and talents to our 

organization. 

The suggested reading in this issue is, “Sleep Medicine 

Care Under One Roof: A Proposed Model for Integrating 

Dentistry and Medicine.” I selected this article to give 

members a look at some of the challenges – and potential 

opportunities – facing dentists and physicians who are 

considering how to integrate oral appliance therapy into the 

delivery of care for sleep-disordered breathing. 

I am grateful to 

the members 

who contributed 

an article to 

one of the 

recent issues of 

Dialogue and I 

encourage all of 

you to consider 

opportunities to 

submit an article 

for publication in 

JDSM. 

The case presentation from Sue Ellen Richardson, DDS, 

MAGD, FICD, FAACP, involves a patient requiring quick 

and effective treatment for severe obstructive sleep apnea. 

The patient had been involved in four car accidents within 

five months due to cognitive impairment related to OSA. 

The case is a good reminder that treating OSA can promote 

both personal health and public safety. 

aspx. 

Lydia Sosenko, DDS, provides a valuable 

follow-up to her article from last issue about 

the best ways to build ties with the medical 

community. Her new article will help you 

anticipate questions about oral appliance 

therapy that referring physicians may ask 

you. 

This issue also includes another update 

about the AADSM’s ongoing public 

relations campaign. The initiative continues 

to raise public awareness of oral appliance 

therapy and the care provided by AADSM 

member dentists. 

I am grateful to the members who 

contributed an article to one of the recent 

issues of Dialogue, and I encourage all of 

you to consider opportunities to submit an 

article for publication in JDSM. Submission 

categories include original reports of clinical 

or laboratory investigations or case series, 

reviews, case reports, “pearls,” book reviews 

and special reports. You can review the 

Manuscript Submission Guidelines on the 

JDSM website at http://jdsm.org/Authors. 

In closing, it has been my pleasure to serve as Editor of 

Dialogue. I appreciate the generous support of all of our 

advertisers, and I thank you for reading. 

Kathleen M. Bennett, DDS, D. ABDSM 

Editor-in-Chief

6 

AADSM Through the Years 

For this final issue of Dialogue, this retrospective photo collage takes 

a look back at some of the AADSM members and leaders who have 

appeared in the magazine through the years. The AADSM thanks all of the 

members who have contributed their time and talents to the growth of our 

organization.

8 

ISSUE 4 | 2013 

PR Campaign Expands to Raise More Awareness 

On Solid Ground, PR Campaign Forges Ahead 

Last year, we secured an agency to help raise awareness of oral 

appliance therapy (OAT) with consumers, resulting in the field 

of dental sleep medicine being included in nearly 2,000 articles 

and generating more than 100 million media impressions. 

Building upon this foundation, we’ve bolstered our efforts 

this year to further elevate OAT awareness with a focus on 

education and adoption. 

We are bringing exciting new programs into play, including 

a blogger campaign. Each of our activities provides more 

opportunities for sharing success stories and educating our 

audiences about the benefits of OAT. 

Working with Consumer Media 

Since the launch of the PR campaign, we’ve been building 

relationships with daily newspaper and magazine contacts 

across the country. We’re currently working with popular 

men’s, women’s and health magazines and the most prominent 

newspapers throughout the U.S. and Canada. Since the summer, 

we’ve garnered placements in several publications with others 

in the works. 

With ongoing outreach to TV, online, magazine and newspaper 

contacts, we continue to generate awareness for OAT as our 

messages are included in stories. 

Generating Online Buzz 

Patients often turn to the internet and online communities to ask 

sleep questions and share their personal sleep stories – making 

it an important location for planting dental sleep medicine 

messages. A blogger campaign will create partnerships with 

popular online destinations to create interest and build OAT 

awareness among influential digital communities. 

Launched in September, the AADSM blog tour, “Keep Calm 

and Sleep On,” is educating consumers on sleep apnea warning 

signs and the benefits of OAT. More than 15 bloggers are 

working with the AADSM to spread the word. Each one will 

dedicate a blog post and several social media updates to inform 

readers about OAT 

On Air and Informed 

The audio and visual aspects of broadcast media can help us 

to effectively communicate how OAT can help patients with 

sleep apnea. During our national TV media tour in August, 

lifestyle expert Andrea Jackson brought OAT into households 

across the country. More than 2.2 million total viewers were 

reached during morning news programs to hear how OAT is 

an effective alternative to CPAP and how easy it is to travel 

with. The segment aired in several of the top media markets 

– including New York, Los Angeles, Philadelphia and Boston – 

which allowed us to reach many people nationwide. 

Building Thought Leadership 

Our ongoing trade media efforts continue to expand the 

thought leadership of AADSM members among sleep and 

dentistry focused publications. 

By making a deeper impact with trade media, we will further 

elevate both awareness in and interest of the AADSM 

throughout the year. In May, trade media conversations 

were centered around the annual meeting. News articles 

on highlighted abstracts, awards and OAT trends appeared 

in several trade magazines, including Surgical Restorative 

Resource and Dentistry IQ. 

In October, we built on this momentum with a second webinar 

for Advance for Respiratory Care & Sleep Medicine hosted 

by AADSM president Dr. Gail Demko. During the webinar, 

“The Role of a Dentist in Sleep Apnea Treatment,” Dr. 

Demko discussed how dentists can work together with sleep 

physicians to improve both patient care and outcomes when 

it comes to sleep apnea treatments – such as OAT – based 

on her experiences and best practices. The webinar reached 

sleep doctors and dentists across the country, expanding the 

leadership and influence of the AADSM 

Bolstering Member Communications 

Throughout the past year, many members have taken advantage 

of the Member PR Toolkit. 

The AADSM Member PR Toolkit provides a guide for you to 

promote the national campaign locally. By using the toolkit’s 

resources – including media training tools, press releases and 

talking points – you can not only be an advocate for OAT, but 

you can increase awareness and demand for your dental practice. 

This year, we will bolster the toolkit with additional content to 

give you more resources for generating local publicity. 

The Member PR Toolkit can be downloaded on the 

“Promotional Resources” page of www.aadsm.org. 

Looking Ahead 

This year, our PR campaign brings the opportunity to expand 

our efforts by concentrating on education and adoption of 

OAT through the strategic initiatives already in place. We’re 

continuing to build awareness by integrating OAT into sleep 

apnea discussions and stories – happening online and in the 

media – and we look forward to educating even more patients 

on the benefits of OAT. 

About L.C. Williams 

L.C. Williams & Associates team brings 25 years of PR expertise to the 

AADSM, including consumer product expertise, experience with dental 

associations and a track record of success with health and sleep stories.

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10/3/13 2:35 PM

SPECIAl ARTIClE 

10 Reprinted with permission of the American Academy of Sleep Medicine 

ISSUE 4 | 2013 

http://dx.doi.org/xxxxxxxxxxxxxxx 

http://dx.doi.org/10.5664/jcsm.2934 

Sleep Medicine Care Under One Roof: A Proposed Model for 

Integrating Dentistry and Medicine 

Sunil Sharma, M.D., F.A.A.S.M. 1 ; Greg Essick, D.D.S., Ph.D. 2 ; David Schwartz, D.D.S. 3 ; Amy J. Aronsky, D.O., F.A.A.S.M. 4 

1 

Jefferson Sleep Center, Thomas Jefferson University & Hospitals, Philadelphia, PA; 2 Department of Prosthodontics and Regional 

Center for Neurosensory Disorders School of Dentistry, University of North Carolina, Chapel Hill, NC; 3 The Center for Sleep 

Medicine, Chicago, IL; 4 Comprehensive Sleep Associates, Capital Health Medical Center, Hamilton, NJ 

Although sleep science has significantly advanced in the 

last decade, the delivery of care for sleep-related breathing 

disorders remains fragmented. Oral appliances in particular 

have historically been underutilized. This article discusses 

some of the challenges we have faced and proposes a care 

delivery model that is designed to integrate the disciplines of 

dental sleep medicine and sleep medicine. While in the past 

there has been a natural tendency to build separate “shops” for 

each specialty (separate-office model), the current emphasis on 

multidisciplinary care stresses the need to be able to play in the 

same “sandbox” (care-under-one-roof model). As will be discussed 

below, this model offers distinct advantages to improved 

patient care, continuity of treatment, and the central coordination 

of benefits, both insurance-related and clinical. 

Past Challenges to Integrated Care 

Reasons for the inability of dental sleep medicine to integrate 

fully with the delivery of sleep medicine care have been many. 

First, the growth of dental sleep medicine has not kept pace 

with the exponential growth of sleep medicine in the treatment 

of obstructive sleep apnea syndrome (OSA). Dentists who provide 

appliance therapy for sleep-related breathing disorders are 

seemingly few in number. Although the American Academy of 

Dental Sleep Medicine (AADSM) website (http://www.aadsm. 

org/FindADentist.aspx) lists about 3,000 US dentists as members, 

only about 200 dentists have obtained diplomate status 

with the American Board of Dental Sleep Medicine (ABDSM) 

(http://www.abdsm.org/Diplomates.aspx), and only about a 

dozen dental practices have been accredited as dental sleep 

centers. (http://www.aadsm.org/PDFs/AccreditationStandards. 

pdf). Thus, with the possible exception of using these websites, 

the thousands of sleep disorders centers (both accredited and 

non-accredited) in the United States have found no easy way to 

identify dental sleep medicine experts to whom patients can be 

Integrating oral appliance therapy into the delivery of care 

for sleep-related breathing disorders has been a challenge 

for dental and medical professionals alike. We review the 

difficulties that have been faced and propose a multidisciplinary 

care delivery model that integrates dental sleep 

medicine and sleep medicine under the same roof with educational 

and research components. The model promises to 

offer distinct advantages to improved patient care, continuity 

of treatment, and the central coordination of clinical and 

insurance-related benefits. 

keywords: Integrated sleep medicine, dental sleep medicine, 

delivery of care 

Citation: Sharma S; Essick G; Schwartz D; Aronsky AJ. Sleep 

medicine care under one roof: a proposed model for integrating 

dentistry and medicine. J Clin Sleep Med 2013;9(8):XXX- 

XXX. 

referred for evaluation and treatment with oral appliances and 

for whom the specialized training and experience in oral appliance 

therapy can be assured. 

Second, the lack of education in the specialized use of oral 

appliance therapy for sleep disordered breathing among dentists 

and sleep physicians has been a limiting factor. 1 A survey of 

dentists found that 40% knew little or nothing about oral appliances 

for treatment of OSA. 2 Moreover, 49 responding dental 

schools of the 58 US schools recently surveyed reported only 

3 hours of total curriculum time devoted to sleep medicine. 3 

With the exception of short courses offered by the AADSM, 

dentists have relied on training from marketing groups often associated 

with specific appliances and products for sleep medicine. 

Knowledge of new materials, techniques, procedures, and 

continuing education has also been attained from dental journals, 

periodicals, and advertisements. Efforts are under way to 

formalize dental sleep medicine training in our dental schools. 

The University of North Carolina School of Dentistry is hosting 

a conference for dental educators across the United States and 

Canada to begin the process of developing pre-doctoral DDS 

and clinical residency programs. 

Education to sleep physicians and technologists about oral 

appliances has been virtually nonexistent. Indeed, there have 

been recent efforts to train physicians to practice oral appliance 

therapy at professional meetings. Although this practice raises 

awareness of oral appliance therapy, it can undermine recognition 

of the training dental sleep experts undergo to properly 

evaluate the integrity of the teeth, the surrounding bone, and 

temporomandibular joints; to obtain accurate impressions and fit 

removable oral appliances (such as dentures and bite guards) to 

the teeth; and to minimize negative side effects of their presence. 

Third, communications between sleep physicians and dentists 

have been suboptimal in most healthcare settings. Even 

in academic settings, interactions between medical and dental 

1 Journal of Clinical Sleep Medicine, Vol. 9, No. 8, 2013

ISSUE S Sharma, 4 | 2013 G Essick, D Schwartz et al 

11 

professionals have been limited by their separate and different 

clinics, patient record systems, administrative priorities, and 

business models. There has been little need to co-treat patients 

in the past; thus the infrastructure and administrative support 

to encourage good communication between medical and dental 

sleep providers are lacking. 

Fourth, the co-treatment of patients with dental clinicians has 

been viewed as vaguely competitive to some physicians who 

provide CPAP as the primary treatment modality. This view 

has likely limited referral of patients for oral appliance therapy. 

However, a truly successful relationship between physicians 

and dentists will only be established by close communication 

and sharing the common goal of patient-centered treatment. 

Fifth, referrals to dentists have been discouraged by the lack 

of, or limited reimbursement for, oral appliances by insurance 

carriers. Although the AASM recognized oral appliance therapy 

in 2005 as a potential first-line therapy for mild and moderate 

OSA and for patients with severe OSA who fail positive airway 

pressure therapy, many medical insurance carriers (including 

Medicare) are now only beginning to provide benefits for oral 

appliance therapy. 4,5 Progress on this front has been slow and 

severely challenged by (i) claims processing centers that are 

not prepared administratively to negotiate contracts with, or 

process claims from, dentists who are treating a medical condition, 

(ii) dental practices that are unfamiliar with submission of 

medical insurance claims and the appeal process upon denial, 

and (iii) reduced reimbursement rates for appliances that may 

not meet the dentist’s costs for high quality oral appliances and 

the chair time required for comprehensive follow-up care. 

Sixth, post-intervention care with oral appliances has left 

much to be desired. Many patients are reluctant to return to 

the referring physician for follow-up evaluation of the efficacy 

of the oral appliance therapy, often citing the costs of another 

sleep study or its inconvenience as reasons for their reluctance. 

In one study, only 18% of patients receiving oral appliances underwent 

polysomnography after the initiation of therapy. 6 For 

those patients who do return for a follow-up sleep study and 

for whom there is residual sleep disordered breathing, another 

sleep study with yet further costs and inconvenience may be 

indicated after the dentist or patient adjusts the appliance. 

Seventh, outcome measures have not been well documented 

for oral appliance therapy. While some controlled trials have 

shown improvement in daytime sleepiness and blood pressure 

on a short-term basis, the impact of oral appliances on cardiovascular 

disease on a long-term basis remains largely unknown. 7-9 

Such data on robust outcomes measures are needed to substantiate 

the long-term benefit of oral appliance therapy when compared 

to those of nightly use of positive airway pressure. 

Future Demand for Integrated Care 

The future of sleep medicine will invariably be influenced by 

healthcare system reforms to focus more on prevention, multidisciplinary 

care, and longitudinal disease management in a 

patient-centered medical home concept. It is, therefore, in the 

best interest of sleep medicine that a dialogue on innovative 

improved models of care be reviewed, discussed, and implemented 

to address the above-mentioned barriers to achieve 

comprehensive care. We feel that a strong partnership model, 

based at least initially in academic tertiary care centers, will be 

able to initiate and to build all aspects of the program including 

clinical, educational, and research components. Such an integrated 

model will be able to provide the much needed leadership 

and backbone that can then successfully form a blueprint 

for community-based programs. 

Our model is based on an integration of the academic center’s 

sleep medicine program (American Academy of Sleep 

Medicine [AASM]-accredited sleep disorders center) and its 

dental school to form a partnership in clinical, educational, and 

research activities and to include the longitudinal collection and 

analysis of outcome measures. We believe that the unique scope 

of practice for physicians and dentists can be preserved and 

business success achieved. Implementation of the model across 

the country will require a significant and novel commitment of 

dental schools to educate students in the field of sleep medicine 

and to demonstrate how the dentist can play a significant role in 

the success of oral appliance therapy by working closely with 

sleep physician colleagues. 1 

The Care-Under-One-Roof Concept 

Since fragmentation of care and limited communication have 

been major stumbling blocks to comprehensive care, we propose 

a care-under-one-roof (“one sandbox”) concept allowing 

sleep physicians to be in face-to-face contact with dental sleep 

faculty for discussion of patient care issues pertaining to diagnosis, 

treatment, follow-up, and to provide the necessary dental 

care that must be delivered prior to rendering dental appliance 

treatment. We anticipate that co-treatment of patients in the 

same facility would raise expectations and clinical successes 

within the facility and improve patient care. Care-under-oneroof 

would effectively minimize patient travel from office to 

office. This would ensure that patients are treated, that patients 

receive follow-up care and post-treatment evaluation, and that 

all medical caregivers receive communication on the patient’s 

treatment plan. This approach has been well validated in other 

disease models and has been shown to improve outcomes. 10,11 

A care-under-one-roof model also provides a ready venue 

for the practitioners to effectively collaborate. For example, the 

current AADSM-approved protocol for oral appliance therapy 

for sleep disordered breathing in adults (http://www.aadsm. 

org/PDFs/TreatmentProtocolOAT.pdf) includes the possibility 

of combining positive airway pressure and oral appliances for 

patients who have a subtherapeutic response to oral appliances 

alone. 12-14 However this therapy is rarely offered to patients because 

of the lack of a setting in which the dental (oral appliance 

and its titration) and medical (PAP and its titration) components 

can be implemented together or the lack of business plan to bill 

insurance companies for the combined service. The care-underone-roof 

model offers a means to overcome these limitations 

as well as the venue for the conduct of much needed clinical 

research on combination therapy. 

Preliminary Organizational Structure and Personnel 

Any integrative and collaborative model should adhere to 

accreditations standards set by the AASM. Sleep disorders centers 

should comply with AASM practice parameters including 

comprehensive assessment of patients by, or under the supervision 

of, a board certified sleep specialist (http://www.aasmnet. 

org/accred_centerstandards.aspx). The Medical Director of the 

Journal of Clinical Sleep Medicine, Vol. 9, No. 8, 2013 

2 

continued . . .

12 

ISSUE 4 | 2013 

continued . . .

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14 S Sharma, G Essick, D Schwartz et al 

org/PDFs/TreatmentProtocolOAT.pdf). Thus, in the proposed 

model the patient would be scheduled for administration of 

OCST by the sleep disorders center or in-lab polysomnography 

at the sleep disorders center, once adjustments in the appliance 

to eliminate the patient’s symptoms had been made. Published 

studies have shown that a higher proportion of patients can be 

treated effectively if the custom-fabricated oral appliance is adjusted 

during an overnight sleep study. 17,20,21 

Patients who respond to OAT with AHI normalized as determined 

during OCST or polysomnography reevaluation, would 

be seen for routine follow-up in the sleep center in 6 months, 

12 months, and yearly intervals thereafter in accordance to 

recommendations of the AASM practice parameters (see 3 in 

Figure 1). 4 On the yearly visits, the patient would be seen by 

the dental team and the sleep center healthcare professional, 

who would evaluate compliance with therapy and assure continuity 

of medical care. 

Patients whose sleep disordered breathing could not be corrected 

solely with an OAT would be reevaluated for CPAP or 

surgical procedures (see 4 in Figure 1) or undergo CPAP titration 

while wearing the dental appliance (see 4R in Figure 1). 

Because the jaw is stabilized in a forward and upward position, 

the effective pressure may be less than that required without 

an appliance, thereby decreasing pressure-related patient complaints. 

13,14 Moreover, support for nasal pillows or a mask can 

be obtained directly from the appliance, eliminating all straps 

and contact with the patient’s face except for the nasal or perinasal 

region. 

There are other advantages to patient care of an integrated 

care-under-one-roof delivery model. There is growing interest 

in determining which patients are good candidates for oral 

appliance therapy prior to treatment. Cephalometric measurements 

may help predict patients who may benefit from OA. 23 

Alternatively, in-lab “prognostic” titration has been shown 

not only to produce rapid results but can also be helpful in predicting 

patient response. 24-27 During the titration study, the teeth 

are engaged by upper and lower trays of impression material 

that can be slid apart manually or by remote control to advance 

the mandible. The goal is to determine if the patient’s sleep disordered 

breathing can be alleviated by jaw advancement and 

to estimate the extent of advancement required. The procedure 

is anticipated to be particularly important in the assessment of 

patients who have failed CPAP repeatedly and who have been 

considered poor candidates for oral appliance therapy based on 

other factors such as a high BMI. 28 The authors are already investigating 

this newly validated approach to patient care and 

have included it as a research component for select patients in 

the care-under-one-roof model (see 1R in Figure 1). 

Patients may also be offered a trial of jaw advancement using 

a less expensive boil and bite appliance, before a custom-fabricated 

appliance is suggested. 29 We feel that prognostic sleep 

studies and temporary oral appliances can be successfully used 

to determine the efficacy of jaw advancement and acceptance 

by a segment of patients before ordering a more expensive permanent 

appliance. For example, temporary appliances are indicated 

for patients who are undergoing dental treatments over 

an extended period of time. However, custom-fabricated appliances 

have been shown to be more efficacious and compliance 

is higher. 29,30 


4 

ISSUE 4 | 2013 

Safety and Compliance Monitoring 

Safety and compliance monitoring would be conducted every 

4-6 weeks after an appliance is delivered until treatment efficacy 

and patient adherence have been established. In addition to 

compliance, patient adverse effects would be documented and 

addressed by the attending dental sleep expert. Noncompliance 

(compliance being defined as ≥ 4 h use for ≥ 70% the nights) 

or failure due to intolerance of oral appliance therapy would 

trigger an alternative treatment strategy in consultation with 

the sleep specialist. These might include hybrid therapy, PAP 

therapy, or surgical intervention in select cases. A sleep specialist 

would manage any concomitant sleep disorders, which a 

patient may have to avoid overlap of visits. Cardiovascular and 

cognitive markers would be recorded for outcome data analysis 

and quality control. 

Outcomes Measures 

We recommend outcome measures form the backbone of the 

proposed model’s care of patients with obstructive sleep apnea. 

Outcome measures would serve as benchmarks for quality assurance 

and improve our understanding of the natural history 

of the disease with different interventions. Several outcome 

measures would be evaluated for quality assurance including 

compliance (patient-reported until reliable low-cost objective 

measures can be obtained), post intervention reductions in the 

AHI and excessive daytime sleepiness (e.g., Epworth Sleepiness 

Scale) and improvements in scales of neurocognitive functioning 

(e.g., psychomotor vigilance testing). Recently, mouth 

temperature-sensing compliance-monitoring chips embedded 

in oral appliances have been shown to be useful in recording 

hours per night and nights per week of therapy. 31 This technology 

will provide oral appliance data similar to compliance monitoring 

of positive airway pressure therapy. Long-term follow-up 

and monitoring of blood pressure, cardiac and cerebrovascular 

events, and mortality would be undertaken, so that the benefits 

of oral appliance and positive airway pressure therapies can be 

compared. A concomitant surveillance of adverse effects (both 

short-term and long-term) would be documented. 

Educational Activity 

The integrated care-under-one-roof model provides educational 

opportunities at all levels consistent with the mission of 

the medical and dental schools of the faculty working at the 

sleep disorders center. The weekly multidisciplinary conferences 

would provide a forum for cross-training of medical and dental 

personnel as well as other healthcare professionals present 

(e.g., otorhinolaryngology and pulmonary medicine). Dental 

school residents (particularly those in general practice residency 

programs, advanced education in general dentistry programs, 

and orofacial pain residency programs) would be given 

the opportunity to rotate in the sleep disorders center to practice 

the dental sleep medicine skills taught at the dental school by 

both medical and dental faculty. Fellows at the sleep disorder 

center and the dental residents would present clinical cases during 

ground round presentations with literature reviews. It is 

anticipated that sleep medicine education would eventually be 

incorporated into the pre-doctoral M.D. and D.D.S. curricula. 

Opportunities would develop for continuing education of physician 

and dentists in private practice, as well as for sleep techcontinued 

. . .

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16 

nologists and respiratory technicians providing CME, CDE, 

and CEU credits, as appropriate. 

Research 

The establishment of a strong and productive integrated careunder-one-roof 

program would naturally motivate research activities. 

The collection and analysis of outcome measures for 

oral appliance therapy from short-term efficacy to long-term 

compliance and impact on medical comorbidities of untreated 

OSA would be most vital. Clinical trials on combined oral appliance/positive 

airway pressure therapies are needed and would 

be made readily possible with a single healthcare visit. Depending 

on infrastructure and support, we suggest that research from 

outcome measures, prospective trials on combined therapies, 

and therapy compliance be a mission of the integrated careunder-one-roof 

program. 

Maintaining Defined Scopes of Practice 

There are specific Medical and Dental Licensing Laws and 

Practice Acts, which dictate the scope of practice for physicians 

and dentists (http://www.aasmnet.org/resources/pdf/ 

AADSMJointOSApolicy.pdf). As per individual state law, 

laws only a licensed physician can make a diagnosis and treatment 

plan for sleep disordered breathing. Similarly, a dentist’s 

scope of practice includes evaluating the candidacy of patients 

for oral appliance therapy as well as construction and fitting 

of the appliances. The proposed “care-under-one-roof model” 

will be structured within the practice parameters established by 

the AASM. 4 Updated practice parameters are currently being 

prepared by the AASM for publication. 32 

Responsibilities of sleep physician specialist: 

1. Assess patients with sleep-related complaints. 

2. Order appropriate diagnostic tests and diagnose 

obstructive sleep apnea. 

3. Discuss treatment options with the patient based on 

practice parameters and standard of care guidelines. 

4. Counsel on behavioral therapy, sleep hygiene, weight 

loss, and driving precautions. 

5. Manage concomitant sleep disorders which often 

accompany OSA, such as restless legs syndrome 

(RLS)/periodic limb movement disorder (PLMD), 

circadian rhythm disorders, and insomnia. 

6. Follow and document comorbid conditions and impact 

of treatment on hypertension, diabetes, heart failure, 

arrhythmia, and neurocognitive function. 

7. Engage in active consultation with staff dental sleep 

expert on treatment plan. 

8. Participate in periodic multidisciplinary rounds and 

conferences. 

9. Provide follow-up sleep testing after OSA therapy has 

been instituted. 

10. Provide ongoing and routine follow-up patient care. 

Responsibilities of staff dental sleep expert: 

1. Evaluate patients for dental sleep medicine therapies. 

2. Discuss treatment options (mandibular advancement 

splints, combination MAS/PAP therapy, tongue 

retaining device, maxillofacial surgery, etc.). 

ISSUE Special 4 Article | 2013 

3. Manage coexistent dental disorders, such as bruxism. 

4. Counsel on dental hygiene and daily maintenance of 

oral appliances. 

5. Follow-up patients every 4-6 weeks until treatment 

efficacy and patient adherence to therapy have been 

established. 

6. Review compliance and manage potential 

complications or adverse effects of therapy. 

7. Maintain communication with sleep physician 

specialist for outcome measures monitoring. 

8. Assess the need for change in treatment, or repeat PSG 

for either re-titration or resolution of sleep disordered 

breathing. 

9. Establish protocols at the sleep disorders center on oral 

device titration, technician training, consent procedure, 

off-hour call coverage issues. 

10. Participate in periodic multidisciplinary rounds and 

conferences. 

11. Provide ongoing and routine patient follow-up care. 

Business Model 

Sustainability of the integrated care-under-one-roof model 

would depend on development of a business model that can 

successfully address the financial challenges faced by many 

dentists today who provide oral appliance therapy. Ideally, 

the sleep clinic administration would negotiate contracts with 

medical insurance companies for the dental providers in much 

the same way the physicians are enrolled to deliver contracted 

services and are credentialed as providers. The clinic office 

would ideally handle preauthorization and file insurance claims 

for the dental component of the patient’s evaluation and treatment. 

A single, unified electronic medical record (EMR) system 

would be used by all providers. Financial sustainability would 

be made possible, in part, by the efficiency of care delivery and 

the quantity of care delivered. The dental sleep expert may be 

able to bill for his services provided to the patient at the sleep 

disorders center even if seen on the same day as the sleep specialist, 

as services provided are different and performed by two 

different specialists. 

The care-under-one-roof model raises legal concerns that 

would need to be addressed to comply with individual state and 

federal laws. For example, dentists in some states are bound 

by a “corporate practice” doctrine, which prevents non-dentists 

from owning any part of the dental practice. Moreover, compliance 

with the federal Stark laws also require that the referring 

physician have no financial interest in any business that provides 

positive airway pressure (CPAP provider) or oral appliance 

(dentist), as both are viewed as durable medical equipment 

(DME) providers by the Centers for Medicare and Medicaid 

Services. However, several large hospitals and institutions now 

have DME services and can provide integrated care-underone-roof 

with appropriate safeguards. Due to these limitations, 

we believe that this model is best suited initially for use in an 

academic/institutional setting with a community-based model 

evolving from the experience of these centers. 

Community-Based Non-Academic Model 

Although the above model is proposed with academic institutions 

in mind, this model can be adapted for non-academic 

5 Journal of Clinical Sleep Medicine, Vol. 9, No. 8, 2013 

continued . . .

18 S Sharma, G Essick, D Schwartz et al 

centers. We propose that this collaboration take place in AASMaccredited 

sleep disorders centers. Board-certified sleep physicians 

at the center should form alliance with dedicated dental 

practitioners who have adequate training in sleep medicine 

and are motivated to serve this population. The dental expert 

should have scheduled clinic hours at the sleep center where 

a comprehensive dental evaluation may be performed. Dentist 

“chair” is a small investment which the sleep center or the dentist 

has to make (a refurbished chair can be obtained for around 

$3,000.00). The use of radiographs is essential to the treatment 

decision (http://www.aadsm.org/PDFs/TreatmentProtocolOAT. 

pdf), but these can be obtained from the patients’ general dentists. 

Many dentists have digital offices and therefore are able 

to email the radiographs upon patients’ permission. This will 

all be done in conjunction with a comprehensive dental exam, 

periodontal screening, muscle evaluation, TMJ evaluation, and 

review of medical history. 

From a business perspective, the sleep center charges the 

dental sleep expert for renting space and equipment. The dental 

sleep expert, by his presence and expertise, determines which 

patients are good candidates for OA. The dentist utilizes the 

center’s expertise to titrate patients either by OCST or in-lab 

titration, and in long-term follow-up. 

Oral appliances for OSA are considered durable medical 

equipment, so several models out in the real world can exist. 

Under one model, the sleep center provides DME, and the dentist 

is contracted to provide under the DME services of that 

group. This model allows the DME company to bill on behalf 

of the dentist for those services. Other models have the dentist 

with their own DME, then provide services and bill for their 

services. The advantage of the dentist contracting under the 

sleep center DME is that most of these DME companies already 

have insurance contracts in place to provide CPAP, another 

DME item. It is then easy for the contracts to be extended 

to oral appliances. 

While the reimbursement for OA is varied, it is a covered 

benefit to most patients with private insurance. Medicare has 

also come on board in reimbursing for these appliances with 

fairly strict coverage and mandating delivery by a dentist. 

We feel this model will not only improve patient care and 

comfort, but it is also financially viable and professionally 

satisfying. 

CONClUSION 

Integrating oral appliance therapy into the delivery of care 

for obstructive sleep apnea syndrome has been a challenge 

and few effective models exist so far. It is imperative that the 

sleep medicine community develops a realistic and effective 

model of this underutilized but promising treatment modality. 

We believe that the best structure is to integrate dental sleep 

medicine with the sleep disorders program is via a care-underone-roof 

concept. Training, communication, education, marketing, 

and evaluating outcome data are vital. Such centers 

of excellence at academic institutions are best suited to lay 

this foundation. These institutional centers can provide care in 

their community as well as serve as a model of integrated care 

delivery for sleep medicine throughout the country in nonacademically 

based sleep centers. 

REFERENCES 

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1. Ivanoff CS, Hottel TL, Pancratz F. Is there a place for teaching obstructive 

sleep apnea and snoring in the predoctoral dental curriculum? J Dent Educ 

2012;76:1639-45. 

2. Loube MD, Strauss AM. Survey of oral appliance practice among dentists treating 

obstructive sleep apnea patients. Chest 1997;111:382-6. 

3. Simmons MS, Pullinger A. Education in sleep disorders in US dental schools 

DDS programs. Sleep Breath 2012;16:383-92. 

4. Kushida CA, Morgenthaler TI, Littner MR, et al. Practice parameters for the treatment 

of snoring and obstructive sleep apnea with oral appliances: an update for 

2005. Sleep 2006;29:240-365. 

5. Brown DB. Taking a bite into oral appliance therapy. Sleep Rev 2011. 

6. Bian H. Knowledge, opinions, and clinical experience of general practice dentists 

toward obstructive sleep apnea and oral appliances. Sleep Breath 2004;8:85-90. 

7. Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on 

neurobehavioral functioning in obstructive sleep apnea: a randomized controlled 

trial. J Clin Sleep Med 2005;1:374-80. 

8. Tan YK, L’Estrange PR, Luo YM, et al. Mandibular advancement splints and 

continuous positive airway pressure in patients with obstructive sleep apnoea: a 

randomized cross-over trial. Eur J Orthod 2002;24:239-49. 

9. Vanderveken OM, Boudewyns A, Ni Q, et al. Cardiovascular implications in the 

treatment of obstructive sleep apnea. J Cardiovasc Transl Res 2011;4:53-60. 

10. McGill M, Felton AM. New global recommendations: a multidisciplinary approach 

to improving outcomes in diabetes: Global Partnership for Effective Diabetes 

Management. Prim Care Diabetes 2007;1:49-55. 

11. Antoline C, Kramer A, Roth M. Implementation and methodology of a multidisciplinary 

disease-state-management program for comprehensive diabetes care. 

Perm J 2011;15:43-8. 

12. Denbar MA. A case study involving the combination treatment of an oral appliance 

and auto-titrating CPAP unit. Sleep Breath 2002;6:125-8. 

13. El-Solh AA, Moitheennazima B, Akinnusi ME, Churder PM, Lafornara AM. Combined 

oral appliance and positive airway pressure therapy for obstructive sleep 

apnea: a pilot study. Sleep Breath 2011;15:203-8. 

14. Borel JC, Gakwaya S, Masse JF, Melo-Silva CA, Sériès F. Impact of CPAP interface 

and mandibular advancement device on upper airway mechanical properties 

assessed with phrenic nerve stimulation in sleep apnea patients. Respir 

Physiol Neurobiol 2012;183:170-6. 

15. Krucien N, Gafni A, Fleury B, et al. Patients’ with obstructive sleep apnoea syndrome 

(OSAS) preferences and demand for treatment: a discrete choice experiment. 

Thorax 2013;68:487-8. 

16. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous 

positive airway pressure versus oral appliance treatment for obstructive 

sleep apnea. Am J Respir Crit Care Med 2013;187:879-87. 

17. Holley AB, Lettieri CJ, Shah AA. Efficacy of an adjustable oral appliance and 

comparison with continuous positive airway pressure for the treatment of obstructive 

sleep apnea syndrome. Chest 2011;140:1511-6. 

18. Tsuiki S, Lowe AA, Almeida FR, Kawahata N, Fleetham JA. Effects of mandibular 

advancement on airway curvature and obstructive sleep apnoea severity. Eur 

Respir J 2004;23:263-8. 

19. Fleury B, Rakotonanahary D, Petelle B, et al. Mandibular advancement titration 

for obstructive sleep apnea: optimization of the procedure by combining clinical 

and oximetric parameters. Chest 2004;125:1761-7. 

20. Almeida FR, Parker JA, Hodges JS, Lowe AA, Ferguson KA. Effect of a titration 

polysomnogram on treatment success with a mandibular repositioning appliance. 

J Clin Sleep Med 2009;5:198-204. 

21. Krishnan V, Collop NA, Scherr SC. An evaluation of a titration strategy for prescription 

of oral appliances for obstructive sleep apnea. Chest 2008;133:1135-41. 

22. Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of 

unattended portable monitors in the diagnosis of obstructive sleep apnea in adult 

patients. J Clin Sleep Med 2007;3:737-47. 

23. Liu Y, Lowe YY, Fleetham JA, Park YC. Cephalometric and physiologic predictors 

of the efficacy of adjustable oral appliances for treating obstructive sleep 

apnea. Am J Orthod Dentofacial Orthop 2001;120;639-47. 

24. Tsai WH, Vazquez JC, Oshima T, et al. Remotely controlled mandibular positioner 

predicts efficacy of oral appliance in sleep apnea. Am J Respir Crit Care 

Med 2004;170:366-70. 

25. Dort LC, Haduk E, Remmers JE. Mandibular advancement and obstructive 

sleep apnoea: A Method for determining effective mandibular protrusion. Eur 

Respir J 2006;27:1003-9. 

26. Petelle B, Vincent G, Gagnadoux F, Rakotonanahary D, Meyer B, Fleury B. Onenight 

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pilot study. Am J Respir Crit Care Med 2002;165:1150-3. 


6

ISSUE 4 | 2013 Special Article19 

27. Remmers J, Charkhandeh S, Grosse J, et al. Remotely controlled mandibular 

protrusion during sleep predicts therapeutic success with oral appliances in patients 

with obstructive sleep apnea. Sleep 2013;April. 

28. Chan ASL, Lee RW, Cistulli P. Dental appliance treatment for obstructive sleep 

apnea. Chest 2007;132:693-9. 

29. Friedman M, Hamilton C, Samuelson CG, et al. Compliance and efficacy of titratable 

thermoplastic versus custom mandibular advancement devices. Otolaryngol 

Head Neck Surg 2012;147:379-86. 

30. Vanderveken OM, Van de Heyning PH, Braem MJ. Response to “Compliance 

and efficacy of titratable thermoplastic versus custom mandibular advancement 

devices” from Friedman M et al. Otolaryngol Head Neck Surg 2012;147:599- 

600; author reply 600-1. 

31. Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van de Heyning PH, 

Braem MJ. Objective measurement of compliance during oral appliance therapy 

for sleep-disordered breathing. Thorax 2013;68:91-6. 

32. Fleishman S. Personal communication, 2013. 

ACkNOwlEDgMENTS 

The content of this paper is the sole responsibility of its authors and is not meant 

to represent the opinion of the American Academy of Sleep Medicine. The authors 

thank Dr. Sam Fleishman for his helpful suggestions during preparation of the manuscript. 

Legal and financial models proposed are personal viewpoints of the authors 

and all entities are advised to consult their state/institutional regulatory bodies to 

seek expert counsel. 

SUBMISSION & CORRESPONDENCE INFORMATION 

Submitted for publication February, 2013 

Submitted in final revised form May, 2013 

Accepted for publication May, 2013 

Address correspondence to: Sunil Sharma, M.D., F.A.A.S.M., Director, Pulmonary 

Sleep Medicine, Associate Director, Jefferson Sleep Center, Thomas Jefferson 

University & Hospitals, 834 Walnut Street Suite 650, Philadelphia, PA 19107 

DISClOSURE STATEMENT 

This was not an industry supported study. Dr. Sharma served on the Speaker Bureau 

of Actelion and Gilead pharmaceuticals and has a portable sleep device grant 

from Cadwell Industries. Dr. Essick has received devices for research on loan from 

SleepImage and from Airway Management, Inc. He has also received teaching materials 

at no charge from Airway Management, Inc. and serves as the chair of the Research 

and Ethics Committees of the American Academy of Dental Sleep Medicine. 

Dr. Schwartz is on the Academy Faculty of Somnomed. Dr. Aronsky serves on the 

Board of Directors of the American Academy of Sleep Medicine. 


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7 Journal of Clinical Sleep Medicine, Vol. 9, No. 8, 2013 

1/23/13 3:37 PM

20 

ISSUE 4 | 2013 

Case Presentation: Patient requiring quick and 

effective treatment for severe obstructive sleep apnea 

By Sue Ellen Richardson, DDS, MAGD, FICD, FAACP 

Introduction 

This is an interesting case because the patient urgently needed 

treatment: Her untreated severe obstructive sleep apnea (OSA) 

and disrupted sleep precipitated enough cognitive impairment 

to cause her to have four car accidents in the previous five 

months. It is well known that untreated sleep apnea is a significant 

contributor to motor vehicle crashes. 1-3 The treatment of choice 

for severe obstructive sleep apnea is continuous positive airway 

pressure (CPAP) because this affords an immediate benefit to the 

patient. This patient could not tolerate CPAP. She felt terrified of 

the mask, secondary to acute claustrophobic reactions and feelings 

of suffocation. She chose to attempt conservative oral appliance 

therapy (OAT) first before considering any of the surgical sleep 

apnea treatments. 

Because the patient required immediate treatment, this put a 

significant demand on the oral appliance to succeed quickly. 

Rapidly advancing a patient to a therapeutic position with OAT 

could irritate the temporomandibular joint (TMJ) and this patient 

presented to my office with pre-existing minor TMJ disorder signs 

and symptoms; she also had an unusual excursive movement habit. 

It has been reported that a high prevalence, 52 percent, of OSA 

patients referred for OAT arrive at the dental office with joint 

pain, or symptoms of TMJ disorder. 4 Indeed, wearing an oral 

appliance (OA) to treat OSA can even aggravate the TMJ. 5,6 Up 

to 77 percent of patients wearing an OA for the treatment of 

OSA report temporomandibular discomfort as a side effect. 4,7 

However, despite this prevalence, significant and persistent TMJ 

problems with OA use are uncommon 4,7 and OAT use has proven 

harmless to the TMJ. 8 It has also been found that TMJ discomfort 

isn’t connected to discontinuation of OA use. 9 In fact, sometimes 

long-term use can often improve TMJ disorder symptoms. 10 

The patient usually awakens with general pain in her joint, neck 

and teeth that lasts until late morning. She protrudes on a 2mm 

diagonal to the right on full protrusion. She habitually bruxes 

SUE ELLEN RICHARDSON 

DDS, MAGD, FICD, FAACP 

Dr. Sue Ellen Richardson has been in the private 

practice of General Dentistry for 32 years. She has 

taught at the University Of Texas School Of Dentistry 

and the Greater Houston Dental Society. She became 

involved in the sleep field four years ago when her 

mother needed help for her sleep apnea. She is a 

Diplomate of The American Board of Dental Sleep 

Medicine and a Fellow in The American Academy of 

Craniofacial Pain. 

diurnally and nocturnally, at which time she postures to her right 

para-functional excursive position. However, when examined 

midafternoon, she had no tenderness or pain of the masticatory 

or TMJ regions. We chose to treat the patient who had joint 

symptoms in light of these ambiguities. 

Case Description 

This 51-year-old married female struggles with fatigue and fights 

significant drowsiness during the day. It scares her that she feels 

sleepy while she is driving; in the past five months, she has been 

involved in four car accidents. She is distressed that she doesn’t 

feel alert and competent. She complains of nighttime choking 

and gasping spells that awaken her. Additionally, her husband 

complains that her loud snoring is disruptive to his sleep. 

History of Present Illness 

Continuous positive airway pressure (CPAP) was prescribed. The 

patient’s medical history includes Type 2 Diabetes, metabolic 

syndrome and menopausal symptoms. She currently takes 

Adderall (stimulant), Bi-est (estrogen replacement hormone), 

injectable Victoza (Type 2 diabetes), progesterone and injectable 

growth hormone. The patient is a smoker. She has uncontrolled 

OSA that is severe, according to both the sleep physician’s report 

and the out of center sleep testing (OCST). She scored 15 on the 

Epworth Sleepiness Scale (ESS), which mirrors her feelings of 

excessive daytime sleepiness (EDS). 

Relevant Past Medical History 

The patient had a tonsillectomy as a child. She’s been monitored 

for generalized, moderate to severe chronic periodontitis for years. 

In the past, she said she’s had periodontal surgery with a gum graft, 

and by her description, it was most likely flap surgery with scaling 

and root planing and a gingival graft. She had three wisdom teeth 

extracted and her right lower first molar. She feels cold and hot 

sensitivity in most of her teeth. She has noticed a change in bite, 

probably shifting due to her bone loss. Food now becomes caught 

between teeth. 

Clinical Findings 

The patient presented with a blood pressure of 127/69, with a 

pulse of 96, and a body mass index (BMI) of 31.5. Her tongue 

examination showed it was scalloped and a level III (high) tongue. 

A Mallampati airway inspection showed a Class III airway. 

Her uvula appeared elongated. She developed a small maxillary 

torus in her palate, and medium mandibular tori on the lingual 

aspect of her mandible. Her mandibular range of motion 

measurement recorded as low normal at 43 mm maximum interincisal 

opening. Her lateral movements registered as normal with 

a left lateral excursion of 12 mm and a right lateral excursion of 12

ISSUE 4 | 2013 21 

mm. Her mandible deviates to the right approximately 2 mm at full 

opening. Her midlines are not coincident: her mandibular midline 

sits 2.5 mm to the right of her maxillary midline in habitual closure. 

The patient’s oral examination revealed generalized abfractions, 

some of which had been restored. The longer clinical crown length 

of the teeth secondary to attachment loss creates more potential 

for cervical flexing stress and loss of cervical tooth structure. 

Gingival recession has developed on teeth #2, 3, 4, 5, 7, 9, 10, 11, 

12, 13, 14, 15, 18, 19, 20, 21, 28, 29 and 31. Her anterior teeth 

reflect an incisal wear pattern. The patient is missing teeth #1, 16, 

17 and 30. Her full mouth series of x-rays showed generalized 

periodontal attachment loss (osseous and gingival). A Miller’s Class 

1 mobility was recorded for teeth # 23, 24, 25 and 26. She opens 

with a 2 mm deflection to the right at full opening. Her overbite 

measures 3 mm, and her overjet measures 5 mm. Her oral cancer 

screening was negative. 

The patient presented with a Class II (retruded lower jaw) dental 

relationship on the right side and a Class I (normal) dental 

relationship on the left side. She had significant open contacts 

between teeth #10 and 11, 12 and 13 and 24 and 25. We examined 

her in the late afternoon, at that time of day she had no tenderness 

or pain of the masticatory or TMJ regions. Stethoscopic evaluation 

of her joints revealed slight crepitus upon opening on both sides. 

Her neck muscles are stiff every day and she has pain with cervical 

rotation on her left side. She refused further TMJ or cephalometric 

x-rays. 

Diagnosis 

Per OCST, the sleep physician diagnosed the patient as follows: 

1. Snoring 

2. Severe Obstructive Sleep Apnea Syndrome 

AHI - 37.5 

Supine AHI – 53.9 

Lowest Desat - 70.0 

RDI – 52.4 

Non – Supine AHI – 

Percent Below 90% - 5.6% 

Decision Tree 

I selected an Elastic Mandibular Appliance (EMA) for this patient. 

The EMA has upper and lower vacuform polycarbonate trays 

connected with forgiving stretchable straps that button onto the 

trays. The straps come in nine different lengths for changing or 

titrating protrusion, each strap numbered according to its length in 

millimeters. In addition, each numbered strap is available in four 

different color-coded elastic strengths or tensions or 36 total straps 

in all. Patients usually start with a softer strap and move to a firmer 

strap as their joints permit. This variable strap design of the EMA 

allowed for customized lateral movement and joint care that this 

patient needed and allowed her jaw to move to its excursive posture. 

We delivered the EMA and she wore it for two weeks with the size 

17mm length straps on both sides in yellow (moderate stretch). 

On her follow up appointment, the patient complained of pain in 

her left joint. Since she naturally protrudes her mandible to the 

right, I suggested that she wear a longer 19mm yellow strap on her 

left side. The 19 mm strap allowed her excursive jaw posture and 

provided gentle tension on her joints. I reduced her vertical slightly 

also from the 5mm vertical established with the original 5mm fork 

George Gauge bite registration. 

She continues to wear longer straps on the left to enable her right 

protrusive movement: #19 yellow on her left and #17 yellow on 

her right. Her joints are quite comfortable; we did not need to 

change the length or stretch of the straps. She prefers the previous, 

more vertical opening so I added acrylic to slightly open her vertical 

back to 5 mm. She feels negligible discomfort in the morning in her 

joint and teeth for about 15 minutes. 

The patient is very comfortable with the appliance and feels much 

less daytime sleepiness and fatigue. We referred her for follow up 

sleep testing. The evaluation showed an AHI of 9.2, an RDI of 

17.2 and a nadir SpO2 of 88%. 

Since the patient’s AHI was still above normal, we suggested shorter 

straps for more protrusion. She currently wears shorter straps, 16 

mm and 18 mm yellow straps, but has not returned for follow-up 

OCST. 

“Since the patient naturally protrudes her mandible to the right, I suggested that she wear a longer 19mm yellow strap on her left side.” 

continued . . .

22 

ISSUE 4 | 2013 

Patient’s Progress and Outcome 

Comparing her diagnostic OCST baseline with the patient’s later OCST after using her Elastic Mandibular Appliance, the patient’s condition 

improved as follows: 

Summary 

This case describes a patient that needed a quick and effective treatment of her severe sleep apnea. The patient presented with an unusual 

lateral excursive movement habit, which could’ve possibly limited the success of a mandibular advancement device (MAD). We successfully 

accommodated her oral parafunction with an EMA with a greater than 50 percent reduction of her original severe AHI with a final AHI of 

less than 10. In addition, she feels alert during the day now; her Epworth Sleepiness Scale score was reduced from 15 to 5. Since treating her 

OSA with OAT, she hasn’t been involved in any more car accidents. 

References 

1. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep 

Med. 2009 Dec 15;5(6):573-81. 

2. Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, Swann P, Campbell DA, Pierce RJ. Sleepiness, sleep-disordered breathing, and 

accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. 2004 Nov 1;170(9):1014-21. Epub 2004 Aug 18. 

3. de Mello MT, Narciso FV, Tufik S, Paiva T, Spence DW, Bahammam AS, Verster JC, Pandi-Perumal SR. Sleep disorders as a cause of motor vehicle 

collisions. Int J Prev Med. 2013 Mar;4(3):246-57. 

4. Cunali PA, Almeida FR, Santos CD, et al. Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance 

therapy. J Orofac Pain. Fall 2009;23(4):339-344. 

5. AADSM, Consent Form, 2009 

6. Katz S, Pancer J, Dort L. Treatment Complications: Notes from the Fall 2009 Advanced Course in Oral Appliance Therapy. AADSM Dialogue Issue 2, 

2010 20-22 

7.Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. Feb 1 2006;29(2):244- 

262 

8. de Almeida FR, Bittencourt LR, de Almeida CI, Tsuiki S, Lowe AA, Tufik S. Effects of mandibular posture on obstructive sleep apnea severity and the 

temporomandibular joint in patients fitted with an oral appliance. Sleep. Aug 1 2002;25(5):507-513 

9. de Almeida FR, Lowe AA, Tsuiki S, et al. Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive 

sleep apnea syndrome. J Clin Sleep Med. Apr 15 2005;1(2):143-152 

10. Giannasi LC, Almeida FR, Magini M, et al. Systematic assessment of the impact of oral appliance therapy on the temporomandibular joint during 

treatment of obstructive sleep apnea: long-term evaluation. Sleep Breath. Nov 2009;13(4):375-381

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24 

ISSUE 4 | 2013 

Managers Desk: What questions will my 

referring physicians ask me? 

By Lydia Sosenko, DDS, D. ABDSM 

Building relationship ties within the medical community is essential 

to increasing your dental sleep medicine base. In our last article, 

we reviewed some of the basics of reaching out to the medical 

community. 

Over the years of chatting with newer providers of dental 

sleep medicine, I find that many dentists don’t feel comfortable 

approaching the “medical” world. Fear of having enough 

knowledge or using the right ‘medical jargon’ tops many dentists’ 

minds, often preventing them from moving forward with building 

stronger medical relationships. 

Whether you’re involved in a short 5-minute meeting or a longer 

lunch and learn presentation, most dentists who have met with 

physicians have noticed the following: 

• Most physicians have very limited knowledge, if any, in 

regards to mandibular advancement splints (MAS). 

• Most medical providers really enjoy holding a sample or 

two in their hand. 

• A long detailed presentation isn’t necessary and generally 

not preferred. 

• Rarely are very ‘medical-based’ questions asked. 

• Most are genuinely interested in knowing more about 

oral appliance therapy (OAT). 

• Most physicians don’t have a good referring list of 

knowledgeable dental sleep medicine providers. 

To help you feel more comfortable with an actual meeting, 

consider a quick PowerPoint slide, or even easier, a printed fact 

sheet. Use either of these tools as a guide to cover the most 

important facts so that you don’t have to rely on memory on 

important facts you want to share. Leave them some important 

information such as business cards, referral note pads and other 

educational material to broaden their knowledge of OAT. Don’t 

forget to include two or three high quality and relevant key 

studies/articles to share with them. 

Here are a few common questions that I, along with other 

colleagues, have been asked: 

1. Can you show me how they work? 

2. Which one will you choose? 

3. If a patient is a bruxer, can he/she still have an oral device 

made? 

4. What about a patient with temporomandibular joint (TMJ) 

issues? 

5. How successful are these oral devices? 

6. How much do oral appliances cost? 

7. Are these devices covered by medical insurance? 

8. What about Medicare coverage? 

9. Who are the best candidates for this type of therapy? 

10. What are the side effects, if any of mandibular advancement 

splints? 

Knowing the answers to the above questions will help gain 

confidence during your meetings. If any questions do come up that 

you are not prepared to answer, promise the physician that you will 

get back to them. Seek out the correct information, and don’t forget 

to pass along the information back to them! 

Addressing physicians’ concerns and increasing their overall 

knowledge of OAT is essential for developing stronger business 

relationships. Ultimately, creating a win-win-win situation is the 

overall goal in approaching physicians. The medical providers 

will gain by having trusted referring sources for their patients, the 

suffering patients improve their overall sleep quality and the dentist 

gains not only with an increase in incoming new patients, but in 

changing more lives! 

DR. LYDIA SOSENKO 

Dr. Lydia Sosenko is a Diplomate of the 

AADSM and has limited herself to in the 

delivery of dental sleep medicine while 

maintaining a general dental practice. She 

also leads a dental practice coaching company 

and is author of educational material in dental 

sleep medicine. She may be reached at www. 

SmartDentalSystems.com.

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26 

ISSUE 4 | 2013 

Welcome New AADSM Members! 

ALABAMA 

Brad Beasley, DMD 

Athens, AL 

Lynsey W. Brown, DMD 

Huntsville, AL 

James T. Martin, DMD 

Mobile, AL 

Michael F. McCarthy, DMD 

Hoover, AL 

Chet Swartzentruber, DMD 

Montgomery, AL 

ARIZONA 

Brad Beasley, DMD 

Athens, AL 

Lynsey W. Brown, DMD 

Huntsville, AL 

James T. Martin, DMD 

Mobile, AL 

Michael F. McCarthy, DMD 

Hoover, AL 

Chet Swartzentruber, DMD 

Montgomery, AL 

ARKANSAS 

Diane Marosy, DDS 

Mena, AR 

John D. Pitts, DDS 

Little Rock, AR 

CALIFORNIA 

Ara Agopian, DDS 

Encino, CA 

Omer M. Anisso, DDS 

Encinitas, CA 

Hyun S. Bang, DDS 

Mountain View, CA 

Charles U. Basso, DDS 

Escondido, CA 

Alwyn Devaraj, DDS 

Loma Linda, CA 

Marcela Diaz, DMD 

Elk Grove, CA 

Vickie S. Greenberg, DDS 

Altadena, CA 

Mark B. Griffiths, DDS 

San Diego, CA 

Michael B. Guess, DDS 

El Dorado Hills, CA 

Takumi J. Kagawa, DDS 

Los Angeles, CA 

Massoud Kashanchi, DDS 

Costa, CA 

Scott R. Lundy, DDS 

Westlake Village, CA 

Sheila Merat, DMD 

Newbury Park, CA 

Donald Missirlian, DDS 

San Francisco, CA 

Jon L. Montague, DDS 

Encinitas, CA 

Alfredo Paredes, DDS 

Murrieta, CA 

Namrata Patel, DDS 

San Francisco, CA 

Bridget M. Powers, DDS 

Walnut Creek, CA 

Mark A. Reber, DDS 

Morgan Hill, CA 

Stephen J. Rubinkan, DDS 

San Diego, CA 

Sidney L. Spector, DDS 

San Diego, CA 

Russell A. Sutliff, DDS 

Granite Bay, CA 

Daniel Tebbi, DMD 

Encino, CA 

Stuart P. Tenggren, DDS 

Simi Valley, CA 

Gurminder S. Uppal, DDS 

Ceres, CA 

Thomas F. Wuesthoff, DDS 

Westlake Village, CA 

COLORADO 

Jim K. Beck, DDS 

Pueblo, CO 

Carl Feghali, DDS 

Grand Junction, CO 

Nicole K. Furuta, DDS 

Denver, CO 

Paul A. Hamersky, DDS 

Denver, CO 

CONNECTICUT 

Sally Rosenberg, DDS 

Glastonbury, CT 

David B. Sobanski, DMD 

Glastonbury, CT 

Paul-Henry H. Zottola, DMD 

Rocky Hill, CT 

DELAWARE 

Gregg Fink, DMD 

Newark, DE 

DISTRICT OF COLUMBIA 

Michael A. Sims, DDS 

Washington, DC 

FLORIDA 

Jonathan A. Alvarez, DDS 

Santa Rosa Beach, FL 

Rosemary Baghdassarian- 

Mencia, DDS 

Fort Lauderdale, FL 

Helena A. DeLuca, DMD 

Sunrise, FL 

Richard C. Gilbert, DMD 

Bonita Springs, FL 

Paul H. Jaworski, DDS 

Sarasota, FL 

Mitsh Jivan, DMD 

Mount Dora, FL 

Jose F. Lopez, DMD 

Davenport, FL 

Benjamin K. Moricz, DDS 

Sarasota, FL 

Stephen J. Pyle, DDS 

Weston, FL 

Glenn R. Saraydar, DDS 

Saint Petersburg, FL 

GEORGIA 

David B. Carter, DMD 

Martinez, GA 

HAWAII 

David Matto, DMD 

Honolulu, HI 

IDAHO 

David M. Bond, DDS 

Jerome, ID 

ILLINOIS 

Keven Arnold, DDS 

Saint Charles, IL 

Joe Balice, DDS 

La Grange, IL 

John M. Conness, DDS 

Ottawa, IL 

Sheela Gandhi, BDS, DDS 

Westmont, IL 

Lisa O’Grady, DMD 

Morris, IL 

Thomas W. Pogue, DDS 

Mundelein, IL 

Carleigh M. Prane, DMD 

O’Fallon, IL 

INDIANA 

George A. Mighion, DDS 

Mishawaka, IN 

Chad G. Stutsman, DDS 

Goshen, IN 

James B. Wilson, DDS 

Jasper, IN 

KANSAS 

Michael S Klein, DDS 

Overland Park, KS 

Cameron G Walker, DDS, PhD 

Overland Park, KS 

KENTUCKY 

Carl E. Blevins, DMD 

Grayson, KY 

MAINE 

Travis R. Buxton, DDS 

Bangor, ME

27 

Kathleen S. Winn, DMD 

Brunswick, ME 

Laurence P. Schweichler, DDS 

Caledonai, NY 

Bradley D. Nirenblatt, DMD 

Charleston, SC 

Bill J. Mulliken, DDS 

Mill Creek, WA 

MARYLAND 

Anthony L. Boyd, DDS 

Annapolis, MD 

Thomas E. Horton, DDS 

Bethesda, MD 

Daniel C. McEowen, DDS 

Hagerstown, MD 

Alexander Smith, DDS 

Bethesda, MD 

MASSACHUSETTS 

Houssam Alkhoury, DMD 

Holliston, MA 

Stephen Chafkin, DMD 

Newton, MA 

MICHIGAN 

Rohit Reddy, DDS 

Flint, MI 

Albert J. Wesley, DDS 

Rochester Hills, MI 

MINNESOTA 

Gregory K. Ross, DDS 

Forest Lake, MN 

NORTH CAROLINA 

Michael Catanese, DDS 

Charlotte, NC 

John M. Fish, DDS 

Hildebran, NC 

Wilson O. Jewell, DDS 

Wilmington, NC 

James Clark Johnson Jr., DDS 

Morehead City, NC 

Krista Rankin, DDS 

Charlotte, NC 

Mark E. Taylor, DDS 

Gastonia, NC 

OHIO 

Thomas M. Bilski, DDS 

Independence, OH 

Toru Deguchi, DDS 

Columbus, OH 

Linda M. Hippler, DDS 

Lakewood, OH 

Kevin D. Huff, DDS 

Dover, OH 

TENNESSEE 

William Pippin, DDS 

Sevierville, TN 

David H. Sutton, DDS 

Newport, TN 

TEXAS 

Anas Athar, DDS 

Garland, TX 

Yoon H. Chang, DDS 

Carrollton, TX 

Daniel J. Dugan, DDS 

Hurst, TX 

Brandi B. Harris, DDS 

Dublin, TX 

Audrey L. Stansbury, DDS 

Highland Village, TX 

UTAH 

Trenton D. Thalman, DDS 

Richfield, UT 

VERMONT 

Emily J. Samuel, DMD 

Springfield, VT 

Kirby M. Nelson, DDS 

Maple Valley, WA 

Catherine A. Smith, DDS 

Bellingham, WA 

Laura C. VanDyk, DDS 

Sumner, WA 

Sue E. Weishaar, DDS 

Spokane Valley, WA 

WISCONSIN 

George J. Hathaway, DDS 

Wisconsin Rapids, WI 

Ned Murphy, DDS 

Racine, WI 

BERMUDA 

Jewel L. Landy, DDS 

Hamilton 

CANADA 

Nii A. Ayi, DDS 

Calgary, AB 

Jeffrey M. Bilodeau, DMD 

Calgary, AB 

Stacey N. Kreuz, DDS 

Calgary, AB 

MISSOURI 

Clarence E. Simmons, DDS 

Kansas City, MO 

Jeffrey Sindelar, DDS 

Saint Louis, MO 

NEBRASKA 

Katie Hicks, DDS 

Omaha, NE 

Matthew T. McGuire, DDS 

Omaha, NE 

David Mlnarik, DDS 

Omaha, NE 

NEVADA 

Tiffany J. Jackson, DDS 

Las Vegas, NV 

NEW YORK 

Steven Acker, DDS 

Staten Island, NY 

Mitchell A. Charnas, DMD 

New York, NY 

Gary Franco, DMD 

New York, NY 

Stuart G. Kesner, DDS 

Flushing, NY 

Scott Schumann, DDS 

Grove City, OH 

OKLAHOMA 

Rick C. Canady, DDS 

Tulsa, OK 

OREGON 

Norman D. Gregson, DMD 

Milwaukie, OR 

Dain C. Paxton, DMD 

Hillsboro, OR 

Reuben A. Ramillosa, DDS 

Salem, OR 

Sean A. Reisig, DDS 

Salem, OR 

PENNSYLVANIA 

David L. Gordley, DDS 

Slippery Rock, PA 

Marc D. Johnson, DMD 

Aspinwall, PA 

Amadee B. Merbedone, DDS 

Fairchance, PA 

SOUTH CAROLINA 

Stacy L. Blackmon, DDS 

Lake Wylie, SC 

VIRGINIA 

Kelly Bernath Paxton, DDS 

Chesapeake, VA 

Dianne S. Caprio, DDS 

Roanoke, VA 

Kenneth E. Copeland Jr., DDS 

Harrisonburg, VA 

Judith R. Coulter, DMD 

Springfield, VA 

Cecilia M. Gyllenhoff, DDS 

McLean, VA 

Brian P. Midgette, DDS 

Chesapeake, VA 

Gary E. Taylor, DDS 

Portsmouth, VA 

WASHINGTON 

Gary T. Gregg, DDS 

Vancouver, WA 

Liana Groza, DDS 

Spokane, WA 

Todd D. Haworth, DDS 

Port Angeles, WA 

Rodger A. Lawton, DMD 

Olympia, WA 

Elizabeth J. Wong, DMD 

Lethbridge, AB 

Andre Dallaserra, DMD 

Quebec, QC 

Hugo Leveille, DMD 

Kirkland, QC 

Sahag Mahseredjian, DMD 

Laval, QC 

Ashley Slovack, DMD 

Saskatoon, SK 

STUDENTS 

Ahmed I. Masoud, BDS 

Chicago, IL 

Matthew R. Carlisle 

Rock Hill, SC

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companies for their participation in the AADSM Sponsorship Program. Their generous support 

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