Good morning. This is More Than Teeth. The newsletter that helps dental sleep professionals get 1% better every week.

The More Than Teeth community is growing like wildfire and we can’t thank you enough! We are almost to 10% of our 100,000 subscriber goal🤯

This Weeks Issue:

• AHI: The Wrong Metric?

• Study: Breathings Impact on Dental Development

• Which Appliance Should We Use?

• Online Reviews Make or Break Your Business

Happy Father’s Day (yesterday) everyone, let’s dive in👇

Clinical Corner

🥼Use the clinical corner as your secret weapon to impress your colleagues and patients!

1/ The Trouble with the Apnea-Hypopnea Index (AHI)

Today we're diving deep into a topic that's vital in the sleep medicine sphere. We'll break down why the AHI might not be the most accurate measure of Obstructive Sleep Apnea (OSA) severity and explore what could be done about it.

A Quick Recap on AHI

The Apnea-Hypopnea Index (AHI) represents the number of apneas and hypopneas occurring per hour of sleep. It's become deeply embedded in the sleep medicine field and has important implications for diagnosis, treatment, payments, and even employability of those with suspected sleep disorders.

However, it's not perfect. Here's why.

1. The Devil's in the Details😈

   The AHI measures a broad spectrum of variables, but the specifics matter. A 40-second respiratory event is different from a 10-second one. Moreover, the severity of oxygen desaturation varies. Also, factors like sleep stages and body positions can influence these readings.

2. Variables Galore 🔀

   There's no definitive answer to which variables most significantly determine sleep apnea severity. Factors like BMI, medical conditions, and medications can influence the results, complicating the picture even more.

3. Home Sleep Testing & ‘AHI’🏠

   Home Sleep Testing (HST) tends to underestimate AHI because most devices don't record actual sleep time. HST devices estimate sleep time using methods like actigraphy or peripheral arterial tonometry, leading to uncertainty and variability.

We Need a Better System

All these issues underline the need for better ways to assess OSA severity. Oxygen desaturations could be just as crucial, if not more, than AHI. The duration, frequency, type, and timing of respiratory events in relation to sleep stage and/or body position could give a more comprehensive picture.

A Potential Solution

The author suggests considering a "maximum density index." This index would include all periods of the recording where variables like respiratory events, oxygen desaturations, and heart rate are more frequent than the average value.

Looking Forward

The road to a better system won't be easy. Extensive research and patience will be needed, and the answer may not lie in one single index. But as technology improves, we may be able to incorporate more parameters and automate scoring, bridging the gap between diagnostic polysomnography and HST.

As dental professionals, let's keep our eyes on these developments. In the meantime, remember that the best clinical judgment is made by considering all the data and making informed decisions.

2/ Breathing’s Impact on Dental Development

🔬 The Science

The way we breathe might influence dental morphology and overall craniofacial development. Certain conditions like adenotonsillar hypertrophy, allergies, infections, and nasal blockages can cause upper airway obstruction and lead to a mouth-breathing pattern.

Mouth breathing can alter the normal growth of facial structures, leading to changes in dental morphology and malocclusion. Earlier studies showed that mouth breathers might have different facial development patterns than nasal breathers, including a narrower face, jaw retroposition, and protrusion of upper incisors.

📊 The Results

This recent study provided quantitative data that clearly demonstrated the differences between mouth and nasal breathers:

• The average pharyngeal airway measurement for mouth breathers was 4.62 ± 1.10 cm², while for nasal breathers, it was 5.23 ± 1.34 cm². This was a statistically significant difference (p<0.05).

• The mean maxillary arch measurement was also significantly different. Mouth breathers averaged 3.76 ± 0.92 cm², while nasal breathers measured an average of 4.48 ± 1.23 cm² (p<0.05).

• Among the Skeletal Class I and II groups, nasal breathing was associated with larger measures across different areas such as NPV (nasopharyngeal volume), OPA (oropharyngeal area), OPV (oropharyngeal volume), and TPV (total pharyngeal volume). The differences were statistically significant (p<0.05).

• Mouth breathers were found to have a significantly higher palatal height, averaging 1.89 ± 0.22 cm compared to 1.74 ± 0.26 cm in nasal breathers (p<0.05).

3/ Which Oral Appliance is Best for Treating OSA?

We'll be going straight to the heart of an ongoing debate in dental sleep medicine: The efficacy of different oral appliances in treating Obstructive Sleep Apnea (OSA). Strap in for a deep dive into scientific integrity, unbiased research, and the crucial importance of individualized patient care.

🚫 No Clear Winner in Oral Appliances

We start by debunking the popular notion that certain oral appliances are superior to others in treating OSA. Dr. John Viviano, an expert in dental sleep medicine, points out that manufacturers claiming their devices are more effective than others could potentially harm the credibility of oral appliance therapy as a treatment modality. Such claims need to be backed by solid, peer-reviewed scientific evidence, which is currently lacking.

In fact, Dr. Viviano points out that many of these claims might be influenced by study protocols rather than the manufacturing process or design of the devices. He calls out the "confirmation bias" in the way studies are selected for literature reviews, which could skew results and lead to misleading claims about treatment superiority. Mandibular advancement appliances are simply tools that we can use to aid obstructions from occurring with patients nighttime resportory patterns.

🔬 Unpacking the Studies

Dr. Viviano highlights several studies to illustrate his point. He notes that many "traditional" oral appliances such as TAP 1 and Adjustable PM Positioner have shown efficacy in reducing the apnea-hypopnea index (AHI) below 10 for all patients, not just those with mild OSA. These studies challenge the notion that "precision" oral appliances are universally more effective, which he considers to be merely "marketing rhetoric".

He also refers to a 2022 study that, despite documenting clinical differences between various mandibular advancement appliance (MAD) designs, found no statistically significant differences in their impact on OSA symptoms. Various head-to-head studies comparing the efficacy of different oral appliances also support the idea that the appliance's manufacturer or design does not determine its effectiveness.

💡 The Real Game Changer: Patient-centered Approach

The argument that one oral appliance is inherently superior to another seems to be baseless. Dr. Viviano suggests that efficacy might be more related to how we use the appliance rather than the appliance itself. For example, using the MATRx to establish optimum jaw position or continually readjusting the jaw position over several nights has shown to lead to better outcomes.

In the meantime, patients can benefit from a multidisciplinary and patient-centered care approach where clinicians apply the latest research data and collaborate to find the best solution for each individual patient.

🌟 Key Takeaways

• Claims of the superiority of one oral appliance over another should be backed by robust and unbiased scientific evidence.

• The effectiveness of an oral appliance may depend more on how it's used rather than its design or manufacturer.

• A patient-centered, multidisciplinary approach can help find the best solution for individual patients.

• Oral appliances are constantly improving, and manufacturers should be applauded for their advancements. But let's keep marketing separate from science.

Help Us Grow

Our mission is to impact 100,000 dental sleep professionals positively. If this newsletter would help someone in your network, please forward it to them.

And if someone forwarded this edition to you, please don't leave without hitting that Subscribe button now.

Business of Sleep

📈Better businesses = more lives saved!

The Dentist's Guide to Stellar Online Reviews 

In the digital age, the significance of online reviews is akin to the importance of flossing - and we all know how crucial that is. Fact: 91% of 18-34 year olds trust online reviews as much as personal recommendations. When it comes to dentistry, patients aren’t taking chances; they want assurance that their smiles are in expert hands.

Let's delve into where and how to cultivate sterling reviews for your practice:

1. Google: The Digital Frontliner 🌍

The Scoop: Google reviews are the titans of online feedback. They appear in Google’s local three-pack and are invaluable for SEO. But, there's a caveat: reviewers must have a Google account.

Your Move: Simplify the process for your patients by generating a concise Google review link that leads them directly to your listing. This convenience is akin to a well-placed dental chair - it makes everything smoother.

2. Yelp: Not Just for Food Aficionados 📣

The Scoop: Yelp is a formidable ally. Almost half of the surveyed individuals in 2018 consulted Yelp reviews before making decisions. Moreover, Yelp can enhance your Google visibility - a double boon!

Your Move: If your practice isn’t on Yelp, it’s time to claim your territory. Secure your Yelp listing and encourage patients to share their experiences.

3. Facebook: The Social Maestro 👍

The Scoop: With Facebook, recommendations are the crème de la crème of social proof. Boasting approximately 1.5 billion daily users, Facebook can significantly broaden your practice’s reach.

Your Move: Establish your Facebook page, and encourage your patients to share recommendations. It’s like word of mouth, but on a global scale.

4. Embrace Technology 🤖

The Scoop: Dental practice management software can be your secret weapon. Sending a post-appointment text or email asking for a review can be the gentle, professional nudge that patients appreciate.

Your Move: Leverage programs such as Birdeye, Podium, or Doctible. They can send automated messages soliciting reviews and might integrate seamlessly with your practice management software.

Esteemed colleagues, the digital landscape presents endless possibilities. May your pursuit of online acclaim be as meticulous and rewarding as the dental care you provide.

Something Sweet

🍭Stuff so sweet you might get a cavity..

We love all the fathers out there, Happy Father’s Day!❤️