Just breathe

November 7th, 2013

07alumni-sleep-1Dr. Keith Thornton fits patient Jean Graber for her custom sleep mask.

After a rollercoaster year of hearings and proposed rulings, alumni with sleep-based dental practices may finally get the resolution they desire at a Nov. 8 state board session. Some worry the fight to help their patients breathe is far from over.

Everything changed for Jean Graber in 1952. She was just a first grader, and life was about climbing black walnut trees in her backyard, playing in barn haylofts and hanging from the monkey bars on the school playground.

Then polio hit.

For the next three months, home became the hospital, and those first six weeks all of her breathing was done for her in an iron lung — a metal tank that went up to her neck. Air pressure changes guided her chest wall up and down, creating the inhalation and exhalation needed to keep her alive. Graber’s mother kept vigil while her father made the three-hour drive back and forth to the hospital in Hutchinson, Kansas, each weekend. A survivor of bulbospinal polio, Graber lost complete use of her left arm and partial use of her right. But she learned to drive using just her legs, went to college and became a teacher.

Graber wasn’t expecting what happened next. In 1980 came the second diagnosis. She had post-polio syndrome, and by 1983 she needed nighttime ventilation.

“A lot of people who had bulbospinal polio — which damages nerve centers that control swallowing and talking — died before they could figure that out,” says Graber, whose journey to breathe during sleep began with an airtight nylon “poncho wrap” with a sweeper motor and has evolved to breathing masks connected to ventilators.

These days she sees Dr. Keith Thornton ’69, who owns SleepWell Solutions, a Dallas dental practice dedicated entirely to sleep-related breathing disorders.

Once every few years, Graber and her husband make the seven-hour drive from their farm near Pretty Prairie, Kansas, to have Thornton make her a new custom sleep mask.

At such visits Thornton and Graber meet at UT Southwestern Medical Center at Dallas, where Graber climbs into an iron lung. Since she can’t breathe on her own when lying down, the device is necessary while Thornton makes a mold of the area extending from Graber’s chin and cheeks to above her nose.

She stays in the metroplex several days while the clear acrylic mask is created. Thornton attaches the mask to a monoblock appliance that uses the teeth to hold the mask in a fixed position. The mask is then attached to a volume ventilator. A sleep study is performed to make sure the mask doesn’t leak.

“I can just slip it in my mouth, and I’m ready to go,” says Graber of the strapless mask. “I love that freedom. The mask gives me independence, and that’s primary for me.”

Thornton’s ability to help — and that of many dentists who treat patients with sleep-disordered breathing — may hinge on the outcome of a Texas State Board of Dental Examiners open session on Nov. 8 in Austin.

In April 2012, an Austin-based sleep dentist began a correspondence with the state board. He wanted clarification on what a dentist can and can’t do in terms of treating sleep-related breathing disorders. Currently, dentists are permitted to independently diagnose and treat nighttime breathing problems such as snoring and upper airway resistance syndrome, but treatment and fabrication of oral appliances for obstructive sleep apnea — when the airway repeatedly collapses during sleep — can only be done in collaboration with a physician’s diagnosis and orders.

The inquiry set off a firestorm. It didn’t take long for the TSBDE to consult the American Academy of Dental Sleep Medicine and the American Association of Sleep Medicine for their constituents’ opinions. In the 18 months since, a rollercoaster of hearings and proposed rulings has ensued, and at times throughout this dialogue, the right of dentists to independently treat snoring and sleep-disordered breathing has hung in the balance. At the core of the issue is a dentist’s right to order a sleep study or diagnostic home sleep test in order to rule out obstructive sleep apnea. Such studies are interpreted by a licensed Texas physician, and until recently, ordering these tests for patients was something dentists could do without question.

According to an April AASM member e-newsletter, the academy’s official stance is that dentists should not be able to order either test. This would mean that even for issues unrelated to obstructive sleep apnea, such as snoring, dentists would need to refer patients to physicians before providing treatment.

“If you just say you’re snoring, and you tell your patients to go to a sleep physician before you will help them, they will likely not go,” says Dr. David McCarley ’81, president-elect of the Texas Dental Association. “That would shut down a lot of patients.”

Perhaps no one is more passionate about this issue than Thornton who, in addition to creating custom sleep masks for patients, has a patented oral appliance known as the Thornton Adjustable Positioner. Thornton describes this “TAP” device as a tent pole that works by propping the mouth open, preventing the tongue and soft tissue of the throat from collapsing into the airway. It’s become a popular alternative to continuous positive airway pressure — or CPAP — machines, which keep the airway open during sleep through increasing air pressure in the throat.

07alumni-sleep-2Thornton’s patented device, the Thornton Adjustable Positioner

“My device has been FDA-approved for any physician or dentist to purchase and fit,” Thornton says. While he isn’t pushing to treat obstructive sleep apnea patients independently of physicians, Thornton’s concern is that if dentists must refer patients to a physician before using his oral appliance for any breathing problem, dentists could be cut out of the process entirely.

“Treating sleep-disordered breathing with a dental device to position the jaw is a dental problem with a dental solution ,” says Thornton, who, along with several TAMBCD alumni, formed the nonprofit Clinicians for Healthful Sleep to advocate their viewpoint to the state dental board. “That is why I have fought so hard for dentists to do it.”

McCarley adds that some appliances can cause temporomandibular joint problems if incorrectly made or adjusted.

“The sleep physicians really are not trained to diagnose occlusal problems,” says McCarley. “Sometimes these occlusal problems will lead you to a better diagnosis of what patients are doing in their sleep.

“You need both sides. Our intent at the TDA is to work with physicians on something. We don’t want to set up these barriers.”

Dentists won’t have to wait long. According to a Sept. 13 proposal issued from the TSBDE, dentists would still be able to order sleep studies as a screening tool for sleep disorders as well as diagnose and treat any dental comorbidity related to snoring and upper airway resistance syndrome. Diagnosis and treatment of obstructive sleep apnea would continue to require collaboration with a licensed Texas physician.

If the meeting concludes without the opposition that occurred at an August open session, those recommendations could become the official state rule.

If not, and dentists are eventually deprived of their right to independently diagnose and treat non-sleep apnea breathing disorders, it could create a domino effect nationwide, says neurologist Dr. Richard Dasheiff, a former director of the Sleep Medicine Program at the Dallas VA Medical Center.

“If Texas goes through with this, all the other states could follow suit,” says Dasheiff, who is a member of the AASM but has supported the cause of dentists throughout this debate and even testified on behalf of Clinicians for Healthful Sleep.

During Dasheiff’s time at the VA, his team relied on a variety of treatment options, ranging from the use of CPAP machines and oral appliances to prescription medications and — in severe cases of sleep-disordered breathing — surgical intervention through tracheostomies.

“We always tried to educate patients on what their options were,” says Dasheiff. “Having this restricted would ultimately reduce the number of patients who get adequate care.”

Types of sleep-related breathing disorders

  • Obstructive sleep apnea – It is normal for the soft tissues in the throat to relax during sleep, but when those tissues partially or totally block the airway, breathing is interrupted. This type of disorder is different from central sleep apnea, in which the brain fails to send the message to the body to breathe. Only obstructive sleep apnea can be treated with oral appliances and breathing machines. Dentists may treat patients with obstructive sleep apnea and fabricate oral appliances for them only in collaboration with a Texas licensed physician.
  • Upper airway resistance syndrome – This occurs when the soft tissues in the throat relax and cause the airway to decrease in size. Not quite as severe as sleep apnea, the resistance in the airway leads to an increased effort to breathe. This can cause individuals to wake up during sleep but for periods so brief they are not aware of it.
  • Snoring – the most common of sleep-related breathing disorders and a potential symptom of obstructive sleep apnea, this occurs when the airway becomes partially blocked. Instead of the air going to the lungs, some of it goes into the mouth instead, which vibrates the soft palate.

—Jenny Fuentes

— Jennifer Fuentes