Learning what I know... Dental Sleep (Part II)

The beauty of not being an exhibitor is that you can spend all your time at the educational sessions. This year as in past years, courtesy of the management of the ADSM I have attended the meeting at no charge - thank you management of ADSM!

There was an excellent review of sleep disorders and how oral applicances are a treatment option for some sleep apnea suffers. What followed the overview were three presentations - one on sleep apnea and metabolic syndrome, sleep apnea and cardiovascular disease and sleep apnea and oxidative stress and inflammation.

The case for a relation between sleep apnea and metabolic syndrome has always been clear un my mind. But in the first presentation, Naresh Punjabi, M.D., Ph.D. from Johns Hopkins established rather persuasively that OSA and metabolic syndrome are linked through a condition that develops in people with both conditions - obesity.

The second presentation was offered by Dr. John W. Shepard, Jr. of the Mayo Clinic. He began talking about breathing and the problems caused to the heart by the cessations in breathing that occur during apneas. He presented through numerous diagrams and charts that described the acute cardiovascular responses to asphyxia (which is what happens, for some, countless times during the night. He closed his presentation with the Ode to the Pickwickian (an allusion to the Dicken's novel the Pickwick Papers where a character with a form of sleep apnea was first described).

The third presentation in this series was from Virend Somers... who I had met while in Detroit earlier in the year. His presentation took the discussion to a whole different level... the molecular level. There are three actors in his drama - Adioponectin, C-reactive_protein (CRP)and Leptin. The stage where this drama is played out is in the Endothelium. Without going into a lot of detail... which is more than I can do. CRP had been shown to be a mediator of heart disease and sleep deprivation increases the amount of CRP in the blood stream. More CRP... more heart disease.

The keynote address was delivered by Dr. Remmers and his presentation was an exhordation the sleep dentists assembled to do more to recognize and treat sleep apnea. He used the series of slides showing the increase in obesity in the United States from 1990... it is frightening! As he was speaking I thought to myself... I should comment on the Institute of Medicine (IOM) report about the need changes in diagnostic technology. And as if he was reading my mind he mentioned the IOM report. Nothing like having your sentences finished by someone you admire.

I can see why the sleep dentists made Dr. Remmers and honorary member of the Academy.

Next... onto the main event... Sleep 2006

Dental Sleep Meeting Part I

The Academy of Dental Sleep Medicine (ADSM) meeting is much smaller than the American Academy of Sleep Medicine (AASM) meeting. It has a much different feel. Dentists who decide to pursue dental sleep medicine are a dedicated lot and very interested in learning about sleep apnea... the condition that they treat through the use of oral applicances.

Recently a number of changes... updates have occurred that has made the practice of dental sleep medicine much more interesting. Late last year the AASM released a revised set of practice parameters for the use of oral appliances in the treatment of certain forms of sleep apnea... mild to moderate (AHI = 5 to 30). So the field got the formal blessing from the sleep doctors. Second and perhaps just as important happened at the beginning of the year without a lot of fanfare. The Centers for Medicare and Medicaid Services approved two reimbursement codes for the use of an oral appliance for the treatment of OSA.

These codes will make it possible, at some point in time in the future (perhaps a year from now), for people getting a device to be reimbursed by their insurer. Up to now, there hasn't been insurance coverage, so other payment arrangements were necessary.

So these are exciting times for the sleep dentists. There are still some impediments to their being able to diagnose *and* treat the patient, but let's let them savory the advance in peace... for now.

If it is a medical meeting, there has to be an exhibit hall. This is not one where the ASAA exhibits, though in the future we will need to strongly consider doing so. It is a small meeting ( a couple of hundred attendees) and so a small exhibit hall. The majority of exhibitors are manufacturers of the applicances themselves. A recent entry to the field is Respironics. They will begin marketing, in July, a "boil and bit" type applicance that comes in three settings: 00 (no adjustment forward) 2.5 (the lower insert is advanced 2.5 mm forward) and .5 (the lower is advanced 5 mm forward). This device is intended as a spare appliance or perhaps something for a CPAP user to use when they are away from the power grid to use their machine.

This could be a signal they are serious about oral applicances as an additional arrow in their quiver in the battle with OSA... very interesting. Another item they had was a single channel apnea screening device similiar to what ResMed has and has had on the market for a year or so.

One more item on the exhibit hall... in addition to the appliances there are sleep apnea screening devices. This is the equipment the dentist use to determine if their patients may sleep apnea before sending them for an overnight sleep study (a polysomnographic examination or PSG for short).

Among those marketing this type of machine was Dr. John Remmers of Calgary in the province of Alberta Canada... who is also an emeritus member of our board of directors. Dr. Remmer's has developed a very sophisticated unattended sleep apnea monitoring device. I had occasion to listen in while he reviewed a couple of test studies with attendees who stopped by. Certainly the technology is currently available to provide the precision needed to diagnose 99% of the sleep apnea cases out there without needing to have a PSG... now if only the "powers that be" could come to some agreement.

Next up... the educational sessions and the return of Dr. Virend Somers.