Hey everyone, welcome. My name is Dr. Christopher Hart and this is Screening for Sleep-Related Breathing Disorders in the General Dental Practice Part 2. We here at the American Academy of Dental Sleep Medicine are glad to have you for this presentation and we are excited to come alongside you as dental professionals and to share how you can have an even greater impact on the lives and health of your patients. First of all, I want to say thank you to Dr. Jeff Horwitz for his great contributions to the first part of this lecture. He has a wealth of knowledge and experience, so thank you Jeff. That was great content. Well, I'm a general dentist and I practice in Mitchell, South Dakota. I practice dental sleep medicine in addition to general dentistry. I have the qualified dentist designation from the American Academy of Dental Sleep Medicine and I'm a diplomate with the American Board of Dental Sleep Medicine along with some other designations that you can see here, but I've been in dentistry for almost 25 years and I've been providing dental sleep medicine treatment for just a little over a decade now. As I mentioned, we are excited to give you some great content today on what is a health crisis and what you as dental professionals can do to help your patients and their loved ones. As Jeff mentioned earlier, this is truly a crisis of the undiagnosed. You're coming across people that have undiagnosed sleep disorders every single day. In dental school, we spend hours learning how to perform exams and screen for things like oral cancer. We studied and memorized survival rates and treatments. There's all kinds of tests and screenings that we can use to screen for things like oral cancer, but how often do we actually come across it? Well, not very often and don't get me wrong, every second that we spend for oral cancer is absolutely worth it, but what we're sharing with you today is something that you will most likely come across almost every single day of your practice and that is undiagnosed sleep-related breathing disorders. One of the most common of them being obstructive sleep apnea. So before we jump in, these are the objectives that I want to accomplish with you today. At the conclusion of this lecture, I want to be able to help you to equip and empower your team members and your practice to participate in screening patients for sleep-related breathing disorders or SRBD for short. I want to be able to help you to take protocols that are easy, effective, and efficient and implement them into your routine exams and daily practice just as it is. I want to help you to know how SRBDs in kids are screened for and treated differently, to know how to document findings and refer patients that you suspect may be dealing with an SRBD, and finally I want to give you some resources that the AADSM has to offer you if you need some more information or if you want to grow in your knowledge and understanding of SRBDs. Okay, so first of all we're going to discuss screening and that's really the important first step, right? Knowing how to screen patients during our routine evaluations can be very easy but so important. Now I know most professionals watching this may already have some education and knowledge about SRBDs but what I want to do is give you a very easy but effective screening tool, tools that are going to help you to accomplish this. That is why I have a picture of the one-minute timer here because even though we are going over a lot of valuable information in a small amount of time, I want you to be able to walk away from this presentation knowing that this does not need to add much to your already busy exam. I would say the vast majority of your time screening should really take less than 60 seconds on average, and that includes your communication with your team member. So if we can make this easy, I think the more people you're going to be able to help. Screening and treating or referring for SRBDs will be most effectively and efficiently accomplished with a team approach. As I mentioned, as dentists, we are looking at many things in that small window of time that we do an exam. We're performing head and neck exam, looking for caries, evaluating periodontal health. We're looking at radiographs, maybe discussing digital scans. If you're new to adding screening for sleep disorders, it can feel like an even greater squeeze for time in an already packed appointment. So how do we accommodate for just one more thing? Well, just as we do with most everything else we do in our practice, we need to rely on our team members to help us. We need a team approach. An example I like to use when I'm teaching about screening for sleep disorders is, what are the processes that we use when we see most pathologies that are going to be referred out? Well, granted, you may perform some biopsies in your practice, but when there's something that you see that's really concerning, you don't hesitate to refer it out. You don't freeze up because you don't know if it's a problem or not or what you might be doing about it or what might be done about it at the specialist. You just decide that a diagnosis is needed. Your hygienist might bring something to your attention. You confirm that it looks concerning and the team pretty much takes care of the rest. The same should really be true for suspected sleep disorders. Screening and referring should not be time-consuming, so have your hygienist and assistants learn alongside you. When you see signs of an SRBD, point it out to your team member and encourage them to also look for these things as well, especially your hygienist. Ideally, your hygienist will beat you to the punch and will already have done most of the legwork for you and will give you a heads up before you've even looked into the mouth. Furthermore, have your business team have some pre-formatted letters ready to fill in for any communication with doctors that you refer to and utilize them to help streamline this process of referring. Now, considering the fact that so many people suffer from obstructive sleep apnea or other SRBDs, most team members have some kind of awareness or might even have a loved one that suffers from these disorders and therefore they love helping to alert, educate, and help people. It's also a different aspect to their job that provides a little diversity in what they normally do and there's a lot of satisfaction that comes from it because it's truly improving and changing lives. So these are some screening methods that we're going to discuss today. First, screening questions or forms. These are very short and brief forms that can easily be added into a medical history. There's the clinical exam. I'm going to give you some things to look for when you're performing your clinical exam and then follow-up questions if needed. We're going to just briefly touch on how to use some of these follow-up questions if you're unsure if there's a concern for a possible SRBD. The first screening method I'm going to share with you is screening questionnaires and forms. I wanted to discuss this one first because in many offices these types of screening questions are already included in medical history forms and therefore are often the first place we go to when we're alerted that there's a potential sleep disorder that may exist. It's a very easy way to have someone potentially self-identify a potential disorder before you've even interacted with the patient. These are the three screening forms that I'm going to be briefly discussing with you. As with everything we're discussing today, these are very easy and the first two specifically are historically very effective and also the most commonly used in the medical community. The first one is the Epworth scale. If you choose only one, I would choose this because it's easily the most commonly used. The specialists that I work with use this one universally. One of the reasons is that many medical insurance companies require this score to communicate the severity of symptoms. Insurance companies want a diagnosis. They want that hard data indicating the severity, but they also want to know that this patient's condition is actually having a negative impact on their life. This score speaks directly to that. The next one is the stop bang, another very common one. I would not hesitate to use this one either if you like it better. The beauty of having a few simple questions in this form, or the Epworth for that matter, is that it provides a very simple picture of this patient's subjective or reported symptoms. This combined with a few clinical observation really creates a clear picture that there may be something going on here and it really justifies, helps to justify further observation or investigation. Now I've added this one because sometimes there are certain things that we like to focus on or things that other questionnaires might leave out. So some of you might find it more easy to create your own, maybe make it more dental specific. So creating your own questionnaire can make record-keeping even more streamlined as well. Next we have the clinical exam. This is the good stuff that really sets us apart in the identification of patients who are struggling with sleep disorders. This specifically is where dental professionals do a huge service for the population in identifying patients that might otherwise slip through the cracks and go undiagnosed. When you think of someone having sleep apnea, a lot of people think of that overweight male who's over 50 snoring away in the easy chair and that that's a very common misperception even in the medical world. I have seen that SRBDs like obstructive sleep apnea present in people of all shapes, sizes, ages, and genders. I have a relative that's a young middle-aged 5'4 active healthy woman who actually suffers from severe sleep apnea. So the adage is true, you can't always judge a book by its cover. Now when we observe the clinical signs that we are looking at here, does it mean that the patient has a sleep disorder if these things are present? No it doesn't. These clinical signs are not diagnostic. Just like seeing a very odd lesion in the mouth does not mean that they have oral cancer. Now do they need to have all of these signs clinically if they have a sleep disorder? Again, they do not. So what do we do with these clinical observations? Well I see them as red flags. The more I see, the more I'm suspicious. As soon as I see even a couple, I start to conclude that we need to find out more information from either some follow-up questions or refer for a diagnosis. And I will add too that these signs that we're discussing today are very telltale signs. These signs may not be diagnostic, but they are pretty loud and clear warnings that it's likely that something is going on. First one is the Malampati classification 1 through 4. I have the screening method first because it's often the first thing I do. It takes seconds. If someone has a Malampati score of 3 or 4, that's the first red flag that goes up for me. And I'll be paying particularly close attention for the other potential red flags. This score is valuable not only for communicating with physicians, but also from the perspective of using it with patients to educate them on why we're concerned. When I communicate with patients, I will usually start with the fact that it was the size of the airway opening that first caught my attention. When you tell them it looks like the roof of their mouth dead ends on their tongue, that's a pretty clear way of communicating that it's a pretty tight fit back there. To perform this test, just have the patient stick out their tongue and observe. Make sure you avoid depressing the tongue as we do when we're observing the pharyngeal area. The next one is the pharyngeal grading again 1 through 4. A little different than the Malampati, it's looking more specifically at the palatal pharyngeal arch. And again, you can use this for recording your findings and your documentation that you might communicate when you refer. Crowding and narrow arches. The mouth is one of the first entries to the airway, so it just makes sense. If it's narrow, then the tongue often gets posteriorly positioned, increasing the collapsibility of the airway, especially when patients are laying in the supine position on their back when they're sleeping. An anterior open bite, diastemas, now this might be the exact opposite of narrow dental arches. These diastemas between the front teeth can result from tongue thrusting, which is often just an effort from the body to improve the airway volume. Anytime you see someone with that tongue hanging forward, sticking out in between the arches or in between their front teeth, that person is most likely suffering from a sleep disorder. Imagine the struggles a patient like this would have when they're laying on their back. Erosion. Here's a very common one. Often from nocturnal acid reflux or GERD. It's often associated with obstructive sleep apnea. As patients struggle to breathe, gastric juices make their way up the esophagus. Some of it being aerosolized as the diaphragm is actively working to get air into the body. About 60% of OSA patients have GERD, and some researchers actually believe that for some patients the GERD is the cause of their OSA. You can see the telltale signs in this picture of one of my patients on the far right. How many times have we seen these little craters? For years we we wrote it off as just some aggressive wear. Well, when the two teeth grind back and forth, it will usually create a flat surface, but once that dentin is exposed, acid will have a much more destructive effect on the dentin than it does on the enamel, therefore creating those little craters. It's not uncommon to see a very glassy finish around these areas as well as a result of that acid. A vaulted palate. Another sign. Not only is it a sign of narrow opening to the airway, but it affects nasal cavity volume, and since the tongue helps to shape and expand the palate during growth, it may actually be a sign of some tethering of the tongue as well. That can impact the airway if the tongue, again, is not allowed to rest in a more anterior position. That can also contribute to collapsing of the airway by the base of the tongue. Now, most of these pictures I'm going to show you are actually from my patients, except for maybe one or two. Dr. Jeff shared one with me. But you can see in this picture in the middle, this narrow arch is from a patient of mine that just came in for a routine periodic exam. She had no idea that her malocclusion was pointing to the fact that she had a sleep disorder. She was, she obviously, we got her tested and then she's now getting treatment. We approached her treatment from many different aspects that has improved everything from not just her sleep and her health, but even her overall appearance. Very life-changing stuff. Bruxism and clenching. We know a lot about this. When the body, though, as it relates to a sleep disorder, is not getting enough oxygen, our sympathetic nervous system is going to do everything it can to keep the body alive. And as the body goes through different stages of sleep, the body's muscles will often become paralyzed as part of helping the body to rest and recover. In people with obstructive sleep apnea, this can contribute to collapsing of the airway, that paralyzing effect, because part of the airway is defined by musculature. So when this paralyzing effect occurs, it can result in increased obstruction of the airway, making matters worse. So this is where the bruxism and clenching come in. The bruxism, the grinding, the clenching is part of that process that the body uses to bring that, bring the body out of that state of sleep so that the body can breathe better again. This is a hypoxia-induced sympathetic response, fight-or-flight. Attrition, abfractions, again, very similar. This is some of the destructive effects related to that bruxism and clenching. Now the bony architecture, like palatorae or mandibular exostoses, just as bones in your arm respond to stress when you lift weights, the bone in your jaws also respond as well to stress. And this is where we see the overgrowth of the tori and exostoses. And as with all these signs, just because you see this present doesn't mean that they have an SRBD, but I will say that the vast majority of my sleep patients exhibit these things that you're seeing on the slide. So when I see these things, I am definitely on high alert and doing some more investigation. The tongue. The tongue can obviously be a problem, as we just discussed. If the car is too big for the garage, it can't fit, so it's got to go somewhere. So it's squeezing in between the teeth, creating those scalloped shapes, and that's a very telltale sign. What's happening when this occurs is that tongue is being positioned posteriorly, contributing to a greater collapse, as we discussed earlier. And here's a tongue grading system that you can use for your documentation as well. Finally, I'm going to briefly discuss the value of some possible follow-up questions as part of your screening, if you need. Sometimes we are not sure what we're dealing with exactly, so a couple of follow-up questions might be helpful. For example, if I'm not seeing really strong answers on my screening form or in the med history, I might ask a couple of questions just to flush it out a little bit more. I might ask something like, after a normal seven to eight hour night of sleep, do you get up pretty easily, ready to take on the day, or are you kind of dragging, reaching for the caffeine? I might also ask, how are you doing mid-afternoon? Are you reaching for caffeine, or do you feel pretty good? Questions like these can easily help you to lean one way or the other in your assessment for a possible sleep disorder. Again, it's not up to you to diagnose, just try to give the patient some guidance. So a referral is never a bad option. We're all accustomed to keeping our documentation and charts up to date, so this would really not be too difficult. In my office, we include it in the section where we document findings from our head and neck exam. We do have a specific section that's designated for sleep, but you can do what works best for you. Just make sure you get your findings in the chart. And as a side note, as a dentist who treats sleep disorders, we do put exams that are specifically for sleep consultations in the soap note form. So at some point in time, if you decide to pursue education in treating sleep disorders, putting it in a soap note form will help in your consultation with your medical colleagues and for medical insurance purposes. So once we have a patient with a suspected SRBD, this is how we can take action. If you don't have a referral pad for any of these providers, all it takes is a simple letter documenting your findings and concerns. If you think that the patient would be a good candidate or is interested in oral appliance therapy, a dentist that has been trained in treating sleep disorders is a great place to refer. A dentist that has been trained in dental sleep medicine will still work with the patient's physician, but they also have a network of specialists to work with. They'll also typically have additional patient education and treatment methods to complement their oral appliance treatment. I'll also add that for some dentists, it can sort of feel like a risk referring one of their patients to another dentist. I'll just say that every dental sleep medicine provider I know loves what they do and would love nothing more than to practice as much dental sleep medicine as possible. So we would never want to jeopardize that opportunity to help more patients suffering from sleep disorders. So that's a relationship that I know would always be respected. A sleep physician can obviously evaluate for and treat sleep disorders, but ENTs do as well. And many ENTs are actually board certified specifically in treating sleep disorders. They also have the added benefit of evaluating other contributing factors such as sinus problems. My experience has been, it all depends on the ENT's area of training and interest. So if you're not really sure who to refer to, a dentist, again, trained in dental sleep medicine would be a great resource for referrals. Sometimes patients may want to discuss a potential sleep disorder with their primary medical provider first. So in that situation, I would just send them the information just as I would a specialist. The only caveat is that I would add that although specialists are often aware of the importance of oral appliance therapy as described by the American Academy of Sleep Medicine, which is a physician's organization, many primary care providers are not quite as familiar with oral appliance therapy. So if oral appliance therapy is something that patient is interested in or that you want them to have, encourage them to really share that desire with the provider. Now Jeff did a great job of discussing and demonstrating the pathophysiology of the airway obstruction that occurs in obstructive sleep apnea. So the primary focus of treatment is, of course, to find, as we know from that, a way to open the obstruction. Now although the goal of this presentation is to focus mainly on screening, not treating, I think it is helpful to just be aware of what some treatment options might be. The first treatment option, of course, we're going to discuss is oral appliance therapy by a trained dentist. Now this dentist, like I said, will be knowledgeable about many aspects of sleep disorders. The American Academy of Sleep Medicine gives us some guidelines for oral appliance therapy. Number one, that the appliance is custom fit for the patient. Number two, the appliance is titratable because there's no really one position that works for all patients. So it really takes someone who has some experience in this. Number three, the appliance is fabricated by a trained and qualified dentist in the area of dental sleep medicine. Some of the benefits of working with a dentist like this or getting the training yourself is that this dentist will have a network of specialists, like we mentioned, to work with. They're often able to utilize sleep studies from the physician to aid in treatment and evaluation of the efficacy of the treatment. They're also knowledgeable in the strengths of different types of appliances. And from a clinical perspective, one of the most important aspects of appliance delivery is being trained in managing and preventing unwanted side effects to the patient's occlusion or TMJ with oral appliance therapy. So one of the benefits of getting trained and working with someone who has trained in DSM is being knowledgeable about medical insurance as well. The ins and outs, what's required for documentation, and the type of appliances that are actually considered to be true medical devices is important to some insurance policies as well. Now CPAP is a very common form of treatment for sleep disorders. The obstruction that Jeff showed us earlier is treated with machines like a CPAP by essentially inflating the airway in a way that creates a positive pressure system so that then air can be exchanged. It's very effective and some people use it with no problem at all. The challenge with this treatment though is that usually only 50% of people are able to tolerate it and usually not even through the entire night. The worst part is that very often people who can't tolerate it sometimes do not find another form of treatment such as oral appliance therapy or surgery and therefore go untreated. It is very, very important to let patients know that there are other options. We will discuss surgery. That's another option. There are various types of soft tissue reconstruction, laser therapy that can be performed to aid in treatment, especially in the area of the soft palate and there are some surgical procedures like the hypoglossal nerve stimulator which has had a lot of success, but a lot of times those will require a trial of oral appliance therapy or CPAP first before being approved to have that surgery performed. And finally there are a lot of adjuncts that we use for treatment. Things like nasal dilators, sinus rinses and even possibly medication. Sleep studies often give us information on how to utilize positional therapy for the best sleep position. Orthodontics is really valuable as well. If a patient has narrow arches, they will no doubt benefit from better occlusion, but it also gives their tongue more space to rest. Next we're going to be discussing our pediatric patients. I love treating and helping people with their sleep disorders. It's one of my favorite things to do and as much satisfaction as we get in helping adults, helping kids is even more satisfying because you're helping someone who knows really nothing different from their current experience. They often don't realize that they even need help. So you're not only helping those kids, but you're also helping their parents because the parents often know that their child is struggling with something, but often do not know what it is that's wrong or really how to get the help that their child needs. I'm going to show you a screening form here to start with because communication with children obviously has a few more challenges than necessarily with our adult patients. So a screening form is very helpful in uncovering potential sleep disorders in kids. It's an excellent tool for not only helping us to uncover these potential signs, but for some parents, for them, they themselves to discover that there might be a problem that they weren't even aware of. It's an easy way for the parent to open up a discussion about maybe their concerns or for you to discuss the concerns that you see with them. It's easy to do. They can do it while the child is in the chair and then either you, your hygienist or your assistant can review it. It's easy to do and can make a huge difference in the trajectory of a child's life. Here's another little questionnaire, just a little shorter list of questions that you can use, anything to get that conversation started. We're going to use the same format we just used for adult patients, but I'm going to point out both some similarities and some unique differences in regards to these areas as it relates to pediatric patients. Before I get into it though, I want to give you a word of encouragement about pediatric patients and that's advocate, advocate, advocate, advocate. Treating sleep disorders in adults is rewarding. It helps them to live a better life, but the biggest difference with kids is that their treatment may actually help them to avoid needing treatment when they're adults. So if you see something, inform the patient and advocate for this child. If you saw a mouthful of decay, you would not hesitate to have that conversation with the parent. Sometimes parents just don't know what normal is and what it isn't. However, many parents do know something is wrong. They see it, they hear it, but most importantly, they feel it. They can sense that something is not right with their child. They may have even had a medical professional or multiple ones tell them that their child will just outgrow it. You might be the voice of hope for that parent and might be the first person to give legitimacy to their concerns, maybe for the first time. Medical professionals will provide stimulants. We often label children as just troubled. Sometimes we just think that they're either low energy or hyperactive or maybe both at times. In reality, sometimes they're just not getting enough sleep and that is keeping them from functioning properly. Here are some clinical signs that are very similar in presentation and causation to adults. Again, clenching, bruxism, tongue thrusting, diastemas, daytime sleepiness, especially in the afternoon or in the car, snoring, mouth breathing, narrow arches, very similar things. As I said, for years in dentistry and in medicine, we've often seen these signs of sleep disorders and we've just written them off saying, well, they'll outgrow it. These are signs and alerts that there's really something going on here in these little mouths and these little airways. Now here are some clinical signs and symptoms that are a little more unique to children. I'll list them off here. Bedwetting, more pronounced mouth breathing, adenoid facies, more obvious and disruptive behavior struggles or disorders such as ADHD symptoms and large tonsils are definitely more common. Difficulty staying asleep through the entire night, malocclusion, some of the malocclusion may be similar to what we see in an adult but often have a more obvious presentation such as cross bites or anterior opening of the incisors due to tongue thrusting. Malocclusion is sometimes more pronounced like I mentioned and if these things are present, it generally means that the child either does or this is what's different, did have a breathing problem or sleep disorder. Maybe some of these clinical signs that we're seeing were perhaps from before they had their tonsils out. That's why it's good to have some follow up questions when you're discussing this with the parents. The malocclusion can still be corrected but it may not necessarily be corrected for sleep purposes so keep that in mind. If you don't remember anything else about pediatrics, I want to show you again that tip that Jeff shared earlier, the three C's, cross bites, crowding and constricted arches. If you see these, ask the parent and do a little further investigation. With referrals, I will continue to stress advocating for the child. Years ago, I really had to fight to get physicians to consider tonsillectomies. I would often hear parents come back to me and say, well my child hasn't had strep throat often enough to justify removing them or the parent will say, I was told it was normal for kids to grind their teeth and he most likely has ADHD. Once you begin to see these signs and see the results from kids getting help, it will give you more confidence to advocate for them. Thankfully, the pendulum has swung the other way and the medical community is taking a harder look at sleep disorders, especially in children. Now if I refer a child for evaluation, they usually agree, the medical professionals do with my concerns or I know that they will at least give treatment a strong consideration even if they've never had strep throat. So thankfully, we're not having that fight as much but keep that in mind when you are referring to just encourage that parent to advocate for their child when they're communicating with the medical professional. Regarding potential pediatric sleep disorder, there are really two common aspects to consider when evaluating pediatric patients. Number one, addressing their specific sleep concerns and number two, their orthodontic needs. For addressing sleep specific concerns, I'll usually refer to an ENT as I usually have a more consistent experience when referring for sleep concerns. They're also able to address one of the most common causes of sleep disorders for children and that's the tonsils and adenoids. However, if I have a good relationship and I know their primary care provider, I'll also consider referring to them as well. Pediatric sleep physicians are an option but they're generally more difficult to get access to but whoever you refer to, be clear with the physician about both the clinical signs and the reported symptoms that you're hoping to address. For the orthodontic needs, I would recommend a dentist or an orthodontist trained in addressing sleep disorders. Communicate with that doctor that you are concerned about potential airway issues and again just as in the medical field, there are a variety of opinions in the orthodontic world as well. So make sure you're working with someone that will listen to both yours and the parent's concerns. Pediatric treatment can really vary compared to adults, especially since we're dealing with a growing body. Some of the most common treatment for our pediatric patients is tonsil and adenoid removal. Orthodontics can be useful as well. With early intervention, you can help to address crowding and arch development. There are also surgical options that may include things like frenectomies. Functional appliances can help. Those work well because children are growing and those can address orthodontic space issues, in addition to airway issues. Myofunctional therapy can be used to help in a number of different ways to address airway issues. Medications such as topical nasal steroids are really helpful in helping to ease some of the sleep apnea symptoms for children. The nice thing is you don't have to decide how to treat it. It's just important that you are there to advocate for the child and get the ball rolling. Now I have just a couple more things before we wrap up this portion of the presentation, but I want to share with you my own personal obstructive sleep apnea story. For years, I was struggling with getting enough sleep. I would take two to three hour naps with my kids every Saturday and Sunday. I have five kids, so I could do this for years. Even in dental school, I would sneak out to my car for naps during lab time and get a quick 45 minute nap in the backseat of my car. I actually had a pillow and a sleeping bag in the back of my car. I was healthy, active, I was not overweight, but as a result of some continuing education that I took, I became interested in sleep disorders and I got a sleep test. I realized that I had obstructive sleep apnea and I've been using an oral appliance for years now and it's changed my life. It was never really the amount of sleep that was the problem, it was the quality of sleep. Even though I am saddened by lost hours and weekends from all those naps and missed out on some increased quality of life that I could have enjoyed, I'm very thankful now to be living better than I've lived in years and I still might get a nap in once in a while if one of my kids requests it. Your patients will share similar stories as well. Here are a few stories from our patients that we hear. We can sleep in the same bed again. We like to say that we're saving marriages every day. My doctor says that my blood pressure has gone down. I feel I have more energy and I'm more alert during the day. I can watch movies again without falling asleep. I'm thinking much more clearly. One patient said I jumped right out of bed right after the first night of wearing their oral appliance. If your advice had been taken sooner, I would not have had a heart attack and that was from a patient that I had been really encouraging to get treatment. To be honest with you, it was getting delayed mostly from the medical side and they ended up having a heart attack. Glad we could still get that patient though treated before it was too late. In summary, I will keep it simple. As a team, screen, inform, and refer. In less than 60 seconds, you truly can change a patient's life. We're not talking about just one or two a year. You can do this on a weekly and even daily basis. If you would like to learn more about dental sleep medicine, here are some great articles for you that I think you would like. There is a link on here as well. Here is the AADSM website. Tons of good information on here as well as learning about opportunities on how to get more education and training in the area of dental sleep medicine. Thank you very much for your time today and for learning about screening for sleep-related breathing disorders. I know that lives will be changed and saved as a result of your time here today. Thank you very much and God bless.

sleep-related breathing disorders

dental practice

screening

obstructive sleep apnea

pediatric patients

screening methods

team approach