KDA Today

KDA Today

For Immediate Release

Date: Aug 20th, 2024
Contact: Glenn R. Blincoe, DMD, D.ABDSM
Phone: 800-292-1855
Email: kda@kyda.org

Q & A with Dr. Glenn Blincoe: Obstructive Sleep Apnea…a Journey Toward Dental Sleep Medicine

Dr. Steve Robertson: Glenn, can you briefly review the medical condition known as obstructive sleep apnea (OSA)?

Dr. Glenn Blincoe: Sure Steve. OSA is part of a family of sleep related breathing disorders (SRBDs). It is a chronic, often progressive, condition that results from the collapse of a patient’s airway. It is thought that 80-85% of the “obstruction” in OSA is due to aspects of the base of the tongue in the airway. This obstruction causes reductions in airflow with breathing during sleep as the tongue can fall back into the airway.

Obstructive Sleep Apnea (OSA) differs from a less common sleep issue called Central Sleep Apnea (CSA) which is a poorly understood and difficult to treat condition when the brain basically tells the body to stop breathing for short periods of time. Upper Airway Resistance Syndrome (UARS) is more common and associated with soft tissues/muscles of the airway relaxing during sleep and reducing airflow - not thought to be as serious as OSA.

In an effort not to get too deep in the weeds of OSA, there are multiple factors (anatomy, muscle tone, CO2 receptor sensitivity, weight gain) involved with OSA susceptibility in patients. While attention can be paid to other factors, the most common approach to treat OSA these days involves moving, pushing, pulling the base of the tongue to open the airway. CPAP has been around for over 30 years. Long considered the gold standard for treating OSA, CPAP moves the base of the tongue to open the airway using Continuous Positive Airway Pressure (CPAP). Compliance is a big issue with CPAP. Some estimates are that 50% of patients stop CPAP in the first 3-6 months.

Mandibular Advancement Device (MAD) therapy was developed shortly after CPAP due to compliance issues with CPAP. MAD therapy moves the mandible forward in an effort to pull the base of the tongue out of the airway. {Also referred to as Oral Appliance Therapy (OAT), sleep appliance therapy, dental device therapy.}

Hypoglossal nerve stimulation (HNS), commercially known as “Inspire,” is a device that is surgically implanted to electronically stimulate the tongue muscle to contract and open the airway.

There are other surgical options that typically involve "tissue removing" procedures with a variety of predictable results that can be performed by an oral surgeon or ENT.

Tongue Retaining Device (TRD) is a prefabricated soft acrylic "device" that attaches to the anterior third of the tongue by suction. It has a firm portion that protrudes beyond closed lips, pulling the tongue forward. This can be a consideration for totally edentulous patients.
As you might imagine, all of these therapies can work…none of them work 100% of the time in all patients due to a variety of reasons. For example, hypoventilation due to excessive body weight may make CPAP more effective than MAD therapy or Inspire…then compliance can be the issue. All of the treatments have their pros and cons.

Dr. Robertson: Why should dentists be aware of OSA?

Dr. Blincoe: It is estimated that nearly 20% of women and 35% of men suffer from OSA. Since dental patients are typically seen frequently and on a regular basis, dentists need to be aware of oral signs associated with OSA, especially how the tongue sits in the airway. When obvious scalloping on the sides of the tongue is observed (tongues get bigger as time goes by), a dentist should ask patients about sleep issues/snoring.

In 2017, the American Dental Association published its position paper: “The role of the dentist in the treatment of Sleep Related Breathing Disorders.” This publication encourages dentists to include aspects of dental exams related to screening and referral consideration for patients that show signs and /or have symptoms of OSA.

Dr. Robertson: If a patient snores, does that mean they have OSA?

Dr. Blincoe: No, not every patient that snores will be diagnosed with OSA. However, most patients with OSA will snore to some degree. Snoring is caused by vibrations that can be caused by turbulence in the airflow through the upper portion of the airway, the oropharynx. Therefore, snoring is considered a red flag for OSA. When associated with weight gain and other “sleep” symptoms, it is a major red flag. A consultation with a physician should be considered.

Dr. Robertson: Can you describe for KDA members how you became involved with treating OSA?

Dr. Blincoe: Like many colleagues, my partner, Dr. David Shutt, and I, over the years, made the occasional “anti-snoring” device to help a patient with snoring. Ten years ago, one of our long-time patients, a physician, asked me to make him a dental device to specifically treat his OSA. He told me he had severe OSA and was 100% compliant with CPAP. He hated traveling with his CPAP machine. He said he had done the research and found out that OSA can often be treated with a Mandibular Advancement Device (MAD). He asked his sleep physician about it…sleep physician, said, “Ask your dentist.” Because my patient was, himself, a physician, I paid attention to him…he got my attention.

Over the years, I sent a handful of possible OSA patients to Dr. John McCrillis, who was board-certified by the American Board of Dental Sleep Medicine and limited his practice to OSA and sleep disordered breathing.

However, this time I was intrigued. My “guinea pig” physician was very excited about possibly treating his OSA with MAD therapy, or at least use MAD therapy for traveling. He was the perfect first-time patient for me. He was almost leading me through the process - educating me to the overall health benefits for patients when OSA is treated and managed.

Another reason I was inclined to fabricate a MAD for this particular patient - a physician - I knew it would involve collaborating with my patient’s sleep physician. They both knew I was a rookie. As I was to learn, typical MAD therapy involves a follow up sleep study with the dental device to verify device effectiveness and determine an optimal protrusive treatment position for the MAD. I think all three of us were curious about MAD therapy.

Dr. Robertson: What was your first step?

Dr. Blincoe: Well, my very first step was to call a sleep physician I had known for years, as our sons had played sports together in high school. I asked him, “Do these things really work?” He said sometimes they work great…sometimes not so great…sometimes not at all. He was excited about my interest and pointed me in the direction of the American Academy of Dental Sleep Medicine (AADSM). The AADSM is kind of the “sister” organization to the sleep physician’s national organization, the American Academy of Sleep Medicine (AASM).

The AADSM is a great organization that has a lot of introductory information for treating OSA with MAD therapy. They have a wealth of information for dentists looking to introduce dental devices for treating OSA to their practice…going beyond “anti-snoring” devices.

The AADSM and its continuing education opportunities and annual meeting aids in coordinating much of the current research over the last 25 or so years that gives credence to the concepts and effectiveness of MAD therapy.

Dr. Robertson: Did you run into any obstacles along the way?

Dr. Blincoe: The biggest obstacle I immediately ran into ten years ago was the issue of sticking my toe into the world of medicine and medical insurance…who is paying for what? If insurance benefits are available in a particular case, they are medical insurance benefits… no dental insurance is involved. Typical protocol for MAD therapy involves a physician or APRN writing a prescription for the fabrication of a dental device. The dentist is considered a durable medical equipment (DME) provider. This notion of “unknown” medical insurance “stuff” is probably still the biggest obstacle keeping the dental community from getting involved with physicians and APRNs.

Dr. Robertson: Did you find a way to navigate the medical insurance issues?

Dr. Blincoe: Funny you should use the term “navigate.” Nine years ago, I felt like I was in a rowboat with one oar…I felt like I was going in circles trying to get some answers about how medical insurance fits into MAD therapy. These days there are more options for software businesses, specifically for dental sleep medicine (DSM).

Fortunately, nine years ago, I found out about Dental Sleep Solutions. Not only do they provide DSM specific software - DS3, but they also offer access to their third-party medical billing services.

A key aspect of Dental Sleep Solutions for me was the online national study club that typically meets every other Wednesday evening. The two dentists that founded and developed the DS3 software (one is from Kentucky) alternate facilitating the one-hour (longer, if needed) sessions that answer questions from Dental Sleep Solutions members. The questions can range from patient screening, implementing DSM in your practice, developing referrals, device design, insurance/billing, treatment protocols, managing possible side effects…anything related to DSM. This bi-weekly study club was instrumental for me with the “how to do it” aspect of DSM.

Nine years ago, the AADSM seemed to deal more with the research aspects of “why we do it.” Nowadays, the AADMS is much better about the “how to do it” aspects of DSM. In fact, the AADSM has created its Mastery Program to help train dentists who choose to sit for the American Board of Dental Sleep Medicine’s examination to attain Diplomate status.

Another consideration is how involved you may or may not want to get with some medical insurance companies. I do not participate with any commercial medical insurance. Patients can utilize out-of-network benefits, if or when it makes sense.

I would encourage dentists to consider becoming Medicare-certified since so many OSA patients will be on Medicare. The application process can be done by your staff…or some DSM specific software/billing companies can do it for you for a fee. We are Medicare certified.

Dr. Robertson: What else has occurred in the last 9-10 years related to Dental Sleep Medicine?

Dr. Blincoe: The most important thing l have seen has been the increase in public awareness. As I mentioned, the ADA’s position paper on the dentist’s role for screening and referring for OSA patients was published in 2017. This was intended to put OSA on the radar for dentists.

As far as the general public is concerned, OSA awareness has benefited tremendously from the introduction of hypoglossal nerve stimulation (HNS) therapy - commercially known as Inspire. The marketing for Inspire is all over the media – radio, T.V. etc. Patients today are consulting with physicians or sleep specialists knowing there is an alternative to CPAP. Conversations these days can often lead to dental device therapy. Patients are becoming more aware that CPAP is not the only “tool” in the toolbox.

A very significant event, relative to cooperative care, was the publication in 2015 in the Journal of Clinical Sleep Medicine of a position paper by the AASM and AADSM stating the MAD therapy can be considered first line treatment for mild/moderate OSA and is to be considered for severe OSA patients that are CPAP intolerant.

Another nice development is the shift to physicians using more home sleep tests as opposed to overnight in-lab/hospital sleep studies. This has probably helped more patients consider a consultation with a physician or sleep specialist about OSA.

Dr. Robertson: How would you compare your years of general dentistry to your years of dental sleep medicine?

Dr. Blincoe: They are two different worlds for sure. With general dentistry I was accustomed to very precise, predictable procedures. With DSM, the only thing I can guarantee a patient is that we can move their tongue forward with MAD therapy. The question is, can we move their tongue out of the airway enough to adequately treat their OSA? In other words, MAD therapy is more sensitive to anatomical differences from patient to patient. CPAP is considered a more predictable therapy in that, regardless of anatomical differences, CPAP will blow though just about any obstruction caused by the base of the tongue in the airway. Increasing pressure overcomes variations in anatomy. Then, of course, CPAP compliance is an issue.

As I explain predictable outcomes to patients, I tell them that we have successful outcomes in about 70% of our cases. The physicians I work with are happy with 7/10 positive results. As a dentist, seven out of ten won’t cut it. Can you imagine three of ten crowns not fitting? The physicians remind me I am in their world…stop thinking like a dentist! Knowing 50% of patients may not tolerate CPAP helps to put things in perspective.

Dr. Robertson: What would you suggest for KDA members looking to possibly add dental sleep medicine (DSM) to their practices?

Dr. Blincoe: The first thing I might suggest is for members to re-visit the 2017 ADA position paper on a dentist’s role in OSA screening. Investigate what the American Academy of Dental Sleep Medicine (AADSM) offers regarding an introduction to DSM. Get some basic information regarding bite registration techniques and possible side effects.

I would suggest thinking about making a mandibular advancement device (MAD) for yourself or a family member or a member (or spouse) of one or two of your staff. Is snoring an issue? Keep in mind signs and symptoms of OSA that would point someone toward a consultation with a physician or sleep specialist.

Some of the DSM specific software/billing companies also offer some nice, practical introductions to DSM. Specific DSM software helps organize all the details related to each patient’s treatment information/documentation and electronic medical records (EMR). The software should also provide templates for your progress notes and various letters/correspondence to physicians/sleep specialists/dentists.

I would suggest enhancing basic TMJ/muscle anatomy knowledge. By no means an expert, I have learned more TMJ related “stuff” in the last ten years than the prior 30 years…and that’s on me. Patients need to be informed about possible TMJ/bite change side effects and aspects of treatment to minimize and manage possible side effects. (Signed informed/consent forms are necessary…AADSM can help.)

The possibility of side effects is always a concern for me and often an obstacle for dentists. I was fabricating a MAD for a CPAP intolerant physician who started to giggle when I was discussing possible side effects. He told me we were discussing “nuisances.” He said he writes prescriptions for drugs that can cause kidney failure - that is a side effect. I told him I appreciated his sentiment. But as a dentist, the possibility of a bite change bothers me…not as much these days since we have had so many success stories over the years. (“I love my dental device and cannot sleep without it!”) Sleep physicians I work with told me long ago to “get over” possible side effects, as the long-term benefits of breathing properly during sleep outweigh the risks.

Dr. Robertson: Any final thoughts?

Dr. Blincoe: Over the years, by attending many national/regional DSM related meetings, I have met some wonderful, caring dentists in a variety of practice settings. Many have incorporated DSM into their general practices. Some have used DSM as part of their “exit” strategy from general dentistry like I did. (I do not miss working on second molars!). Depending on their location and demographics, some in urban areas with sleep centers/sleep physicians may choose to limit their practice to DSM. Those dentists in rural areas can take advantage of working with local physicians as baseline sleep studies are more often than not, these days, utilizing home sleep test kits.

I would encourage dentists who find that their interest in DSM increases beyond merely “dabbling” in DSM, to consider investigating the AADSM’s Mastery Program that leads to sitting for the American Board of Dental Sleep Medicine’s examination. It does require time and financial considerations…but it will let the physicians you need to work with know you are serious.

And, as I tell everyone…keep flossing!

Dr. Blincoe is a Diplomate of the American Board of Dental Sleep Medicine. He practiced general dentistry for 40 years in Louisville, KY before limiting his practice to dental sleep medicine and sleep disordered breathing five years ago.

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