CONTINUING ED

To read more information about the TAP or sleep disordered breathing, check out the articles below. You will learn all that you want to know. Please contact us if you still have questions.

"Case Control Study in the Treatment of Obstructive Sleep-Disordered Breathing with Mandibular Protrusive Appliance"
Rose, Edmond C., Germann, Martin, Sorichter, Stephan, Jonas, Irmtrud E. Journal of Orofacial Orthopedics 2004; v. 65; no. 6:489-500

"Oral Appliance Therapy for SDB"
By Jeffrey P. Pancer, DDS
Sleep Review, July/August, 2003
Medical World Communications
Efficacy and Reimbursement: Good medicine consists of using the least invasive effective technique that is well tolerated by the patient. Oral appliances very often have been shown to be as effective as CPAP7,12,16 at all levels of severity; nonetheless, many health insurers cover CPAP, but not oral appliances. The advantage of CPAP therapy is that it forces air into the patient. If patients tolerated this therapy well, it would unquestionably be the method of choice for treating all types of apnea. However, CPAP is notorious for its poor acceptance by patients, especially those with mild or moderate apnea who are non-symptomatic. With anterior mandibular positioners, the patient must inhale actively. Patients in our study prefer oral appliances to CPAP 20:17; 99 patients preferred oral appliances given the choice, with four patients who had good results with an oral appliance still preferring CPAP and using the oral appliance only for traveling.7 Studies10,11 have shown that patients also comply better with oral-appliance therapy. If oral appliances were offered on a par with CPAP and prescribed as a very acceptable alternative to CPAP therapy, insurance companies would have to fund oral appliances in the same manner as CPAP. Costs of excellent oral appliances vary from $1,000 to $2,000, a price range similar to that of CPAP. CPAP is, and should be, the main therapy for severe apnea patients. In 1995, Schmidt-Nowara et al2 wrote, "Oral appliances present a useful alternative, especially for patients with simple snoring and others with moderate OSA who cannot tolerate nasal CPAP." Our study7 demonstrated an 87% positive response across the board for snoring and an 81% positive response for apnea, no matter what the severity level was. For these reasons, if the patient desires an oral appliance, it should be available. If patients are followed, as they should be for all SDB treatments, when one type of therapy fails, another may commence. The key to adequate therapy is follow-up care.

"Case Report: Sleep Apnea and Stickler Syndrome"
By Jeffery P. Pancer, DDS
Sleep Review, March/April, 2003
Medical World Communications
Conclusion: The importance of an oral appliance for moderately-severe apnea in a patient for whom CPAP would not work was demonstrated.15,16 Another surprising result was that two Le Fort I surgical mandibular advancement surgeries were performed17 to open the airway, but did not improve the apnea, whereas the oral appliance (which is presumed to open the airway in a similar manner by advancing the jaw nonsurgically) was effective. The multiple problems experienced by this patient show the extreme importance of the input of various specialties. The sleep rounds, at which this patient was present as the subject, was presented at the Center for Sleep and Chronobiology on February 4, 2002. This was the third time this patient was presented as the subject of the rounds, which enabled wide-ranging and fast access to information from psychiatrists, respirologists, otorhinolaryngologists, rheumatologists, orthopedists, and dentists.
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"New Device for Snoring & Sleep Apnea"
KVBC-TV / Las Vegas, September 18, 2003

"Oral Device Muzzles Obstructive Sleep Apnea and Snoring in a 2-Year Study"
By: Jack Gerschman, PhD
Internal Medicine News, Vol. 35, No. 15, August 1, 2002
Copyright 2002 by International Medical News Group, an Elsevier Science Company
Summary: Seattle- The Thornton Adjustable Positioner oral device was effective in a 2 year study of patients with obstructive sleep apnea and snoring, reported Jack Gerschman, Ph.D., at the annual meeting of the Associated Professional Sleep Societies. The device costs about as much as a continuous positive airway pressure (CPAP) device, and it has a higher level of patient acceptance, he said. . .
www.einternalmedicinenews.com

"A Case Study Involving the Combination Treatment of an Oral Appliance and Auto-Titrating CPAP Unit"
By: Martin A. Denbar, DDS
Sleep and Breathing, Vol. 6, No. 3, 2002, pp. 125
Thieme Medical Publishers, Inc.
Ph. (212) 584-4662
Summary: Treating severe obstructive sleep apnea can be a challenge. In this case it necessitated combining treatments to obtain the desired result. Now that oral appliances are a viable treatment of obstructive sleep apnea, they can be combined with continuous positive airway pressure or surgery to give the physician and patient more options.
KEYWORDS: Obstructive sleep apnea, oral appliance therapy, auto-titration, CPAP, combination treatment.

"The Efficacy of a Mandibular Advancement Splint in Relation to Cephalometric Variables"
By: Margot A. Skinner, M.Ph.Ed.; Christopher J. Robertson, MDS; Ruth N. Kingshott PhD; David R. Jones, RPSGT; and D. Robin Taylor, MD
Sleep and Breathing
Vol. 6, No. 3, 2002, pp. 115
Thieme Medical Publishers, Inc.
Summary: The efficacy of a titratable mandibular advancement splint (MAS) for the management of obstructive sleep apnea (OSA) was investigated in relation to supine cephalometric variables. Fourteen adults with diagnosed OSA were recruited following an initial polysomnogram. Supine cephalographic radiographs were taken at baseline and subjects wore the MSA nightly for 6 to 8 weeks. The ploysomnogram and cephalogram were repeated with the MAS at maximal titration. The MAS resulted in complete or partial treatment response in all subjects as measured by the improvement in mean apnea/hypopnea index (AHI) (baseline AHI 34 +/- 22/hr, with MAS 10 +/- 5/hr; p = 0.001). the perpendicular distance between the hyoid bone and the mandibular plane (HYML) measured in awake subjects decreased with the MAS (baseline HYML 25.3 +/- 7.8 mm, with MAS 16.5 +/- 9.6 mm: p =0.002). Baseline HYML was the only cephalometric variable associated with a successful clinical outcome. It was strongly linked to improvements in AHI (adjusted R2 = 0.37, p = 0.012) and arousals (adjusted R2 = 0.455, p = 0.005). We conclude that the MAS is an effective therapy for OSA and baseline HYML is an important predictor of improvement. Improvements in AHI may be explained by the MAS maintaining the new or existing relationship of the hyoid and its surrounding structures, thus preventing obstruction in the upper airway during sleep.

"Combined CPAP-Oral Appliance Therapy"
Case Report by Dr. W. Keith Thornton, DDS
Sleep Review Magazine, January/February 2002, Volume 3, Number 1, Pages 16, 18, 20, and 21
Medical World Communications
Discussion: The treatment of sleep-disordered breathing requires a paradigm shift from one-time diagnosis and treatment with CPAP to a strategy that manages a chronic condition over a patients' lifetime. This requires the appropriate therapy at the appropriate time with continuous assessment at least yearly. Once the patient has been diagnosed with sleep apnea, then simple assessment with modalities such as pulse oximetry can determine any changes in the effective ness of a particular therapy and, as necessary, adjustments of other therapies can be added. In this case, although both the CPAP and the oral appliance were shown to normalize a severe apneic, neither was well tolerated alone. The reasons for failure were either the excessive pressure and leakage with CPAP or the maximum protrusion of the mandible with the oral appliance. A combination therapy with a strapless CPAP-oral appliance interface effectively resolved the problems experienced by the patient. The most logical modality to treat severe OSA patients may be the use of this interface, lowering air pressure while improving leakage and comfort of the mask.

"Innovative Therapy Brings Dental Solutions to Sleep Disordered Breathing"
By Annie Grace James
Doctor of Dentistry, Dallas/Fort Worth, January 2002
Sunshine Media, Inc.
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"Overnight Pulse Oximetry for Sleep-Disordered Breathing in Adults"
By Nikolaus Netzer
Chest Magazine, August 2001
http://www.findarticles.com/cf_0/m0984/2_120/77806171/print.jhtml

"Treatment of Sleep Apnea; Unmet Needs"
By: Peretz Lavie, PhD
CHEST Magazine
Vol. 116, p. 1501-1503, December 1999 Issue

"Evaluation of Variable Mandibular Advancement Appliance for Treatment of Snoring and Sleep Apnea"
By Jeffrey Pancer, DDS; Salem Al-Faifi, MD; Mohammed Al-Faifi, MD; and Victor Hoffstein, PhD, MD, FCCP
Clinical Investigations, Chest Magazine, Vol. 116, p. 1511-1518, December 1999 Issue
Objective: To evaluate an adjustable positioning appliance got treatment of snoring and sleep apnea.
Methods: One hundred thirty-four patients with baseline apnea/hypopnea index (AHI) of 37+/- 28 events/h (mean +/- SD) receive the appliance. The efficacy of the appliance was assessed by the following investigations, performed at baseline and with the appliance: Polysomnography, Epworth sleepiness scale, bedpartners' assessment of snoring severity, patients' assessment of side effects, and overall satisfaction.
Results: Thirteen patients were lost to follow-up. An additional 46 patients had no follow-up Polysomnography, but answered the questionnaires. A total of 75 patients had polysomnography at baseline and with the appliance. We found a significant reduction in AHI from 44 +/- 28 events/h to 12 +/- 15 events/h (p < 0.0005) and a reduction in the arousal index from 37 +/- 27 events/h to 16 +/- 13 events/h (p < 0.05). Epworth scores fell from 11+/- 5 to 7 +/- 3 (p < 0.0005). Bedpartners' assessment revealed marked improvement in snoring. For example, at baseline 96% of patients were judged to snore loudly "often" or "always" by their bedpartners', whereas only 2% were judged so while using dental appliance. The most frequent side effect was teeth discomfort, present "sometimes" or "often" in up to 32% of patients. Follow-up clinical assessment in 121 patients conducted on the average 350 days after the insertion of the appliance revealed that 86% of patients continued to use the appliance nightly; 60% were very satisfied with the appliance, 27% were moderately satisfied, 11% were moderately dissatisfied, and 2% were very dissatisfied.
Conclusion: We conclude that the adjustable mandibular positioning appliance is an effective treatment alternative for some patients with snoring and sleep apnea.
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"Should the Dentist Independently Assess and Treat Sleep-Disordered Breathing"
By: W. Keith Thornton
CDA Journal
August 1998, Vol. 26, No. 8

"Nonsurgical Management of the Obstructive Sleep Apnea Patient"
By W. Keith Thornton, DDS, and D. Heath Roberts, DDS
Clinical Controversies in Oral and Maxillofacial Surgery: Part One
Journal of Oral and Maxillofacial Surgery, September 1996, Volume 54, Pages 1103-1108
WB Saunders Co.
Conclusion: There are many different non-surgical modes of treatment for obstructive sleep apnea. Some can be used independently of one another; others can be used as part of an overall treatment plan. What is important is that the practitioner develops a new paradigm for diagnosis and treatment of this disorder. This paradigm must recognize the available modalities and prescribe a logical sequence for treatment. Oral appliance therapy should become a part of this paradigm. Most patients seek treatment for their snoring because of social repercussions, and only a few recognize the life-threatening consequences of OSA. OAT offers a cost effective, user-friendly method for combining this condition.

"A Crossover study comparing the efficacy of continuous positive air pressure with mandibular positioning devices on obstructive sleep apnea patients"
By Clark GT, Blumenfeld I, et al.
Chest 109 (6):1477-83, 1996

"The Diagnostic and Treatment Process for Obstructive Sleep Apnea: A Clinical Experience"
By Kramer M., Bailey S.
Annual Meeting Abstract Book
American Professional Sleep Society, p. 346, 1996

"Dentist Takes Others Snoring Seriously"
By Kimberley Goad
Dallas Morning News, November 16, 1994
Summary: Biography of W. Keith Thornton, DDS and his invention, the Thornton Adjustable Positioner (TAP) that treats snoring and sleep apnea.
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"Objective Measurement of nasal CPAP patterns of use by patients with obstructive sleep apnea"
By Kribs N, Pack A, et al.
Am Rev Res Dis 147:887-95, 1993