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Treatment Plan
Orthodontic Strategies
for Sleep Apnea
A team of orthodontists has developed a strategy to effectively implement
treatment of obstructive sleep apnea into a practice and improve patients’ lives
BY TERRY D. CARLYLE, DDS, MSC, FRCDC; LOUIS CHMURA, DDS, MS;
PAUL L. DAMON, DDS; NELSON DIERS, DDS, MS; DAVID PAQUETTE, DDS,
MS, MSD; JUAN-CARLOS QUINTERO, DMD, MS; W. RONALD REDMOND,
DDS, MS; AND BILL THOMAS, DDS, MS
Courtesy of David Paquette, DDS, MS, MSD
E
ach of us has our own
story to tell about sleep
apnea. We all know
someone who snores, struggles
to breathe while sleeping, or has
even been diagnosed with sleep
apnea. If together we are able to
make a total health difference in
the lives of someone we know
and love—particularly, someone
suffering from sleep apnea—
would the effort be worth it? We
were convinced that it would be
and, working with Henry Schein
Orthodontics, we came together
to create the Orthodontic Sleep
Apnea Clinical Advisory Team to
design a strategy that broadens
the scope of the orthodontic
practice and is implementable
for orthodontists to effectively
screen, test, and treat patients for
obstructive sleep apnea (OSA).
“Pursuing an initiative of this
nature is in direct alignment
with one of Henry Schein’s core
values of ‘doing well by doing
good,’ ” says Ted Dreifuss,
vice president of global sales
and marketing, Henry Schein
Orthodontics. “We recognized
a significant unmet healthcare
need and acknowledged that
only a small percentage of the
OSA population is being diagnosed, with an even smaller
percentage receiving treatment.
We also realize that current
treatment options (CPAP, or
68
Figure 1: (Top) The patient was a severe sleep apneic with an AHI = 52 and CPAP dependent. (Bottom) The patient
received orthodontic treatment and an FDA-cleared sleep oral appliance as a retainer. Post-treatment and retainer,
the patient’s AHI score decreased to 5.8.
continuous positive airway pressure) are not satisfactory for
most people. We presented the
hypothesis that changes to the
oral environment could have a
positive and lasting impact on
the airway and sleep apnea.”
Our team embarked on a
mission nearly 2 years ago to
determine if there might be an
orthodontic component to the
problem of sleep apnea, and if
so, what orthodontists could
do to address the problem
with their patients. Here is the
mission we agreed on:
To identify and develop the
products and protocols to enable
orthodontists to improve the lives
of people who suffer from obstructive sleep apnea. Our goal is to
ORTHODONTIC PRODUCTS / April • May 2014
provide an easier, more efficient
route to diagnosis, and treatment of
symptoms that yield positive airway
changes with more durable results.
The Orthodontic Sleep Apnea
approach will be a complete system,
intended to establish a new standard
of care and an expanded healthcare
role for the orthodontists.
For some of us, our involvement is personal. Lou Chmura,
DDS, MS, was diagnosed with
sleep apnea in 2005. He often
tells his own personal story of
struggling with sleep apnea,
how he has undergone multiple
treatments over the years, and
understands the debilitating
nature of the disease.
For David Paquette,
DDS, MS, MSD, it was his
father-in-law, a severe sleep
apneic, who sparked his interest
in treating sleep apnea (Figure
1), while Juan-Carlos Quintero’s
8-year-old son changed his
practice philosophy. Through
CBCT, Quintero diagnosed a
severe airway obstruction that
had been missed by his son’s
medical team.
“I was committed to try to
‘grow’ his airway through a combination of ENT surgery and orthodontic treatment and improve his
life,” says Quintero, DMD, MS.
“The results were mind-boggling
and speak for themselves (Figure 2,
page 70). Not only did I improve
his life, but changed the way I
practice orthodontics and the way
I speak to my patients.”
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Treatment Plan
Courtesy of Juan-Carlos Quintero, DMD, MS
Patient Awareness and Market
Demand for Sleep Apnea
Treatment
Obstructive sleep apnea is an
exciting area for orthodontists
to be involved in now. The level
of awareness of sleep apnea and
related health issues is growing
rapidly. Public figures such as
Reggie White, Shaquille O’Neil,
John Candy, William Shatner,
and Sylvester Stallone have been
in the news and are bringing
the topic of sleep apnea to the
forefront. Television stations are
regularly running public segments on sleep apnea awareness
and encouraging patients to be
screened, tested, and treated if
they have signs or symptoms of
this disorder.
It is important to realize that
our patients now are coming
into our offices aware of sleep
apnea, and what would be a
casual, patient conversation
may lead to a positive discussion
about how an orthodontist could
help in the process of treating
and alleviating sleep apnea.
Understanding Obstructive
Sleep Apnea
OSA is essentially a physical
obstruction of the upper airway.
Normal sleep involves the air
passing through and going
directly down to the lungs. With
an obstructed airway, the structures in the back of the throat
(the tongue, the tonsils, and/or
adenoids) occlude the airway and
prevent the air from passing.
Patients with OSA experience
repetitive episodes of obstruction of the upper airway, causing
a loss of breath and oxygen, for
anywhere from 10 to 30 seconds
or longer per episode. When this
occurs, blood oxygen levels drop,
and heart rate and blood pressure
rise. The brain ultimately sends
a distress signal that partially or
fully wakes the person and alerts
the body to breathe, causing the
patient to gasp for air.
The standard OSA severity
measuring system is called the
70
Figure 2: Diagnosed with a severe airway obstruction, the 8-year-old patient was treated with a combination of ENT
surgery and orthodontic treatment.
apnea-hypopnea index, or AHI,
which uses the number of events
(or episodes) per hour a person
experiences while sleeping to
score OSA severity (Figure 3).
For example, a normal AHI score
for children is less than one event
per hour.1
If OSA is untreated, the insult
to the body is quite remarkable.
Studies show that serious risks
of OSA include stroke, 2 heart
attack,3 obesity,4 diabetes,5 and
motor vehicle accidents.6
The Wisconsin Cohort Study
(1,522 subjects) documented up
to a 35% reduction in 18-year life
expectancy for severe apneics.7
OSA is emerging as one of the
most prevalent health issues in
the United States, and is known
to affect more than 18 million
Americans, including men,
women, and children—85%
of whom are undiagnosed. 8,9
Children with sleep breathing
disorder symptoms suffer from
behavioral problems and lower
IQ scores.9,10 In addition, studies
show that OSA is a chronic, progressive disease with hereditary
factors.11 The OSA genetic component alone opens the door for
orthodontists to screen and treat
entire families in the practice.
Current Routes to Diagnosis
and Treatment
Conventional OSA testing is
done through a Polysomnogram
ORTHODONTIC PRODUCTS / April • May 2014
Figure 3: The apnea-hypopnea index, or AHI, is used to measure the number of
times that breathing pauses or severely slows per hour of sleep.
(PSG), which means an overnight stay in a sleep laboratory.
The patient is wired with many
connectors (Figure 4, page 72)
and observed through the night
by a sleep technician. PSGs are
oftentimes time-consuming,
invasive to the patient, and
expensive. A large percentage
of patients referred for a PSG
never show up for their study.
While some cases—patients with
significant co-morbidities—may
require a PSG, for many OSA
cases there must be a more efficient, patient-friendly, and less
expensive route to testing.
The OSA treatment most
prescribed by physicians today is
the CPAP machine, which can
be effective for treating moderate to severe OSA when used as
prescribed. However, CPAP users
have up to a 70% noncompliance
rate due to the discomfort of the
mask and machine, the significant
social impact, potential inhibition of midface development (in
children), and side effects such
as headaches and dry nose and
throat. In fact, many patients
cannot tolerate CPAP therapy, and
ultimately, CPAPs do not address
the underlying cause of OSA.
Surgical treatment options
can be effective, particularly
in children (T&A), especially
when combined with maxillary
expansion and lifestyle changes
(weight loss, etc). Combining
orthodontics with mandibular
advancement (MA) or maxillomandibular advancement
(MMA) has been shown to be
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Treatment Plan
Courtesy of Lou Chmura, DDS, MS
one of the most successful management strategies for OSA.17,20,21
However, the most commonly
recommended surgery—uvulopalatopharyngoplasty (UPPP)—not
only includes the typical major
surgery risks, but is costly, painful
with lengthy recovery times, and
has a high recurrence rate.
The current medical approach
presents significant barriers in
the form of time, inconvenience,
and cost. The referral process
includes a patient visiting the
primary care physician, then
a sleep physician and/or ENT,
completing a PSG, and in the
end, the patient will most likely
also receive a CPAP machine.
Figure 4: Here, Lou Chmura, DDS, MS, undergoes a polysomnogram to diagnose his obstructive sleep apnea.
Discovering an Orthodontic
Strategy
Why should orthodontists
consider treating sleep apnea?
Orthodontists see a lot of people
with airway problems and have
been trained in facial growth,
de v e l o p me n t , a n d a i r w a y,
so orthodontists are ideally
suited to screen for problems.
Orthodontists are the qualified
healthcare professionals to identify
and treat craniofacial abnormalities and guide the growth of the
craniofacial complex to structurally address the symptoms of OSA.
Together, we studied sleep
apnea, its tremendous health
problems, invasive and costly
methods, and uncomfortable
treatment options. We were
inspired by the amount of
medical literature about sleep
apnea, little of which had been
published in the orthodontic
industry. We then asked an
important question: Are there
orthodontic approaches to OSA that
simplify the testing and treatment,
and provide a better experience and
outcome for the patient?
During our due diligence,
we discovered that OSA is a
medical problem with orthodontic treatments. Approximately
50% of OSA cases involve the
bony structure that surrounds
the airway, and by modifying
72
Figure 5: The Orthodontic Sleep Apnea Clinical Advisory Team, working with Henry Schein Orthodontics, created the
above strategy to provide orthodontists with an understanding of the physiology of sleep apnea and the current
diagnostic and treatment options, as well as a new orthodontic approach, its protocols, and product options.
ORTHODONTIC PRODUCTS / April • May 2014
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Treatment Plan
Courtesy of Juan-Carlos Quintero, DMD, MS
Figure 6: The patient underwent maxillamandibular surgery due to CPAP intolerance. Pre-MMA, the minimum cross sectional area equaled 83 mm (left). PostMMA, the minimum cross sectional area was 345 mm, increasing the pharyngeal volume (right).
the bony structure (upper arch
expansion, advancing the mandible), the orthodontist may be
able to address the underlying
cause of the condition. With
the right information and tools,
the orthodontist is ideally positioned to identify and potentially
74
prevent sleep-related breathing disorders in children, and
perhaps reverse the condition in
adolescents and adults.
Certain key technology
developments supported our
strategic direction. Maxillary
expansion (RME and SME)12,13,14
ORTHODONTIC PRODUCTS / April • May 2014
and maxillomandibular advancement 15 procedures have been
reported to help normalize
tongue position, reduce nasal
airway resistance, and decrease
or eliminate OSA symptoms.
In 2006, the American
Academy of Sleep Medicine
stated that oral appliances could
be used for the first line of treatment for sleep apnea for mild to
moderate cases, and for patients
who are CPAP intolerant. 16
Research has been published
showing mandibular advancement devices open the airway
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Treatment Plan
Courtesy of
Lou Chmura,
DDS, MS
and can provide immediate relief.17,18 Home sleep tests now enable people
to test for OSA in the comfort of their own homes and are often covered
by third-party insurance. Software applications for record keeping and
medical billing simplify the process for integrating sleep into the practice.
In addition, we are in alignment with the American Academy of
Pediatrics’ (AAP) professional organization standards. In 2012, the AAP
stated that all children and adolescents should be screened for snoring,
and any child with symptoms of OSA should be referred for a sleep
study. These new guidelines emerged since research suggests delayed
diagnosis of childhood sleep apnea “can result in severe complications if
left untreated.”19
Orthodontic Strategies for Sleep Apnea: Education Program and
Complete System
Figure 7: Before beginning treatment using an FDA-cleared sleep oral
appliance, the patient had an AHI = 45. Post-treatment, the patient
was retested and his sleep apnea score had dropped to -1.
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ORTHODONTIC PRODUCTS / April • May 2014
Working in partnership with Henry Schein Orthodontics, our
Orthodontic Sleep Apnea Clinical Advisory Team designed the first-of-itskind, 2-day educational course and comprehensive, evidence-based system
to implement sleep apnea treatment in the orthodontic practice. The
program provides an understanding of the physiology of sleep apnea and
the current diagnostic and treatment options, as well as a new orthodontic
approach, its protocols, and product options (Figure 5, page 72). The
orthodontic approach is intended to provide patients with immediate relief
from OSA, as well as changes to the airway that may address an underlying
cause. We demonstrate innovative technologies and convenient, costeffective processes to improve the diagnostic and treatment experience.
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We believe it is important to screen every
patient, regardless of age, and ask the critical
questions to take the best possible care of
our patients. We gather sleep apnea histories and complete medical exams, and when
appropriate, send our patients home with
high-quality home sleep testing devices.
Once we recognize the possibility of a sleep
breathing disorder, we refer patients to sleep
specialists to gain their definitive medical
diagnosis and work together to ensure
optimal patient treatment.
As orthodontists, we are uniquely
positioned to expand the airway through
slow or rapid maxillary expansion (RME/
SME), combined orthodontics with mandibular advancement, or maxillomandibular
advancement (Figure 6, page 74), and sleep
apnea oral appliances. Many of us use software that organizes and manages patient
documentation, referrals, and medical
billing for sleep apnea treatment. We also
designed a starter plan on how to incorporate OSA into the practice.
Making a Difference
The goal is to give patients options and
improve their lives, as Chmura did with his
patient JC. In 2006, JC came into Chmura’s
office showing signs and symptoms of sleep
apnea. He had tried a CPAP and told
Chmura that he felt like he was “choking”
as he fell asleep. He explained that he had
not slept more than 4 hours per night
since the age of 17 (that’s 35 years; he’s 52
now). His wife reported heavy snoring and
that JC stopped breathing while he slept.
Chmura treated JC with an FDA-cleared
sleep oral appliance. After sleeping with the
appliance, Chmura retested JC, and to his
amazement, his sleep apnea score dropped
from severe (AHI = 45) to normal (AHI =
-1) (Figure 7).
Integrating sleep into the practice
doesn’t happen overnight, but the process
has been inspiring and worth the effort.
Especially when patients thank us for
giving them better health, more energy,
and often better relationships at home.
Our motto is, “Breathe, Smile, Thrive.”
We are excited about the future of the
orthodontic practice, and are convinced
that as an orthodontic community, we can
make a total health difference in the lives
of our patients. OP
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