NEPS 2018

“Tips & Tricks” on Maximizing Outcomes with an OSA Oral Appliance

(Mayoor Patel, Shouresh Charkhandeh, John Carollo, Amanda Juarez, Erin Elliott, Kent Smith, Steve Carstensen, Todd Morgan, Steve Marinkovich, Promila Mehan, Tim Mickiewicz, Dennis Marangos, Tony Soileau, Dan Bruce, Troy Pridgeon, Rick Lawson, Don Malizia, Steve Lamberg, Mark Abramson, Dan Tache, John Viviano)

The LinkedIn Discussion Group, “SleepDisordersDentistry” has just completed an open discussion on “Tips & Tricks” on Maximizing Outcomes with an OSA . Here is a consensus for all to ponder.

What was asked,

“It is well known that oral appliances do not effectively manage OSA 100% of the time. One of the determinants of success is the clinician’s knowledge of the various adjustments, strategies, approaches, techniques and protocols available. Let’s discuss our “Tips and Tricks” for those difficult cases that don’t respond to simply advancing the mandible…”

What was said,

This discussion took an unexpected but interesting detour. We intended to discuss “Tips & Tricks to Maximize Oral Appliance Outcomes”, which to me means “Reduction in AHI”.  However, it turned into “Tips & Tricks to Maximize a Sleep Disorders Dentists Outcomes”, which to me means the pursuit of the overall well being of the patient, NOT restricted to simply the reduction in AHI.  Much more interesting…

Mayoor Patel suggested altering vertical when mandibular advancement alone falls short. He also, investigates if the unresolved apnea is supine related and implements positional therapy when required, and investigates nasal patency and takes measures to correct when necessary.

As is customary with Shouresh Charkhandeh, he methodically and systematically shared his protocols starting with:
1) AP Titration/Calibration 

2) Sleep Hygiene & Life Style factors (Always) 

3) Adding a humidifier in the bedroom (I practice in AB and it’s really dry here) 

4) Nasal Patency e.g. Coblation, Soft Tissue Reduction, Nose Cones, Breathe Right strips 

5) More in depth review of Life Style Habits; Drinking & Smoking 

6) Weight loss 

7) CBT Referral 

8) And of course Last but not least; Refer back to the Sleep Specialist

A number of clinicians suggested the use of Nightlase as an adjunctive therapy (not primary). However, the lack of studies supporting its use was also pointed out. Don Malizia shared that the only papers he found are uncontrolled studies that measure snoring by questionnaire with no PSG. Don also pointed out that Mallampati score does not correlate well with OSA. Once again, we walk a fine line in the physician’s eyes when we use procedures that are not evidence based. Here are the studies Doncited,

Miracki, K. and Z. Vizintin (2013). “Nonsurgical minimally invasive Er: YAG laser snoring treatment.” Journal of the Laser and Health Academy 1: 36-41.

Svahnström, K. (2013). “Er: YAG Laser Treatment of Sleep-Disordered Breathing.” Journal of the Laser and Health Academy 2: 13-16.

Bins, S., T. D. Koster, A. H. de Heij, A. C. de Vries, A. B. van Pelt, M. C. J. Aarts, M. M. Rovers and G. J. M. G. van der Heijden (2011). “No Evidence for Diagnostic Value of Mallampati Score in Patients Suspected of

 Having Obstructive Sleep Apnea Syndrome.” Otolaryngology — Head and Neck Surgery 145(2): 199-203.

Hukins, C. (2010). “Mallampati Class Is Not Useful in the Clinical Assessment of Sleep Clinic Patients ” J Clin Sleep Med 6(4): 545-549.

Todd Morgan shared his hypothesis on vertical with us,

“In my quest to understand how vertical impacts the airway I have gone ‘back to school’ on anatomy and the hyoid. After a lot of that my hypothesis is that vertical principally affect the Infrahyoid muscles. In one of our studies we looked at the posterior airway space (PAS) and hyoid position when vertical was added in isolation. Mostly what we saw on cephs was a “smoothing” effect on the PAS mucosal outline that I associated to tracheal tug. Perhaps more interesting was the change in the angular orientation of the hyoid, which aligned more appropriately to reflect the muscle insertion for non-OSA patients (normals). We know that hyoid swings up and the MP-H distance shortens with mandibular advancement. But, with added vertical it also shifts in rotational relationship. The easiest muscle to understand is the geniohyoid, which should orient the hyoid and the lower anterior body of hyoid to its origin in the mandible. Anyway, I suggest looking at Hyoid bones and check out the ANGLE of the body to the Geniotubercle. Watch what adding vertical does. Don’t know whether the Infrahyoids are formally considered respiratory muscles, but they primarily act to stabilize against Suprahyoid contraction. Interesting that the Omohyoid does not exist in other mammals, nor does it have an analogous muscle. I can’t find any medical cases where Omohyoid is lost / injured / removed and what impact that may have. I doubt that the Vagus is involved but rather the Hypoglossal and Ansa Cervicalis Innervate. Very interesting anatomy here, not studied well.”

In addition to his attention to vertical, Todd is also working more and more with oropharyngeal exercises to improve muscle function using techniques originating from the speech pathologists. He experiences a 25-50% reduction in AHI with these exercises and finds them useful to improve OA outcomes.

Ka´tia C. Guimara˜es1, Luciano F. Drager1, Pedro R. Genta1, Bianca F. Marcondes1, and Geraldo Lorenzi-Filho1. Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome. Am. J Respir Crit Care Med Vol 179. pp 962–966, 2009

Depending on which sleep MD he is working with, Kent Smith suggests Osupplementation when O remains problematic. He also focuses on Sleep Hygiene, suggests a psychologist if insomnia is an issue and manages rostral fluids by promoting the use of bed wedges.

Promila Mehan feels that having the patient take ownership in their health and sleep issues is a key factor in their outcome success. She recommends specific physiotherapists, chiropractors, osteopaths, etc. to deal with their chronic pain issues. After exhausting her knowledge base she refers the patient back to the sleep physician again for further guidance and treatment options. Promila stressed the importance of setting realistic goals and expectations for both the patient and herself before fabricating the appliance, and the need for continuous learning – “Dr. Stasha Gominak’s talk on Vitamin D is very interesting”. She stressed communication, team-work, perseverance, knowing limits as a dentist and continued learning.

Dennis Marangos stressed the role weight loss can play as a permanent fix for many patients,

“If the BMI is reduced (even normalized) then it is amazing how the OSA is significantly reduced. Now we are aiming at structural causes that may aid in CURING the patient (CURE= Correct Underlying Reason for Error).”

Dennis has had at least 6 patients (so far all males) that have lost enough weight that they do not need appliances any longer. Working with physicians that specialize in Eastern and Western Medicine he has also helped many patients with chronic pain issues (and associated sleep issues). For an interesting read, Dennis recommends the book “Lights Out, Sleep, Sugar, and Survival” by T.S. Wiley.

Dan Bruce discussed inflammation and the effect “swelling” of the airway has on breathing. He tells patients that weight, reflux, post-nasal drip, etc. can cause the airway to shrink in size due to swelling of the surrounding tissues. This helps patients who are receptive understand that there are things they can control that can positively impact their outcomes. This is all after horizontal/vertical adjustment and nasal breathing/tongue posture has been addressed.

Tim Mickiewicz feels that the incidence of RERA’s rather than AHI should be the gold standard measurement. He feels that more time should be spent on breathing education, yoga is a standard referral in his practice as is mindfulness meditation. He plans to have his own yoga instructor on staff with a specialty in cervical posture and pain management.

For mouth breathers Steve Lamberg has had great success using 3M Micropore tape (Amazon) on patient’s lips to help them learn to breath nasally. In Steve’s words,

“They always look at me funny but I tell them to think of the tape as “training wheels” and that hopefully in a few weeks they will have developed the habit of nasal breathing.”

Steve explained that the antimicrobial effect of Nitric Oxide (NO) produced when you breath nasally reduces sinus problems and decreases nasal resistance.

“Breath through your nose so you can breath through your nose….sounds counterintuitive but try it”.

Steve also commented that we need to learn more about Functional Somatic Syndrome (FSS), and Anxiety Disorders, and how Chronic Allostatic Stress (wear and tear on the body which grows over time with repeated or chronic stress) on the system may cause an increase in Cyclic Alternating Patterns(CAP).

Daytime mouth breathing may in fact be that stress that sets this all in motion. If this is shown to be the case we should be counseling our patients to nasal breath 24/7 as much as possible.

“CAP related to UARS related to FSS, and I guess the ‘Chicken and the egg conundrum of which comes first’ may apply here, why not error on the side of impacting the daytime behaviour we know is somewhat controllable?

Insomnia also falls into this topic of FSS. Chronic, not acute variant. Studies out of the Mayo clinic last year revealed that 90% of patients presenting for chronic insomnia evaluation actually had at least mild apnea (they did not test for UARS).

In summary of Steve’s comments, he stressed that as dentists, we should pay more attention to Inspiratory Flow Limitation and that our goal is total body wellness and actually treating the patients Chief Complaints rather than simply treating the numbers.

Tony Soileau educates patients on the “fight or flight” response caused by sleep apnea, and how it keeps their cortisol levels high, promoting insulin resistance diabetes. He also refers them to a functional internist to help with weight loss. The internist performs a cortisol, vagus tone, and cell spectrum analysis. By testing for cortisol levels he can determine if the patient is not able to sleep at night, and most importantly why.

“Too much cortisol; that’s anxiety. Too little cortisol; that’s’ depression.”

Testing vagal tone provides information regarding the vagus nerves ability to mediate the cortisol response and the cell spectrum test provides information regarding the body’s response to cortisol levels.

However, Don Malizia had a different opinion on this issue,

“Cortisol levels have a complex and often non-linear relationship with psychiatric diagnoses. The various diagnoses are often co-morbid, and anti-depressants change the values. It is not accurate to say they vary linearly with diagnoses of DSM-IV.” Don provided citations to support his views,

Young, E. A., J. L. Abelson and O. G. Cameron (2004). “Effect of comorbid anxiety disorders on the Hypothalamic-Pituitary-Adrenal axis response to a social stressor in major depression.” Biological Psychiatry 56(2): 113-120.

Burke, H. M., M. C. Davis, C. Otte and D. C. Mohr (2005). “Depression and cortisol responses to psychological stress: a meta-analysis.” Psychoneuroendocrinology 30(9): 846-856.

Blackhart, G. C., L. A. Eckel and D. M. Tice (2007). “Salivary cortisol in response to acute social rejection and acceptance by peers.” Biological Psychology 75(3): 267-276.

Shea, A. K., D. L. Streiner, A. Fleming, M. V. Kamath, K. Broad and M. Steiner (2007). “The effect of depression, anxiety and early life trauma on the cortisol awakening response during pregnancy: Preliminary results.” Psychoneuroendocrinology 32(8): 1013-1020.

Mantella, R. C., M. A. Butters, J. A. Amico, S. Mazumdar, B. L. Rollman, A. E. Begley, C. F. Reynolds and E. J. Lenze (2008). “Salivary cortisol is associated with diagnosis and severity of late-life generalized anxiety disorder.” Psychoneuroendocrinology 33(6): 773-781.

King, N. M., J. Chambers, K. O’Donnell, S. R. Jayaweera, C. Williamson and V. A. Glover (2010). “Anxiety, depression and saliva cortisol in women with a medical disorder during pregnancy.” Archives of women’s mental health 13(4): 339-345.

O’Donovan, A., B. M. Hughes, G. M. Slavich, L. Lynch, M.-T. Cronin, C. O’Farrelly and K. M. Malone (2010). “Clinical anxiety, cortisol and interleukin-6: Evidence for specificity in emotion–biology relationships.” Brain, Behavior, and Immunity 24(7): 1074-1077.

Vreeburg, S. A., F. G. Zitman, J. van Pelt, R. H. DeRijk, J. C. M. Verhagen, R. van Dyck, W. J. G. Hoogendijk, J. H. Smit and B. W. J. H. Penninx (2010). “Salivary Cortisol Levels in Persons With and Without Different Anxiety Disorders.” Psychosomatic Medicine 72(4): 340-347.

Manthey, L., C. Leeds, E. J. Giltay, T. van Veen, S. A. Vreeburg, B. W. J. H. Penninx and F. G. Zitman (2011). “Antidepressant use and salivary cortisol in depressive and anxiety disorders.” European Neuropsychopharmacology 21(9): 691-699.

van Santen, A., S. A. Vreeburg, A. J. W. Van der Does, P. Spinhoven, F. G. Zitman and B. W. J. H. Penninx (2011). “Psychological traits and the cortisol awakening response: Results from the Netherlands Study of 

 Depression and Anxiety.” Psychoneuroendocrinology 36(2): 240-248.

Veen, G., I. M. van Vliet, R. H. DeRijk, E. J. Giltay, J. van Pelt and F. G. Zitman (2011). “Basal cortisol levels in relation to dimensions and DSM-IV categories of depression and anxiety.” Psychiatry Research 185(1–2): 121-128.

Salacz, P., G. Csukly, J. Haller and S. Valent (2012). “Association between subjective feelings of distress, plasma cortisol, anxiety, and depression in pregnant women.” European Journal of Obstetrics & Gynecology and Reproductive Biology 165(2): 225-230.

Mark Abramson joined in and discussed how the OASYS Oral/Nasal Airway System(TM) combines the management of Nasal Resistance with the management of Upper Airway collapsibility. He explained that the area of greatest restriction in the nose is the nasal valve and that ENT physicians evaluate nasal valve function by performing a diagnostic test called the “Cottle Maneuver”, during which they stretch the skin at the face so that the sides of the nose stretch and the nasal valves open. In fact, this is what the OASYS appliance does, it opens the nasal valve by performing the Cottle maneuver from inside the oral cavity. So, along with managing airway collapsibility through mandibular advancement, the OASYS also manages the nasal patency by dilating the nasal valve.

Mark also talked about his role as Consulting Associate Professor at Stanford University School of Medicine, and director of Stanford University Medical Centers mindfulness-based stress reduction clinic, which he founded 20 years ago. This program focus’s on the stress reaction and its effect on health and has led him to understand how sympathetic activation and vagal tone are an important biologic measurement in healthcare.

Mark explained that what we really need to measure as far as overall vagal tone is something called Heart Rate Variability (HRV). A healthy functioning heart and strong vagal tone allows the heart to fluctuate in its rhythm. When we’re very relaxed, inhalation results in a slight Sympathetic arousal, which speeds up the heart rate, and when we exhale there should be a Parasympathetic response, which allows the heart rate to slow down. In a broader sense, there is a 24-hour cycle of cortisol levels. Dr. David Spiegel who is head of the Stanford University Integrative Medicine Clinic conducted groundbreaking research demonstrating that when cancer patients are provided a community to share their feelings with like-minded individuals, they lived longer. Cortisol level goes up during sleep and is highest when we wake up in the morning. With continued stress during the day, and sympathetic arousal, this cortisol level does not drop and these individuals have higher mortality rates. So we should think of two different aspects of the overall global sympathetic or vagal tone and the arousal that happens when we have a sympathetic reaction to apnea during the night.

Mark provided a simple exercise to help us understand this concept, “Notice your overall tone of your body. Kind of like what level is your engine revving. I want you to take your thumb and forefinger and very slightly. Put your fingers onto your nasal valve just above the bolt of your nose and just apply a little pressure to increase the resistance a little bit and feel what happens to the tone of your body or the engine revving. Now take your fingers and put them on the facial skin lateral to the nose and stretch laterally performing the Cottle maneuver opening the nasal valve and notice what happens to your overall tone of your body.”

Don Malizia shared his views, “my reading of the current evidence base tells me that things are much more complex than described. For example it is not purely parasympathetic tone that describes optimal conditions but the “spread”, if you will, of HRV. Of course the HR change with breathing is the respiratory sinus arrhythmia. And it not so much an increase in SNS tone as it is the taking off of the vagal brake. Porges’ Vagal Paradox makes a simple measure of parasympathetic tone not useful, clinically. A complete understanding of the afferent vagal structure, and the dual efferent structures, NA and DMN are critical.” Don also provided some citations in support of his views…

Uijtdehaage, S. J. and J. F. Thayer (2000). “Accentuated antagonism in the control of human heart rate.” Clinical Autonomic Research 10(3): 107-110.

Mizuno, M., A. Kamiya, T. Kawada, T. Miyamoto, S. Shimizu, T. Shishido and M. Sugimachi (2008). “Accentuated antagonism in vagal heart rate control mediated through muscarinic potassium channels.” J Physiol Sci 58(6): 381-388.

Porges, S. W. (2009). “The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system.” Cleve Clin J Med 76 Suppl 2: S86-90.


Mark responded as follows,

“I appreciate that the discussion on physiology of relaxation is a very complex subject and my overview is a simplification of this. I reviewed the articles that you (Don) presented. It seems to me that these are more focused on the basic science focused on heart rate control. In my discussion, I am focusing on “top-down” control” of our physiology and general relaxation. In demonstrating how the underlying sympathetic drive is increased with nasal resistance to rev up the body to move air through the Starling resistor of the nasal valve and how the body can relax or ‘tone down’ with ease of respiratory flow. We have the tools to help our patients have a deeper, more relaxed sleep.”

Troy Pridgeon shared that his company has developed a system based on HRV and Respiration that provides an objective screening of sleep providing a great way to establish efficacy of treatment after the fact. Not having any exposure to this, I checked out the device Troy mentioned. You can find it at, very interesting. Referred to as CardioPulmonary Coupling (CPC), it utilizes the physiological changes that occur with sleep via the ANS through the hypothalamus. By integrating information from brain electrical activity, respiration and autonomic drives, it captures the essence of sleep. A quote from their website…

“CPC is a practical way to measure sleep disruption or sleep decline, it has advantages in access, ease of use, comfort, cost and trending. It is less reliant on interpretation of sleep staging by a trained technologist than PSG and more reliant on demonstrable stability of the electrocortical, respiratory and parasympathetic drives in sleep. This renders a simple metric of coupling, and a spectrogram of distribution over the night that is simple, intuitive and generated immediately after testing is complete.”

As mentioned above, this discussion took a turn (for the better) from what we set out to discuss. Some new and controversial areas were presented, and as usual, the discussion seemed to take place with enthusiasm, even though the literature may not be there (yet?). Nevertheless, it is clear that dentists involved in the management of OSA with an oral appliance see their role as much more than simple technicians that fashion, place and calibrate an appliance to reduce a test established parameter. They are viewing their patient as individuals with Chief Complaints (CC) that need to be resolved. For some, these CCs resolve with correction of that test established parameter, but, for others they do not. It’s simple; you can’t take the dentist out of the dentist! We have been trained to fix things, and that is how we are conducting ourselves in this arena also. I applaud the forward thinking clinicians that continue to advance this field, and the role we all play in the management of our sleep patients, and equally important, I encourage us to stay as close to the evidence as possible to maintain respect on our journey.

I would like to use Dan Tache’s insights to close this article,

“This is exactly where we need to go as a profession to both optimize our OSA patient’s response to therapy but just as important to reveal patients (both pediatric and adult) who are at increased risk for so many medical co-morbidities associated with sleep-related breathing disorders other than just Obstructive Sleep Apnea (OSA) which are rarely, if ever offered treatment including patients diagnosed with Upper Airway Resistance Syndrome (UARS) and “benign” snoring; both categories are also at risk for increased sympathetic tone and the associated co-morbid conditions consequent to patients who are chronically living in a General Adaptation Syndrome funk.”

Notwithstanding Don Malizia’s literature citations demonstrating poor support for some of these concepts, Dan believes dentist should maintain an awareness of these issues. The absence of documented OSA does not mean the patient is disease free. Patients exhibiting UARS or snoring may have sympathetic nervous system activation during sleep and that is a health risk for many diseases. Aside from some notable physicians such as Drs. Guilleminault, Gold and Rapaport, many medical colleagues still refuse to see anything less than OSA as problematic, leaving dentists to manage these issues.

Dan explained his protocols,

“When we are titrating and testing and re-testing, we certainly want to reduce Respiratory Indices of AHI to <5/hr and SpO2 <90%TST TO <1.0% but when that is achieved, a quick review of your patient’s PMH is warranted before you consider your patient to be adequately treated. If they have anxiety, IBS, depression, hypertension, fibromyalgia etc., we need to make certain that we have “maximized” their response to treatment by tracking more subtle indices. RERAs and Inspiratory Flow Limitation, often reported as an elevated flattening index (>60/hr) and if your HST monitor does not provide these sorts of indices in the report, and the patient does have a co-morbidities, a brief look at the flow-form characteristics or in the case where your HST utilizes peripheral arterial tone, the raw data is also very revealing; look for signal attenuation with rises in SpO2 which accompany increasing sympathetic tone. If you see these indices, subtle though they may seem to be, even if the AHI is within normal limits, go ahead and do more titration with additional advancement, or increasing vertical and/or paying attention to their ability to breathe nasally or not; clean this up and you will have truly made a significant contribution to their health because that oral airway device is now optimized! If our profession does not lead the way and complete treatment in this manner, it is likely never to be addressed.”

Guilleminault, C. e. (2005). Heart rate variability, sympathetic and vagal balance and EEG arousals in upper airway resistance and mild obstructive sleep apnea syndromes. Sleep medicine, 6(5), 451-457.

Hedner, J. e. (1988). Is high and fluctuating muscle nerve sympathetic activity in the sleep apnoea syndrome of pathogenetic importance for the development of hypertension? Journal of Hypertension, 6(4), S529-531.

Julu, P. O. (2001). Characterisation of breathing and associated central autonomic dysfunction in the Rett disorder. Archives of disease in childhood, 85(1), 29-37.

Marchesini, G. P. (2004). Snoring, hypertension and type 2 diabetes in obesity. Protection by physical activity. Journal of endocrinological investigation, 27(2), 150-157.

Palombini, L. e. (2011). Upper airway resistance syndrome: still not recognized and not treated. Sleep Sci, 4(2), 72-78.

Once again, I would like to thank all those clinicians that took the time to participate in this discussion, this consensus article is intended to provide guidance for those that are new to this area of practice and also to provide valuable insights for those of us that have been at this a while. I look forward to your participation in future SleepDisordersDentistry LinkedIn discussions.


John Viviano B.Sc. DDS Diplomate ABDSM

John Viviano B.Sc. DDS Diplomate ABDSM

John Viviano B.Sc. DDS Diplomate ABDSM; from Mississauga ON Canada,obtained his credentials from U of T in 1983, he provides conservative therapy for snoring and sleep apnea and Sleep Bruxism in his clinic, Limited to the Management of Breathing Related Sleep Disorders. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally regarding management of Sleep-Disordered Breathing and the use of Acoustic Reflection. Dr Viviano has also conducted original research, authored articles and established protocols on the use of Acoustic Reflection for assessing the Upper Airway and its Normalization. For more info or to contact Dr Viviano click: Website SleepDisordersDentistry LinkedIn Discussion Group

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