Welcome everyone. I'm Dr. Claire McGorry. I'm moderator for this evening's webinar on the top 10 articles in dental sleep medicine. I'm joined with our speaker, Jean-Francois Maas. And finally, the AADSM does not endorse any service, products, devices, or appliances. The use, mention, or depiction of any service, product, device, or appliance during this webinar should not be interpreted as an endorsement, a recommendation, or preference by the AADSM. Any opinions expressed or communicated regarding any product, device, or appliance during the webinar is solely the opinion of the individual expressing or communicating that opinion and not of the AADSM. Whenever possible, presentations should be supported by evidence. In instances where evidence is lacking, speakers have been asked to verbally disclose that their presentation is case-based or based on clinical experiences so that you can use independent clinical judgment to make decisions for your practice and patients. And now I'll turn it over to Dr. Maas. Well, thank you, Claire. Well, thank you everyone for coming here tonight. The beautiful weather here in Quebec City. It's sunny and it's about 72 degrees. I hope the weather is as good where you live. And thank you to the Academy for inviting me to make this presentation on the top 10 articles in dental sleep medicine. These are the top 10 articles of last year. Now, moving on. Next slide, please. I have no conflict of interest whatsoever. I've done this before. I did the same presentation last year at the Canadian Sleep Society. I had to review the year's previous papers, scientific papers, and present the top papers of the year. What I had done then, I had to review 700 different papers and really enjoyed it. Even though it's time-consuming, I felt that it was giving me an edge to what was coming up as far as research was concerned. The problem with that kind of review is that there's what we call an inherent bias. The papers that I selected were the papers that I liked. And obviously, probably not to the taste of everyone in attendance. This year, I've changed my strategy. I've asked 10 different people who happened to read a lot of scientific papers what their best paper was. I went to them and asked them, provide me with one paper that's not one that you've published yourself and you think is really worth looking at for my attendees. It's either educational or scientific. We've been lucky. I've asked them in person and they all said yes. The problem with these papers is they all deserve a one-hour presentation and they're going to have four minutes each. But if you're interested, you will have those papers in your handouts and you can look at those papers by yourself then after. Moving on. Thank you. We have Dr. Gilles Leving's paper. Dr. Leving doesn't need any introduction. He's a professor at the University of Montreal and he just got nominated to be a professor at McGill University as well. Dr. Leving came with this paper called International Consensus Statement on Obstructive Sleep Apnea. It was accepted, as you can see on the slide, in August of 2022, but published in 2023, so it fits. This is a paper that is the most recent knowledge on everything on OSA. It's quite long. It's 423 pages and they've decided to put six pages on sleep appliances. Those six pages were divided in two. Half of the pages, three pages, are on TRDs, which I felt was a bit outdated and I decided not to tell you about, and the other three pages are on oral de-manipulator advancement devices. Next slide, please. What you see here is what the sleep doctors are going to read. The doctors that I'm dealing with and the doctors you are dealing with are usually very literate as far as oral appliances are concerned. The doctors that I work with in Quebec City, they know the different brands, they know how to titrate, they know how to manage some of the problems, and they don't need that kind of introduction. But let's say a group of sleep doctors want to include your services in their portfolio of services. Well, chances are, if they want to have a quick reference, this is what they're going to be looking at. So nothing really new. Next slide, please. Thank you. It's recommended for patients with mild to moderate OSA, intolerant or refuse to CPAP therapy. This sounds like the 2006 or 2007 joint publication of the AADSM and AASM guideline practice. But, you know, it's based on the review of literature, and what they looked at is meta-analysis and systematic reviews. This is what you get when you go through that path, but it's information that's based on rock-solid evidence. Next slide, please. So for your information, in case you forgot, there's some significant differences when you treat a non-treated patient, you treat that patient with oral appliance. It says that modest effect on reducing blood pressure. I've read some people call it a very big effect. It depends on the perspective, I suppose. And if you look at the last line, it says comparative effectiveness. It's less effective than CPAP, obviously, as far as index correction is concerned, but better tolerated by patients. And this makes a big difference. I think we're not at the point in the sleep science where we only look at AHI. AHI is one metric among a lot of metrics. And obviously, if the CPAP is more effective at correcting AHI, but is not being used because it's not tolerated, it's under the bed, I think the oral appliance is a much better choice. When we look at concepts like mean disease alleviation that were brought up by Peter Sistuli, you better have an oral appliance that works a little less on reducing AHI, but is worn all night rather than a CPAP that's worn two, three hours a night. Next slide, please. So comparison to CPAP, as I just said, adherence is maybe better. It's much better, actually. And some patients prefer MRDs due to comfort. This is obvious. So that means that if the doctors are reading this, there's still a lot of education that needs to be done by us dentists. Next slide, please. Patient selection, obviously, most effective for patients with mild to moderate OSA. We know that it works really well for patients with severe OSA, depending on the cases, and the customization is very important for an optimal fit, obviously, meaning that you can't, ideally, you can't buy an appliance from Amazon or Alibaba. Next slide, please. Common side effects, dental jaw discomfort, we know all of this, and temporomandibular joint issues, potential discomfort or pain. I was happy to read that they included in the paper a statement saying that in accordance to what the 2017 side effect consensus paper from the ADSM came up with, the TMJ problems, well, it happens once in a while, not very often, but more often than not, we can control these and get rid of these in the long run. Next slide, please. So follow-up adjustments, that means that the dentists and medical doctors are expecting us to follow up with the patients, the patients that they're referring us. So next slide, please. So as a conclusion, lots of education that needs to be done by the dentists to the medical doctors. You can't expect, provided the fact that we've asked different specialists, this presentation will not be about sleep appliances. It would have been very tempting to talk about Olivier van der Beekhuyzen's last publication where he compares the somnodent event to the somnodent flex, but this is not what this is about. And hopefully the presentation today you'll find interesting. Fernanda Almeida, she doesn't need any presentation herself as well. Very well known, very, very, very good researcher. Fernanda decided to suggest this paper, novel therapies for preventing, managing, and treating obstructive sleep apnea and snoring in pediatric and adult patients. This is a paper I was involved with as a co-chair. It's been published in April of this year in the JDSM. I think it's a paper that's going to age well, even though not the most useful paper for the clinical practice. Next slide, please. So the problem or the situation is that the scope of dental sleep medicine is evolving, not only dental sleep medicine, but sleep itself. The things that are happening with CPAM, AHRQ, the new technologies in testing, which are evolving at the light speed, light speed, speed, that is, light speed, yes, I'm trying to translate from French as I'm saying this. And from the members, from the sleep dentists, to become, not to become obsolete and to rely on a technique that will, in the long run, that would in the long run just become a technique, there's an increased interest in emerging dentistry-based intervention. But we know that there's not much research done on this, and what we wanted to do, what the EADSM board of directors wanted to do is wanted to make a point to what's the science at now. So next slide, please. So what we did, we had a group of people, we reviewed, there were 1600 papers on different topics, and we brought it down to 450 papers. These papers were put in a way to be presented to experts, and we had a meeting with some experts and some readers, and the panel came from 10 countries, and we reviewed the literature from the past 10 years, we didn't want to go earlier than the past 10 years, because it would just never end, and the past 10 years is the most recent literature. We focused on novel therapies as monotherapies. Let me explain. Let's say you have a paper that has looked at patients who got panectomies and then got myofunctional therapies. This is not a monotherapy. So these papers were excluded from the review, because we wanted to make things simple. And we had a voting system called the Modified Rand UCLA. Rose Sheets, who is a colleague, who was the chair of this meeting of this paper, she's an expert in this, it's kind of a political system that we base our decisions on. There's also the Delphi method that can be used. I don't know if you're familiar with this, but the method that we decided was the Modified Rand. Next slide, please. So the therapies reviewed. We looked at four different therapies. Malocclusions, namely premolar extraction and rapid palatal expansion. Intraoral peptoid tissues, that is the panectomies. I learned as a Canadian that panectomies in some part of the United States are becoming very popular. There was a paper published in the New York Times, which was very critical of those, and this needed to be looked into. Thong-motor activity, that is myofunctional therapy, and laser therapy, which is very, very interesting, but there was not much of the research done on this as far as we knew. Please, next slide. So what we wanted to know is that can any of these therapies prevent, manage, or cure OSA or snoring? Prevent, that is, as an example, if we provide kids with myofunctional therapy, every kid with that prevent them from developing OSA. Normalize, let's say we have an adult who is suffering from OSA. If we give him myofunctional therapy treatment, would that make a difference as far as the OSA is concerned? And cure, well, we have the same patient with myofunctional therapy. Would we need just one session or one year of treatment and then it would be cured forever? We need to go and do this for a long time. As an information, we included, yes, thank you, adults, yes, perfect. Adults were 18 years and older. Next slide, please. Well, not surprisingly, if you have been reading all the papers that have been published, the no-review therapies were found appropriate as first-line monotherapies. That doesn't mean that it doesn't work. That just means that we can't not prove that it does work, and it's a big difference. This field of sleep is evolving. What we know today may be something different in the next year or in 10 years, so we have to do more research, and hopefully this publication will help the clinician in decision-making. Let's say a patient comes up to you and wants to have your opinion on finectomies, on newborns, then, well, you have a document. You can rely on your opinion is more than an opinion, and this is the usefulness of this paper. Next slide, please. So this is Don Farquhar's pick. Don Farquhar is a dentist who happens to be the president of the American Board of Dental Sleep Medicine, and I like to call him one of the best sleep dentists you've never heard of because Don is very low-profile. He's a very nice guy. If you meet him at a meeting, I advise you to go and see him. He's very interesting and very funny. So the article he came up with was from Fernanda Almeida, not surprisingly, the one we just talked about, and it's about a focus of dental sleep medicine on obstructive sleep apnea in older adults, a narrative review. Next slide, please. So what is a narrative review in the first place? Well, it's just a really traditional review, subjective selection of the papers. Take it as a regular review. It's not a systematic review. There's no process. You just decide to make a review, and you find this article interesting and this article interesting, and you'll include it in your review. Next slide, please. So the background and objectives. Obviously, the article is very timely because the population is aging. Older adults have many health challenges, obviously, including sleep disorders, and the review discussed the sleep physiology in older adults, common sleep disorders, and OSC management challenges in older populations. Next slide. So what we know is that as we get older, just as a side note, the article didn't discuss frailty. It just discussed getting older, you know. So what we know as we get older, we spend more time in the bed, but we sleep less. We go to bed earlier. We wake up earlier, and we have comorbidities as we age, obviously, that are related or which have an impact on obstructive sleep apnea, and we have common sleep disorders. Insomnia, sleep-related breathing disorders, obviously, periodic limb movement disorder, restless leg syndrome, and REM sleep behavior disorder. This is a disorder when you enact your dreams. Interestingly, I learned that it can be a precursor of Parkinson's disease or lewd body disease. So there's more of this as we get older. Next slide, please. Obviously, there's a higher prevalence and the severity of sleep apnea with age. It kind of increases in the 60s and the 70s and then it plateaus. Then, and there's more substantial effect in younger adults, of course, because of all the comorbidities. And we have treatment challenges and you can read this. Dentalism, well, the jury is still out on whether you should be wearing dentures while you sleep or not. And interestingly, benzodiazepines is a medication that is prescribed for insomnia. And it seems that if you have sleep apnea and you have mild or moderate sleep apnea, then it's okay, but it can be detrimental if you have severe sleep apnea and you have benzodiazepines. Next slide, please. So the treatment approaches remain the same. So the CPAP is still the golden standard, but adherence issues, as it is the case with any age group, mandibular advancement devices, surgery, less common. They're talking about all maxillofacial surgery, which is less and less common in older adults. And tongue repositioning device. When I read this, I thought maybe I should have talked about the TRDs in the first place, but as I thought about it, yeah, well, no. As far as I'm concerned, I never hear about tongue retaining device. So I've done quite a few in my early years. Next slide, please. So conclusion, obviously, treating an older person is different. It's the same treatment, but we have to look at other things that are involved with the treatment of the patient. And we need to have a careful follow-up with these patients and we need to work as a team, obviously, with the sleep doctors. Next slide. So Dr. Flores-Neal-Speak, Carlos Flores-Neal is a professor of orthodontics. We're gonna have four orthodontists out of the 10 articles tonight. The reason why I decided this is that I don't think we give enough emphasis on the pediatric sleep apnea. Fortunately, I was very happy to see that at the last meeting in New Orleans, that there was a day devoted to this and we had very good presentation. Dr. Flores-Neal presented on that topic. Dr. Flores-Neal is a very, very popular speaker, spends probably more time in his plane in a month than we do in a year, but then we were happy to have him. So he brought orthodontic appliances for the treatment of pediatric obstructive sleep apnea, systematic review and network meta-analysis. Next slide. So the idea is to evaluate the efficacy of different orthodontic appliances for treating pediatric obesity. Next slide, please. And what the authors did, they looked at the studies available, they decided to include 11 studies with 600 patients. And then they looked at different treatments, namely mandibular advancement appliances, rapid maxillary expansion, malfunctional therapy. And what they were interested in is the change in sleep apnea hypopnea index. Next slide. So what they found is the mandibular advancement appliance is good at reducing the AHI. May I remind you that two events per hour is much bigger in the pediatric population than in the adult population. So RME plus rapid maxillary expansion plus adenotone selectomy got the largest decrease in AHI. RME plus mandibular advancement device got a good score. Myofunctional therapy, not bad. And RME alone, no significant AHI reduction. This is interesting because this is in line with the recommendations of the American Academy of Pediatric Dentistry, which said that if you wanna do RME on a sleep patient, don't do it alone. You have to work as a team, right, with the sleep doctor. I remember Ben Pliska presented a couple of years back at the meeting some cases where the patient got RME and the apnea worsened. So yeah, if you wanna do this, you do this as a team. Next slide, please. So the conclusion, well, ideally, you wanna do a mandibular advancement appliance and RME or RME plus adenotone selectomy to get the best results. Obviously, it's not a big, for 11 studies, 600 patients, it's not a very big group. We need more quality studies in the future. Next slide. So recommendation, yeah, of course, same thing, stay updated with future research. You'll be good. Next. So this is Rose Kozravis-Pick. Dr. Kozravis is an orthodontic professor, another orthodontist from the University in Washington State. He's a regular speaker, just like Dr. Flores-Mia at the American Academy of Orthodontics. And he will talk this year at the meeting about growth. His interest besides orthodontics is 3D printers. Just as a comment, as I know that some people from the Academy are listening, 3D printers is, I think, the future. We should have them or have, well, a lot of us have 3D printers in the practice. Many of us, including myself, have printed their own sleep appliances. I went back to the labs because I think the labs are better, but we can have a discussion about that later. But I think that we should be talking, we should have a meeting, the meeting, the annual meeting. We should invite people in 3D printing. I understand Dr. Aaron Dweck is very good at this, Dr. Kozravis, lots of people. Not me, obviously, because when I talk to these people, I realize that I'm a junior, but anyhow, I'd be interested. So the study proposes a non-randomized puncture in frontal trial of myofunctional treatment in the mixed dentition children with functional mouth breathing assessed by cephalometric radiograph and study models. This is some title. And the next slide, as it says, they went for 225 about children aged six to 10, and some were mouth breathers, some were nasal breathers. So they took the mouth breathers and divided the mouth breathers in two groups. One of the group would have myofunctional therapy, and the other one would have nothing. And they looked at the models at the beginning and at the end of the treatment, and they looked at cephalometric radiographs for measurements. Next slide, please. So what they found, if you compare the nasal breathers to the mouth breathers, as previously pre-published, this is nothing new, but still interesting, greater anterior lower facial height, large overjet, short overbite, narrower maxillary canine, not surprising. And at T2, when they compared the two groups of mouth breathers, the one who received the myofunctional therapy and the one who received nothing, well, the group with myofunctional therapy got their incisors retracted, their overbite increased. A slight increase in maxillary canine width, but interestingly, no more forward mandibular growth path. So this is good. This is good. Next slide. Conclusion, well, it does work. We can see this through measurement, and it can be helpful for open-bite correction, but more research is needed. The problem with myofunctional therapy, if you look at the study, the patient who got myofunctional therapy, they had to be very compliant. They had to wear ortho braces three times, 10 minutes per day. They had many exercises that needed to be done. It works, but lots of compliance, very, very compliant parents, because that's the only way to go. So in theory, it works in practice. Well, it's hard to convince. We've had some in my clinic doing that type of thing, and we didn't have very, very good results. But it shows that form follows function here. And we've seen in other papers published last year, some people, some other orthodontists say that function follows form. We change the form, and the function would be improved. Well, I'm gonna leave this discussion to my orthodontic colleagues, but it's an interesting discussion going on. We'll see what happens in the future. Next slide, please. Dr. Falaudo, Susana Falaudo is an orthodontist, the third one. She is the president of the European Academy of Dental Seed Medicine. She's from Portugal. She teaches orthodontics in Portugal. And she suggested this paper. It's a systematic review on 4D images of the upper airway in patients with OSA. Next slide. So when they talk about 4D, 3D is a 3D image. It's a scan, or it's an MRI, and this is what it's all about. But 4D, it's a 3D with time. So they take more than one picture of the same patient. So what they do, they take a scan or an MRI of a patient at the beginning without an appliance in, and then you put the appliance in, and then you take another picture. Obviously, the patients are awake. The technique has its limitations, but nevertheless interesting. Next slide, please. Systematic reviews. They decided to do a systematic review of the articles published before June, 2022. After selection, they ended up with four studies from 2010 to 2020. All of these four studies evaluated the effects of MAD on upper airway. Next slide, please. Well, what they found, it's MAD reduced upper airway collapsibility. MAD decreased extraluminal tissue pressure. MAD increased upper airway space, especially in retropalatal area and retroglossal area. What we used to think many, many years ago is that if the obstruction was in the oropharynx, that is behind the tongue in the retroglossal area, then our appliances would work well, whereas if it was behind the soft palate, then we didn't know for sure if it would work well, but the conclusion that we got from this is that if you get a patient who has had a new PPP, that is the soft palate removed, well, the chances were very good at the time we thought, actually. I don't know if it's still the case, but the chances were very good that the appliance would work. So this is what they're saying, that, you know, well, maybe it's true, maybe it's not true. So things are changing. More research. Okay, so nothing really different. You can read this. Next slide, please. Okay, we're up to Michael Simmons' pick. Dr. Simmons is a very literate dentist. He's got a master in public health. He's got a master in lasers, and he's got a master's in sleep at OSA down in Australia. So he's very interesting. I had the chance to work with him on the paper published in the GDSM in April. So he decided to pick up an article made by the group of Danny Eckert. This is very interesting because this is the article that I picked from my last editorial, and if I had been given the choice to participate in this, I mean, meaning to provide an article, this is probably the article I would have picked. So multinite measurement for diagnosis and simplified monitoring of obstructive sleep apnea. Next slide, please. So the background, if you remember, the World Health Organization estimated the number of sleep apneas in 2007 at about 100 million. So now the ResMed study, 10 years later, estimated the number of 936 million adults globally. Quite frankly, I wouldn't be surprised if the number was even more than that. The problem being that we rely on a single night sleep study to make the diagnosis. And we think it happens to all of us. We send the patient to the sleep study, and this is the worst night that they've had in ages or it's the best night that they've had in years. So it's very difficult to see if the diagnosis, you always get to doubt the diagnosis in some instances. So we think that there's a substantial night-to-night variability in OSHA severity cases. Yes, it could be a problem. Next slide, please. So what they did, they used an appliance. It's like a ribbon that you put under the sheets over the mattress, under the sheet of the bed. It's made by Wibbings. It's been calibrated and it correlates relatively well with the PhD. So they've been using this. The advantage of this is that it's very cost-effective. It does, you buy the thing, and then through the cloud, the information is sent, and you just get a ton of information. In fact, they had about, was it 4,000 patients with 170 nights per patient rate that gave 11.7 million nights, 11.7 million nights to analyze. And what they found is that single night studies may misdiagnose OSHA in 20 to 50% of the cases. And multi-night assessments significantly improve diagnostic accuracy. In fact, you will need seven night to get a very good diagnostic. And what they found as well is that some patients, there's a big night-to-night variability in some patients. And then be an independent, an important independent predictor of outcomes. Next slide. As I told you at the beginning, diagnostics are moving at such a speed, it's hard to follow. Now you have this with the withings, we're not done with this. They're gonna be providing us more studies. In fact, I think they've provided another study as in April or May of this year. Of course, the numbers with the high numbers of nights, it's very good for diagnostics. Those of you who know Michael Simmons, know that he's a proponent, he's a very big proponent of dentists doing their own diagnostics. We all have different opinions on this. Michael is, as I said, a highly literate dentist. The way I see this, the withings, is from another perspective. I think as far as follow-up is concerned, this is where I find the real usefulness. As I said in my editorial, if you are diabetic, you check your glycemia once a day. If you're a sleep apnea patient, you check your apnea once for diagnosis, once the appliance has been delivered, and then every three to five years. So for a diabetic, that doesn't make any sense. If we could, in a cost-efficient manner, provide testing on a regular basis for our patients, I think patients would be served better. But that's a matter of opinion. So we have to see what happens in the future. There's a company that I've seen at the sleep meeting. I'm not endorsing it. I haven't been to their website as of yet because I don't want to look like someone who endorses them, but it's called LabFront. And they take your Garmin watch and they tweak it so that it can be used at a sampling rate that makes sense. Because the problem with watches is that the sampling rate of the information is not good enough. If it was to be good enough, then you'd run out of batteries in no time, but they've been able to tweak it so that you can have more information. And with this, it's only available for research as of now, but it's coming. Patients are going to be able to access this in the very, very near future. Next slide, please. Future direction, obviously, you can read this. Next. So Danny Eckert doesn't need any presentation as well. He's speaking at the meeting. He's producing very interesting papers on phenotyping. And when I asked him one paper, he said, well, can I suggest the SAVE study? The SAVE study is the study on CPAP that was published in 2016 in the New England Journal of Medicine. And I told him, no, you can't, because it has to be no more than one year old. So he came up with that study, which is very interesting, Adherence to CPAP Treatment and the Risk of Recurring Cardiovascular Events. Next slide. So what they did is they looked at 4,000 participants, and half of them received the CPAP. The other half didn't receive any. Next slide. Is what they were looking for is major adverse cardiac and cerebrovascular events, the MACEs. And what they found is that there's no difference between CPAP and non-CPAP groups as far as cardiovascular and cerebrovascular events were concerned. Next slide. But then what they found, and this is what's interesting, if you wear your CPAP more than four hours a night every day, then there's a big difference. Next slide. That means that having a CPAP is not good enough. You have to wear it. You've got to use it four hours a night. And if you look at the same study that he was asking me about when I asked him for articles, you know that people are using, on average, the one who are using their CPAP, they're using it on average 3.3 hours per night. So most of the people, according to that study, and according to this study as well, well, they don't benefit in a cardiovascular way from CPAP usage. No wonder the HIV came up with no difference between CPAP users and non-CPAP users. So it's the same thing for us. If our patients get to use our appliances more, we're going to get better results in the long run. Next. Oh, and again, by the way, go back, go back. Thank you. Thank you. Thank you, Megan. So yeah. And if I were a sleep specialist, what I would do is the people who are not using the CPAP, I would take them out to my pool of patients as far as CPAP users are concerned. How difficult is this? It's not very difficult. If you look at studies, you know that if the CPAP user, you give a CPAP to a person, and if that person is not using it for the first two months or barely using it, that person's not going to be a user. Same thing for all appliances, by the way. This is why we need to support our patients when we deliver all appliances. So what I've seen in my practice is that I've got more patients, more sleep doctors, referring me for sleep appliances that I've never had before. It's not that many, but people were used to not sending me any patients. Now they're sending me on a regular basis. Next slide, now. This is our last orthodontist, Dr. Audrey Yoon. She doesn't need any presentation as well. She's from Stanford. So she provided me with this article, which is very interesting, adenotonsillectomy. And this buckles the loop, makes the loop. Anyway, I'm trying to translate from French, but from a Carlos Flores News article, adenotonsillectomy for snoring and mild sleep apnea in children, a randomized clinical trial. This is interesting. Next slide. So what they did, they took 460 patients, age 12 to 12.9 years old, average six year old, and they were mild sleep apnea. Okay. And they follow these patients for 12 months. So imagine, yeah, you can, you can change. Thank you. You can change. Imagine that you have a patient, a six year old patient. It comes to your practice from, for those of you who still do general practice and you look at them out and the tonsils are huge. The patient has ADHD and you're wondering if you could, you know, send the patient and have the tonsils removed. And you send it to the ENT, the pediatric ENT, and the ENT sends the patient back. And it has happened to me. This is why I'm telling you. So, well, I'm not taking out the tonsils and adenoids because the patient doesn't have that long phase that I like, that I feel is an indication for having the tonsils taken out. So this article will prove different. So what they did is half of those patients, they did early adenotonsillectomy and the other half, they waited. Next slide. So what they're looking for, what they were looking for through testing is the change in executive function. So is this going to, an attention function? So is this going to change my patient's ADHD? This is the question that's being asked. And these are the primary outcomes, what they were really looking for. But then, next slide, please. You have secondary outcomes. 22 secondary outcomes were examined. Quality of life, sleep outcomes, health outcomes, behavioral changes. And next slide, please. What they found is that the primary outcomes, no changes after 12 months. Too bad. Secondary outcomes, however, improved behavior, symptoms, quality of life, decreased blood pressure. Those patients who had sleep apnea, once their tonsils were removed, compared to the group, the control group, well, there was a diminution of the index. And in the coming year, there was no increase in the index, whereas in the control group, the index increased on average. Next. So significance, even if it's a mild sleep disordered breathing patient, I think it's worth considering that they should have adenodon selectomy. But I mean, I'm probably sure, I'm pretty sure that all EMTs have seen this article at this time. Next slide, please. The last but not least, Dr. Van der Wecken. Dr. Van der Wecken is an EMT. He's from Antwerp in Belgium. He's co-editor-in-chief of the GDSN. IDVA is doing a lot of work. As I said, he just published something regarding a comparison in AHR reduction of two sleep appliances of the same company, the Somnodem Evam and the Somnodem Flex. And the Somnodem Evam did better. So please find the study and read it. It's interesting. The Somnodem Flex did good, did well as well. So the paper is called Sleep Apnea Multi-Level Surgery Trial Long-Term Observational Outcomes. Next slide. So there was an article published a while ago. It's called the Sleep Apnea Multi-Level Surgery Trial. So what they did is they did surgery, multi-level surgery, namely, what they did is tongue reduction and the back of the tongue reduction and UPPP on patients. And they follow these patients for six months. And the results were good, but they decided to follow up with those patients two years, at least two years post-surgery. And what they looked at mainly was AHI and the APWEB sleep score. Next slide. So after two years, we still had good results. So they started with a baseline of 41 events per hour, and it went down to 21 after two or three years, and APWEB went from 2.3 to 5.5. Excellent, excellent results. Next slide, please. So 25 of the patients were not found for revaluation. So the problem with this is that that might include a bias in the results, meaning that, you know, the results are very good. If you had the surgery, didn't get the result, were not satisfied, maybe you don't feel like reaching back or getting back to the people who did the research in the first place. But the result that they got, they're very good, very interesting. And secondary outcomes also show long-term improvements. Interestingly as well, the control group, there were, if I remember well, 46 patients in the control group, 69% of that group underwent subsequent surgery, and they've got improvement in symptoms and quality of life as well. So it's very, very interesting. Next slide. Well, multilevel upper surgery provides long-term improvement in USA. This is a therapy that is interesting, but I need to remind you it's very big surgery if you compare it to oral appliance. So if I were to choose between multilevel upper airway surgery and oral appliance, I'd try oral appliance in the first place. But they need to, they wanted to, in the discussion, they want to follow up these patients for a longer time. Next slide. But there's more. When Olivier sent me this paper, he said, you know, I did an editorial on that paper. Please look it up. So, and I found it interesting. I'll let you read it, but we go to the last slide of that, of my presentation. Next, next, next. Okay. Sorry. Okay. We're there. No, this one. Thank you, Megan. So conclusion and implications. So I got to read this. We have to emphasize tailored strategies for individual patients. We have to improve global evidence to guide treatment choices. We have to, it's essential for us to advance OSA surgical therapies, and we have to focus on long-term effectiveness and quality of life improvements. That statement could be applied to oral appliances as well. We're all in the same boat. And as the science progresses, we're going to be needing more and more research, more and more papers, and we need more long-term, as far as oral appliances are concerned, more long-term studies. And we have to, to consider more and more cooperations with other fields like ENTs. We're already doing this, but they realize, the ENTs are realizing that they're not going to do it alone. So we need more cooperation, cooperation with ENTs, the specialists. I know I've been hitting on the same nail for years, but it's very important. Next slide. So I hope you enjoyed the presentation. I hope you've learned new things. I purposely decided not to make this on oral appliances only, and just to make sure that we expand our views on dental sleep medicine. Thank you so much. Thank you, Dr. Maas. All right. So if any audience member has a question for our speaker, please submit your questions using the question answer button on the bottom of the screen. I'll be asking the questions from the top down. So please make sure to use the thumbs up feature to move your favorite questions up the list. Also, in some instances, your question may be answered by a moderator in writing, in which case you'll see a text answer under your question. Okay. So the first one that we have is, are there any articles that you know of that show the advocacy of appliances that increase vertical dimension with little or no protrusion? So vertical dimension only. Yes. You have one paper that was made in 2001 by the Randelier, which is good. They used the Sunderman appliance and they increased the vertical by one centimeter, 10 millimeters. What they found is most of the time at the same protrusion, it doesn't make any difference. It doesn't make any difference, but it's less comfortable. As you increase the vertical, it's less comfortable. There was in the graphing, the presentation of the information, one outlier, in which case the change in vertical dimension made a tremendous difference. But for most people, it doesn't make any difference. So you have to consider if your therapy doesn't work and the tongue is very big, because there was another paper published in the JDSM where they found that if you have a scalloped tongue, then you should consider increasing the vertical dimension. Interesting. Another question is, what was your favorite article for you personally, Jean-Francois, for the 2024 year or any previous years? Oh, that's, well, I liked the one with the Wittings, Sleep Device. I like there was one paper from Danny Eckert that was published last year, when instead of providing the patients with the CPAP in the first place, it would provide the patient with an appliance in the first place. And if that wouldn't work, then it would include other modalities of treatment and finishing with the CPAP, if anything, if nothing worked. And they found that it works very well. I don't have the name. I can look it up. It's very interesting, because they decided to solve the problem the other way around, what we're used to see. That is, start with the CPAP, and if the CPAP doesn't work, then we'll go for the appliance. I can find the article. I can find it. I'll find it. Yeah, thanks. And then another one is, regarding compliance tracking, is there anything other than a device that has a compliance tracker based on temperature? Not that I know of. There was the Denti-Trac, and there's the European smaller one. Unfortunately, some of them were supposed to be coming up as early as this year with the new device, but apparently the results were not as promised because it disappeared. I know for some, this is working. I don't know if it's still working with everything that happened with ProSomnus, but they're working at something similar. I think it's going to make the difference. If you have in real time the compliance, and those chips were checking for the CPAP and the oximetry as well. So if you have this in real time, it would be interesting, because you would move the job forward. You would see the difference. You have to realize that we have been relying on AHI for very, very long, and everybody knows that it's not the best metric, but that's all we have. Braban, a testing company, just came up with a new oximeter, and it's not calculating the AHI. It's calculating the hypoxic burden. So I think we're moving away from the AHI, and we'll see what happens. I think AHI is still the best that we have, but it's not there yet. And it does look like someone, Adam Teo, linked the Danny Ecker paper you referred to there. And then also, is there a five-year protocol on retesting while in oral appliance therapy? Example, overnight tests with and without the appliance at the five-year mark? If my memory is good, the AASM protocol is that the patients need to be tested every five years. There was a 2008 article with Marie McLuhan, where they found out they had patients that were given oral appliances, and those patients got rid of the sleep apnea at year one. They got rid of the sleep apnea at year five. They got rid of the sleep apnea at year 10. And sleep apnea came back full-blown at T15. And there was no change in weight of the patient. Nothing has changed. Nothing had changed. So this made us panic at the time. So I called the pulmonologist I'm working with, and I said, well, we're in a socialized country, okay? So we're overwhelmed with patients, the sleep patients, the pulmonologists, they don't want to see them. They have like so many, they don't even have answering machines on their phones because they're scared to have too many messages left. So I asked the sleep doctor, so what do we do? Do you want me to send you back every patient every five years? And he says, no, I don't want that. So we concluded that the centerpiece for the treatment and the protocol and the follow-up for the sleep patient is not the dentist. It's not the sleep specialist. It's a GP who gets all the information and decides whether the patient needs to be retested depending on their symptoms. Is that answer clear? Yeah. Yeah. Thank you.

Dr. Jean-Francois Maass

dental sleep medicine

oral appliances

surgical options

monitoring techniques

compliance tracking

multi-level upper airway surgery

tailored treatment strategies

medical specialties