Gossip Columns are abuzz with the news...

While certainly not the most significant medical news of the day, gossip blogs and "celebrity" web sites are reporting that Kevin Jonas and his new wife have been married only 5 months and are already sleeping in separate beds.

While considered as an insignificant joke among most of these "journalists," snoring can be sign of the serious medical problem - obstructive sleep apnea. Even though a diagnosis of sleep apnea is unlikely, one would think that someone close to the pop star would insist that a sleep study be performed.

Even without the more serious diagnosis, treatment of primary snoring is relatively simple with an oral appliance without the possible voice-altering effects of a surgical procedure.

As dentists who provide oral appliance therapy for snoring and sleep apnea, we need to do more to educate the public of our role in the recognition and management of sleep breathing disorders.

As always your comments are appreciated.

Dr. Barsh

Are professional truck drivers being denied adequate medical treatment for sleep apnea by the very regulatory agencies charged with their protection?

In an online news release today on the Occupational Health & Safety web site (ohsonline.com), there was an article that stated:

For commercial motor vehicle drivers with obstructive sleep apnea (OSA), effective treatment lowers health care costs and disability rates, reports a study in the May Journal of Occupational and Environmental Medicine, the official publication of the American College of Occupational and Environmental Medicine (ACOEM)....

On average, treatment for OSA led to “over $6,000 in total health plan and disability cost savings per treated driver,” the researchers noted. Total costs decreased by 41 percent in drivers treated for OSA (compared to an eight percent decrease in untreated drivers)....

Sleep apnea is an important preventable cause of motor vehicle accidents, and studies have found that treatment for OSA can lower the accident rate. Screening and treatment for OSA has recently been recommended for commercial motor vehicle drivers.

For truckers with sleep apnea, CPAP is the preferred and approved treatment of choice for sleep apnea. But despite the fact that many people cannot tolerate CPAP and despite the fact that CPAP is not always available in trucks or other places where truckers can sleep, oral appliance therapy is NOT an approved method of treatment because of the inability to document compliance with therapy.

This issue arose at the recent Sleep Apnea Truckers Conference held in Baltimore on May 11 - 12.

The problems with CPAP use for a trucker range from inability to tolerate the mask and unit, power supply problems, altitude problems, humidification and heat problems, water sloshing in the humidification chamber while partner is driving,anti-idling laws and problems with cleaning the unit. None of these problems apply to oral appliances and yet their use is not approved.

Patients are considered to be complying with CPAP usage if they wear their CPAP unit for a total of only 4 hours out of every 24 hour period. Is this sufficient for effective treatment? Does 4 hours of use reduce excessive daytime sleepiness to an acceptable level? Yet oral appliances are not approved since their compliance cannot be measured even though research has shown that oral appliances are often better tolerated and worn longer than CPAP.

So if a trucker cannot tolerate CPAP or if it is impossible to utilize the CPAP properly for the above reasons that truck driver cannot be offered an oral appliance simply because compliance cannot be measured.

The other reason for not using oral appliances is, as one speaker at the SATC meeting put it, the fact that oral appliances are not effective in severe sleep apnea.

Following this logic, for example, a driver with an AHI of 60 that cannot use CPAP for one reason or the other is best left uncertified, medically ill and unable to earn a living despite the fact that an oral appliance might only reduce his/her AHI to 20 and because appliance use cannot be quantified. Even if a patient who uses an oral appliance can be documented to show improvement by sleep study, this is not considered adequate evidence of compliance.

Oral appliances have been proven to be an effective treatment for obstructive sleep apnea and have been approved for use in mild to moderate sleep apnea. There is research to show that they are useful in some cases of severe sleep apnea as well.

To simply dismiss their use on the basis that compliance cannot be measured or that they are not as effective in severe sleep apnea as CPAP is dismissing a therapy can can save lives.

Your comments would be appreciated.

Dr. Barsh

It's Your Responsibility!

At Snoring Isn't Sexy, we can't say this often enough but it's up to you to ensure that the dentist you choose for oral appliance therapy has had the education and training he or she needs to provide this service effectively and safely.

With the exception of the Tufts Dental School graduate program, dental sleep medicine is not taught in dental schools so all the training is acquired in continuing education courses.

Snoring Isn't Sexy provides some guidelines at its web site (http://www.snoringisntsexy.com/choosedentist-onecolumn.cfm) but in addition be sure to ask about the training that the doctor has had and be sure the appliance used has been FDA approved.It's way to easy for a dentist to "invent" an appliance and claim that s/he is the only one who has this appliance available.

Do not be mislead by a doctor who claims to treat only snoring, there is no way to determine if you just snore or have sleep apnea without a sleep test. Be sure your dentist works with qualified physicians who will examine you personally. Over the Internet health histories are not worth the kilobytes used to generate them.

Oral appliance therapy is an effective, comfortable way to solve sleep breathing problems but like any other medical treatment it is not always 100% effective and can have adverse side effects.

Dr. Barsh

Will oral appliances be taxed as well?

A bit of distressing news came across my desk this AM.

Ask Mike Amory where it hurts and the owner of a medical equipment supply business points to the health care reform signed into law last week.

The money to pay for a portion of the nearly $1 trillion overhaul package is coming out of the pockets of him and other business owners facing new taxes on the medical devices. The law imposes a $20 billion excise tax over 10 years on manufacturers of the power wheelchairs, sleep apnea, respiratory and other equipment sold at Amory Medical Associates.

[Emphasis added]

Since oral appliance therapy has been classified as a DME, does this mean that there will be a tax on an oral appliance as well?

We will just have to wait and find out.

Dr. Barsh

Choosing a dentist for Oral Appliance Therapy

I know I've talked about this before but as more and more dentists start to provide oral appliance therapy for snoring and sleep apnea, it becomes more important that you, the patient, become more and more aware of the necessity to choose a dentist for this therapy with care and consideration.

Every dentist legally can provide this therapy but this does not mean that every dentist is qualified to do so. Treating snoring and sleep apnea - both problems with serious medical consequences - with a dental device is not dentistry. It is medicine and has to be approached differently than restoring a decayed tooth or replacing a tooth with a dental implant.

Remember that oral appliance therapy is not part of any undergraduate dental school curriculum at this time. Tufts Dental School is the only school (so far) that offers a post doctoral course in dental sleep medicine. This means that most education in this field is provided by continuing education course which, unfortunately, do vary in quality. No organization rates the quality of the courses or the qualifications of the presenters so it is up to you to question the dentist you select to provide this treatment.

I would like to refer you to the web page we have written on this subject as a guideline to choosing a dentist.

Happy Holidays

Dr. Barsh

The Internet and Medicine

In an article today on Medpage Today by Lauren Cox of ABC Medical News Unit describes the 10 Top Medical Advances of the Decade. Among them was"Doctors and Patients Harness Information Technology."

She writes

Patients may not even think of it as they sign in with a pad and pen, then sit in the waiting room while the nurse pulls their file. But doctors say the Internet and information technology has actually changed the way they practice medicine for the better. Even doctors need to look things up from time to time.

"Early in practice, if I had a clinical question to research, I had to go to the library, pull out multiple years of the Index Medicus, look up the topic, write down the references, go to the stacks and pull the volumes of journals, find the article, read the article, go to the copy machine and make a copy& if I were lucky, I would have my answer in about four hours," said John Messmer, MD, associate professor at the Penn State College of Medicine in Hershey.

"Now I can be on rounds and in five minutes have more information on the topic than I need& on my iPod Touch, I can look up a medication, check the formulary to see if it's covered, check for interactions with a patient's other meds and double-check details of the pharmacology of the med plus quickly review the problem I am treating, and I don't even have to go online," said Messmer.

Information technology has also, to some degree, made life safer for the patient. Once admitted to a hospital, they get a bar code which matches their blood samples and their IVs.

"The ways in which computer systems are improving hospital care& are pervasive and radical," explained Margaret Humphreys, MD, PhD, editor of the Journal of the History of Medicine.

But many physicians have been reluctant to go digital because there is a significant upfront investment, which is why several of the healthcare reform measures now before Congress include provisions to underwrite some of this cost.

And with or without reform, the Obama administration has an ambitious program aimed at converting paper records to electronic health records. It has earmarked $20 billion to pay for the switch-over and named medical IT wonk David Blumenthal, MD, to serve as National Coordinator for Health Information Technology.

Snoring Isn't Sexy is proud to be able to provide information on dentistry's role in the recognition and management of snoring and sleep apnea without government or funding from commercial sources.

The information and availability of resources to help manage snoring and sleep apnea have been brought to you solely by the dentists and physicians who are members of Snoring Isn't Sexy and, thus, have been able to remain unbiased with no obligation to any outside influence.

Dr. Barsh

Insulation Isn't Sexy

Tuesday, December 15, 2010

(CNN) - President Barack Obama expressed his true feelings about
insulation.

"I'm calling on Congress to provide new, temporary incentives for
Americans to make energy efficiency retrofit investment in their
homes, and we want them to do it soon," said President Obama. "I know
the idea may not be very glamorous, although I get really excited
about it. We were at the round table and somebody said insulation
isn't sexy, and I disagree. Frank, don't you think? Insulation is sexy
stuff. Here's what's sexy about it: saving money."

Obama referred to someone who said "Insulation isn't Sexy"

Hmmm... Funny that phrase was never used before in Washington. And
just a couple of days after Snoring Isn't Sexy's ad appeared in the
Wall Street Journal Supplement.

Coincidence, I think not ;-)

Larry

5 Things Every Woman Should Know About Her Man's Snoring

"I'm too busy!" "It's nothing, it'll go away by itself." "I can't find a doctor I like." " My insurance won't cover it." "I DON'T SNORE!"

One excuse after another... We men are masters of avoiding a visit to a doctor's office. But whatever the excuse, a woman is often aware that her man is having medical issues long before he is willing to admit it. In the case of snoring and its serious counterpart, obstructive sleep apnea, stalling could be deadly.

So what do you need to know about your man's snoring?

1.Snoring is not his fault

Snoring results from a partial blockage of the airway during sleep. As a snorer breathes, air is forced through narrowed passages around loose tissue like the soft palate and uvula. As the air passes over these structures, noise is created much like the sound of a flag flapping in the breeze.

So snoring is an anatomic, medical noise that he can't control.

But it's still a problem. In 2006, Rosalind Cartwright of the Rush University Medical Center found that wives could be sleep deprived due to their husband’s snoring. This puts a strain on the marriage and creates a hostile and tense situation resulting in a high divorce rate.


2.Snoring alone can cause serious medical problems

Research at the University of New South Wales in Australia this spring found that one in four middle aged men who snore are at risk for developing brain damage while they sleep. Caroline Rae, the lead author, found that snoring associated with obstructive sleep apnea caused changes in brain energy levels that mimic the changes that happens just before dying or after a stroke.

And speaking of stroke, in 2008, a research team headed up by Sharon Lee, again in Australia, found that heavy snoring significantly increases the risk of plaque build up in the carotid arteries that supply blood to the brain. Plaque in the carotid arteries is a leading cause of stroke.

3. Snoring can be a sign of obstructive sleep apnea

When the airway becomes completely blocked, it's called obstructive sleep apnea. This blockage of the airway prevents oxygen from reaching tissues throughout the body and has been implicated in cardiovascular disease, high blood pressure, diabetes, stroke, obesity, depression, excessive daytime sleepiness and depression.

It has been estimated that in the United States alone 20 million men, women and children suffer from obstructive sleep apnea. Millions more snore. Of these 20 million, only about 10% have been diagnosed despite the fact that the average life span of an untreated sleep apneic is years less than those without sleep apnea.


4.Snoring and apnea can be a cause of ED


For those men with sleep apnea, erectile dysfunction may be part of the package (no pun intended). ED may be caused by long-standing intermittent decreased oxygen levels in the blood associated with episodes of obstructed breathing. What is important is that it is possible to reverse erectile dysfunction by treating snoring and sleep apnea dramatically improving the quality of life. One study showed that Cialis may ease the problem of ED, but does not totally overcome the problem in men with obstructive sleep apnea.

Snoring may even effect a man's libido. Men who suffer from obstructive sleep apnea produce lower levels of testosterone resulting in decreased sexual activity.

5.Snoring, Apnea and excessive daytime sleepiness

When complete airway blockage occurs during an apneic episode, your man will partially awaken to start breathing. Although he won't remember this in the morning, it can happen hundreds of times a night leading to fragmented sleep. As a result, he could awake with a headache and be more tired in the morning than he was the night before and tend to doze off easily while driving and at work.

According to the National Sleep Foundation's Sleep in America poll, 60% of Americans have driven while feeling sleepy and 37% admit to actually having fallen asleep at the wheel in the past year. Each year almost 2,000 people die in crashes caused by drowsy driving, according to the National Highway Traffic Safety Administration. And thousands more are injured as a result of sleepy pilots, boat captains and truck drivers.*

So what can you do to help?

Be aware!

If your man snores and stops breathing during sleep, if he has high blood pressure and if he dozes off while driving, get him to see a sleep specialist or a specially trained dentist. Help him to lose weight, help him to stop smoking, control the alcohol consumption - but most of all - make sure he gets to someone who can help.

* SnoringIsntSexy.com has launched a survey to determine the extent of sleepiness with those who interact with the public. The survey is at snoringisntsexy.com.

Sleep and the City

There was an article in the Huffington Post yesterday entitled "Does Anyone in NYC Sleep Well Anymore?"

My wife and I live near the corner of 2nd Avenue and 70th Street, about half a block away from the construction site of the new 2nd Avenue subway line. City ordinances permit construction only between the hours of 7AM and 6PM. This morning at 5:17AM several large construction trucks with the backup signals on came by apparently the express purpose of dropping several heavy metal plates in the middle of the street. When I say dropping, I mean DROPPING.

When I called the city agency responsible for controlling noise, I was advised that indeed city ordinances permit construction only between the hours of 7AM and 6PM unless the construction company really truly feels that it must make noise. In that case the city will give them a variance.

I was also told that the EPA had no control over noise if they had a variance.

New York City can be a great place to live, but it is a lousy place to try to get a good night's sleep.

Forgive the rant, just really tired this AM and more than a little ticked off.

Dr. Barsh

Sleep and the City