DENTAL BLOG

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Obstructive sleep apnea (OSA) can have a devastating effect on patients’ health and quality of life, and its prevalence has dramatically increased in recent years.1 And although OSA affects millions of people in the United States alone, this condition is commonly underdiagnosed. 

CPAP therapy and lifestyle changes–the most commonly recommended treatments for OSA–can often be ineffective or difficult for patients to integrate into their routines, making it difficult for people with OSA and other sleep-related breathing disorders to meaningfully improve their health.2 

Poorly fitted devices and low efficacy of CPAP treatment for severe cases can lead to poor treatment compliance.3 This leaves patients vulnerable to the long-term consequences of OSA, including accidents or injuries due to daytime sleepiness and poor cognitive performance, as well as increased risk of cardiovascular disease, cancer, Type 2 diabetes, and other chronic illnesses.1 

Dentists are in a unique position to help diagnose and treat OSA, ensuring these patients get the appropriate care to improve their quality of life and longevity. Dental care providers can help identify patients who may fit the criteria for alternative treatments, such as maxillomandibular advancement (MMA) surgery–which can effectively address the retrognathia that many OSA exhibit.4

How does jaw alignment affect sleep-related breathing disorders like OSA?

During sleep, OSA patients experience recurrent narrowing or collapses of their airways. These episodes either partially or completely obstructed airflow, referred to as hypopneas or apneas, respectively. According to the American Dental Association, there are a variety of risk factors that can contribute to OSA severity.1

OSA is commonly associated with obesity, a major risk factor for the condition. However, patients may also have craniofacial abnormalities that contribute to their susceptibility to sleep-related breathing disorders (SRBDs) and the severity of their hypopneas or apneas if they do develop OSA.1,5 While other conditions like obesity can exacerbate this effect, even those at a normal body mass index (BMI) can be at risk for OSA if they have jaw misalignment.

What is maxillomandibular advancement (MMA)?

Retrognathia is a malocclusion in which the lower jaw or mandible sits abnormally posterior to the maxilla. This misalignment reduces the space in the adult oral cavity, which is a risk factor for collapsed or blocked airways during sleep.5 Patients affected by this kind of craniofacial abnormality have been shown improved outcomes with treatments like maxillomandibular advancement or MMA.6

MMA involves repositioning the mandibular and maxillary bones to alleviate the airway compression that jaw misalignments and craniofacial abnormalities can cause.7 While invasive treatments are often seen as a last resort, healthcare practitioners can evaluate patients based on their risk profile and the health benefits they are likely to experience as a result of this surgery.

MMA surgery has been shown as an effective and safe treatment that helps patients with severe cases of OSA reduce the incidence of airway collapse during sleep, improving their quality of life and long-term health outcomes.

How can MMA surgery help OSA patients?

Recent research has shown that MMA surgery is a highly effective and safe treatment for OSA. One study examined how MMA surgery affected 30 adult patients with OSA six months after surgery. The study compared their pre- and postoperative health measures, assessing changes in the patients’ condition, including:6

  • Daytime sleepiness (Epwork Sleepiness Scale or ESS).
  • Quality of life.
  • Sleep-disordered breathing (apnea-hypopnea index or AHI).
  • Cardiovascular risk (blood pressure, level of high-sensitivity C-reactive protein).
  • Cognitive performance (psychomotor vigilance testing or PVT).

Across these metrics, these 30 patients saw a consistent improvement in their overall health and a reduction in classic symptoms of OSA, including daytime sleepiness, poor cognitive performance, and apnea-hypopnea incidence during sleep. 

MMA has shown high efficacy for OSA patients with jaw misalignment, as shown in one meta-analysis which analyzed the results of 45 studies examining the efficacy of MMA surgery to treat OSA.8 Outcomes for 518 unique patients were analyzed. Overall, the average patient’s AHI decreased by 80.1% and 98.8% of patients saw improvement post-surgery. Additionally, 38.5% of patients were “cured,” reaching an AHI below 5 episodes per hour and no longer meeting the diagnostic criteria for OSA.

When is MMA an appropriate treatment for OSA?

According to public health resources from the National Institute of Health, “diagnosing this condition will allow for appropriate referral for an orthodontic evaluation and surgical correction when warranted,”45 making dentists a key point of care for patients at risk of OSA.

It’s critical that dentists are trained and educated to understand how MMA can effectively and safely treat patients with maxillomandibular deficiency and OSA. During routine oral exams and patient intake, not only can dentists help address commonly undiagnosed SRBDs, but they can also help identify patients who fit the candidate profile for MMA surgery as a treatment for OSA.When evaluating patients with OSA, dentists and dental sleep specialists can ensure patients exhibiting retrognathia or other types of craniofacial abnormalities receive the treatment they need to achieve better long-term health outcomes. Patients with craniofacial-related risk factors who do not tolerate, comply with, or see long-term benefits from CPAP therapy or other non-invasive treatment can be assessed for surgery candidacy based on their overall health, age, the severity of OSA, and medical history, among other factors.4

Itamar Medical is a global medical device company focused on home sleep apnea testing. The company has pioneered an innovative sleep apnea management program for patients and healthcare professionals.

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Dentists and dental sleep medicine specialists have seen throughout the pandemic how COVID-19 causes stress and inflammation that negatively impact dental patients’ health. According to recent research, COVID-19 patients have exhibited a host of symptoms known to affect oral health, including:1

  • Dry mouth
  • Mucosal blistering
  • Mouth rashes
  • Lip necrosis

Additionally, patients with existing periodontal disease have been found more likely to experience worsened COVID-19 symptoms.2 Altogether, these findings indicate that patients diagnosed with sleep-related breathing disorders (SRBDs) like obstructive sleep apnea (OSA) face an increased risk of complications from COVID-19.

Poor dental health has repeatedly been identified as a contributor to chronic health conditions such as cardiovascular and metabolic disease.3 As such, dentists and dental sleep medicine specialists need to consider how contracting COVID-19 affects patients’ short- and long-term health outcomes–especially in light of the discovery of “COVID clenching.”

What is “COVID clenching”?

Dental practices and organizations like the American Dental Association (ADA) have reported a notable rise in stress-related oral health conditions over the course of the pandemic. According to a September 2020 ADA survey:4

  • 59.4% of surveyed dentists indicated an increased prevalence of bruxism among their patients.
  • 53.4% reported an increase in chipped and cracked teeth.
  • 53.% reported an increase in temporomandibular joint (TMJ) disorder symptoms.

And these numbers only increased as the pandemic continued. When the ADA surveyed American dentists again in 2021, over 70% of dentists reported: “seeing an increase of patients experiencing teeth grinding and clenching, conditions often associated with stress.”5

Researchers have linked the reported risk of bruxism cases–as well as related conditions such as chipped or cracked teeth and TMJ disorders–specifically to COVID-induced stress.6 

According to the American Academy of Sleep Medicine (AASM), sleep-related bruxism is often caused when patients’ jaw muscles have strong, repeated contractions at night.7 Dental healthcare providers and researchers have indicated that “COVID clenching” is responsible for such contractions.

Not only has this trend correlated with a rise in orofacial pain among patients, but the damage bruxism does to patients’ teeth and jaws can also cause significant health issues for patients at risk for or currently diagnosed with OSA and other SRBDs.

How does bruxism impact oral health and sleep?

Bruxism–grinding or clenching one’s teeth–can cause or exacerbate a variety of long-term dental health issues, from oral and facial pain to enamel erosion and tooth damage. While having one’s jaw contract during sleep is common, stress–whether mental or physical–can cause muscle contractions that are strong enough to wear down patients’ teeth. 

On their own, increased damage to tooth enamel and repetitive strain on patients’ TMJs are harmful enough. However, these symptoms–in particular sleep-related bruxism–have been shown to worsen mild to moderate OSA,8 likely by contributing to airway restriction, in turn impacting patients’ long-term health outcomes.

OSA patients, especially those with moderate to severe cases, are at increased risk for several other chronic health conditions. In addition to experiencing potentially debilitating daytime sleepiness and mental and physical fatigue, OSA patients are at increased risk of developing:9

  • Cardiovascular disease
  • Hypertension
  • Type 2 diabetes
  • Cognitive impairment
  • Dementia
  • Depression
  • Mood or anxiety disorders

These conditions threaten the longevity and quality of patients’ lives. As a result, dentists and dental sleep medicine specialists should anticipate and address how COVID-related bruxism and TMJ disorders affect their patients.

How can dental sleep medicine address “COVID clenching”?

According to research in the Journal of Clinical Medicine, patients in two countries reported an increase in night-time teeth grinding from about 10% to 36%. Based on that and reports from the ADA, “COVID clenching” and the resultant health outcomes are clearly affecting a wide range of patients.

Dental healthcare providers need to be prepared to identify bruxism induced by COVID-related stress and take steps to prevent further damage to patients’ oral health and sleep conditions like OSA. Compared to other healthcare providers that OSA patients may see, dentists are uniquely positioned, trained, and qualified to administer airway and OSA screening during routine oral examinations.9 

With the apparent impacts of “COVID clenching”, patients need dental healthcare providers that are prepared to promptly diagnose and treat COVID-related bruxism and prevent future health complications. By incorporating OSA screenings and treatment options like oral appliance therapy into their practice, dental healthcare providers can better identify and meet the needs of their patients during the COVID-19 pandemic. 

Itamar Medical is a global medical device company specializing in sleep apnea diagnosis & management with the WatchPAT home sleep apnea test (HSAT).

References:

  1. Coke CJ, Davison B, Fields N, et al. SARS-CoV-2 Infection and Oral Health: Therapeutic Opportunities and Challenges. J Clin Med. 2021;10(1):156. doi:10.3390/jcm10010156 
  2. Kamel A, Basuoni A, Salem, Z. et al. The Impact of Oral Health Status on COVID-19 Severity, Recovery Period and C-reactive Protein Values. Br Dent J. 2021. https://doi.org/10.1038/s41415-021-2656-1
  3. Yamazaki, Y, Morita T, Nakai K. et al. Impact of Dental Health Intervention on Cardiovascular Metabolic Risk: A Pilot Study of Japanese Adults. J Hum Hypertens. 2021. https://doi.org/10.1038/s41371-021-00551-2
  4. Versaci MB. HPI Poll: Dentists See Increase in Patients’ Stress-related Oral Health Conditions. American Dental Association. Sept 2020. https://www.ada.org/en/publications/ada-news/2020-archive/september/hpi-poll-dentists-see-increase-in-patients-stress-related-oral-health-conditions
  5. New Survey Finds Stress-Related Dental Conditions Continue to Increase. American Dental Assocation. March 2021. https://www.ada.org/en/press-room/news-releases/2021-archives/march/new-survey-finds-stress-related-dental-conditions-continue-to-increase 
  6. Emodi-Periman A, Eli I, Smardz J, et al. Temporomandibular Disorder and Burxism Outbreak as a Possible Factor of Orofacial Pain Worsening During the COVID-19 Pandemic–Concomitant Research in Two Countries. J. Clin. Med., 2020, 9(10), 3250. https://doi.org/10.3390/jcm9103250
  7. Bruxism. Sleep Education–American Academy of Sleep Medicine. Aug. 2020. https://sleepeducation.org/sleep-disorders/bruxism/ 
  8. Martynowicz, H., Gac, P., Brzecka, A., Poreba, R., Wojakowska, A., Mazur, G., Smardz, J., & Wieckiewicz, M. (2019). The Relationship between Sleep Bruxism and Obstructive Sleep Apnea Based on Polysomnographic Findings. Journal of clinical medicine, 8(10), 1653. https://doi.org/10.3390/jcm8101653 
  9. Sleep Apnea (Obstructive). American Dental Association. Accessed Sept 3, 2021. https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive

Dental Sleep Physicians Step Up After Philips’ CPAP Recall

The U.S. product recall announced by Dutch company Philips has shaken sleep medicine practitioners and patients alike. Philips announced in June it was recalling millions of units of the Philips Bi-Level Positive Airway Pressure (Bi-Level PAP), Continuous Positive Airway Pressure (CPAP), and mechanical ventilator devices.1

While patients are being advised by Philips to consult with their doctors about whether to adjust their treatment plans, Philips has said that, in some cases, the benefits of continuing to use the devices “may outweigh the risks.”

But how about other cases? How about the newly diagnosed, or those with mild or moderate obstructive sleep apnea (OSA)? What options are available? With so many unknowns, including how serious or slight the Philips risk may be, and the lack of other CPAP resources beyond ResMed,2 what else might help patients and physicians?

What about oral appliances?

While there are no simple answers or one-size-fits-all solutions, one possibility is oral appliances. 

The American Academy of Sleep Medicine (AASM) recommends oral sleep appliances as first-line treatment options for those with mild and moderate levels of sleep apnea, as well as for individuals who are CPAP intolerant.3

As an alternative to CPAP treatment for obstructive sleep apnea (OSA), oral appliance therapy (OAT) is often deployed by dental sleep medicine practitioners, working in collaboration with referring sleep physicians.3

Studies supporting “the use of overnight pulse oximetry by dental sleep practitioners (DSPs) to confirm their patients’ response to oral appliance therapy during treatment for sleep-disordered breathing (SDB) are well documented.”3

The American Academy of Dental Sleep Medicine recommended in its treatment protocol that “dentists may obtain objective data during an initial trial period to verify that the oral appliance effectively improves upper airway patency during sleep.”

How about home sleep apnea tests (HSATs)?

The Philips recall has not changed the guidance for or the importance of continued screening and diagnostic testing for OSA. In fact, “the trend for home sleep tests is climbing [since the pandemic began], with more physicians who were not on board now embracing this process as they see returned sleep analyses in days, not weeks.”6

What do dentists say?

Commenting on the Philips recall, Pennsylvania dentist Beth Snyder, DMD said “Sleep apnea significantly impacts daytime sleepiness and quality of life, and many patients rely on a CPAP for treatment. To ensure they continue to have treatment during this recall, those suffering from OSA should know that oral appliance therapy is a proven, effective treatment option.”

With OAT, the patient wears a mandibular advancement splint, which is a mouthguard-like appliance that positions the lower jaw forward to open the airway continuously through the night. Studies have shown that patients comply better with OAT than with CPAP. 3(Studies have shown more than half of all patients who use a CPAP machine stop using it within a year due to discomfort.)3

Dr. Snyder also said “Dentists trained in dental sleep medicine work in conjunction with physicians and recommend a specific oral appliance based on a patient’s personal needs. The important thing for patients to remember is that oral appliances should always be custom fit by a trained dentist who provides follow-up care to ensure maximum effectiveness.”5

What’s next?

Philips has recommended for users of their recalled BPAP and CPAP machines to discontinue treatment.4

The AASM has stated, as regards the BPAP and CPAP machines in question, that sleep medicine professionals “discuss treatment options with the patient, taking into consideration comorbidities, severity of symptoms, risks associated with PAP discontinuation, and safety-sensitive roles.”

Further, the AASM suggests:

-when possible, consider procuring another PAP device that is not part of the recall

consider the appropriateness of alternative treatment options, including positional therapy, oral appliance therapy, and surgery. 

-consider the appropriateness of behavioral modification strategies such as weight loss, exercise, and avoidance of alcohol and sedatives before bedtime.4

(NOTE: These are only a few of the AASM suggestions, and those updated 7/16/21. Please refer to the AASM for most recent guidance.)

REFERENCES:

1

Bomey, N.  Philips recalls sleep apnea machines, ventilators over cancer risk. USA Today, Jun 15, 2021. https://www.usatoday.com/story/money/2021/06/15/philips-recall-sleep-apnea-machines-ventilators-cpap-bi-level-pap/7698074002/

2

Spear, L.  Sleep professionals scramble to find solutions for sleep apnea patients amidst Philips device recall.  Sleep Review. Jun 21, 2021. https://www.sleepreviewmag.com/sleep-treatments/therapy-devices/cpap-pap-devices/sleep-professionals-solutions-sleep-apnea-philips-device-recall/

3

Prehn, RS, ThM, DDS. Using overnight pulse oximetry to manage oral appliance therapy. Sleep Review. Oct 2, 2015. https://www.sleepreviewmag.com/uncategorized/overnight-pulse-oximetry-manage-oral-appliance-therapy/

4

American Academy of Sleep Medicine. AASM guidance in response to Philips recall of PAP devices. Jun 18, 2021 (updated July 16, 2021). https://aasm.org/clinical-resources/guidance-philips-recall-pap-devices/

5

WFMZ-TV NEWS. Local dentist responds to Philips recall notification of sleep apnea device. Jun 22, 2021. https://www.wfmz.com/news/area/southeastern-pa/local-dentist-responds-to-philips-recall-notification-of-sleep-apnea-device/article_cdaaa1d6-d37b-11eb-bcbf-4b5df345c2ee.html

6

Bello, T. The future of home sleep testing & CPAP patient compliance and resupply: A new normal in sleep. HomeCare. May 7, 2021. https://www.homecaremag.com/may-2021/future-home-sleep-testing-cpap-patient-compliance

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How dentists can holistically assess obstructive sleep apnea patients 

Obstructive sleep apnea poses a whole-body threat to patients’ quality and longevity of life. Interrupted sleep and repetitive loss of oxygen can severely impact OSA patients’ long-term health, as they experience hundreds to thousands of apnea or hypopneas over the progression of this condition. Having OSA means patients have a higher risk of numerous life-threatening chronic conditions, including cardiovascular disease, hypertension, cancer, dementia, and Type 2 diabetes.1

Dentists and dental sleep specialists often rely on the Apnea-hypopnea index (AHI) to assess patients’ OSA severity and progression. Increasingly, clinical case studies and research into sleep medicine are bringing into question how effective maintaining this decades-old diagnostic practice is for patients’ health outcomes.

Is AHI always a reliable measure of OSA severity?

AHI measures how often a patient experiences obstructive or mixed apnea or hypopneas, expressed as a rate of discrete apnea/hypopnea incidences per hour. For decades, sleep medicine researchers and healthcare providers working in sleep medicine have used this metric to establish cutoffs to the segment OSA population by severity:1,2

  • No diagnosis: Less than 5 AHI
  • Mild OSA: 5 to 15 AHI: Mild OSA
  • Moderate OSA: 15 to 30 AHI: M
  • Severe OSA: 30 AHI

For decades, researchers, dentists, and sleep medicine specialists have used these cutoffs as a way to consistently assess patients’ severity and progression of OSA. 

But some researchers have found the consistency and reliability of this index questionable, particularly because different entities–including the American Academy of Sleep Medicine (AASM) and the Centers for Medicare and Medicaid Services(CMMS)–have different understandings of AHI.2 

AASM and CMMS each use one of the two common definitions of AHI that use different criteria to determine when interrupted breathing during sleep constitutes hypopnea. The AASM follows the definition that states hypopneas occur when “either an electroencephalogram arousal or ≥ 3% oxygen desaturation” are detected(3%ODA), whereas the CMMS’s preferred definition upholds a less inclusive standard, requiring more than 4% oxygen desaturation to consider interrupted breathing a hypopnea.2

Based on a meta-analysis of over 30 studies, having two different AHI definitions in use in the field of sleep medicine can result in real-world consequences for patient outcomes. The analysis found that 17% of study participants would qualify for an OSA diagnosis under the 3%ODA criteria but not if the 4%OD definition was used. These findings, among others, call into question whether health care providers like dentists and dental sleep specialists should rely on AHI alone to assess patients showing signs of OSA.

How can dentists and dental sleep specialists assess OSA patients beyond AHI?

IN addition to inconsistent definitions of AHI, the index alone can correlate poorly with other measures of OSA severity, which is why dentists and dental sleep specialists need other ways to assess OSA patients. Research has shown that measures of excessive daytime sleepiness–one of the most debilitating day-to-day symptoms of OSA–often do not correlate with OSA severity metrics that are solely based on AHI.3

According to Dr. Steve Lamberg, health care providers treating OSA patients should adopt a more holistic approach to screening and staging OSA, rather than relying on AHI alone to determine disease progression and severity.4 

Instead of focusing on the rate of “scored” apneas and hypopneas that patients experience during sleep, Dr. Lamberg recommends that health care providers focus on the combination of disease process and activity level by staging and grading sleep-related breathing disorders (SRBD) like OSA. 

Healthcare providers can categorize patients’ current OSA severity and systemic damage from Stages 1 to 4, measuring tissue damage due to interrupted breathing using:

  • Patients’ medical history
  • Results from the Lamberg Questionnaire v14
  • Physical examinations
  • Laboratory testing

At the same time, providers can assess the risk that a patient’s SRBD will progress, ranging from Grade A (little to no progression) to Grade C (rapid progression) based on a range of systemic inflammatory biomarkers.

Scoring and grading OSA patients enables better long-term care and health outcomes

This approach takes into account the varied rates of sleep interruption as well as how patients suffer different levels of oxygen deprivation, particularly among those that more often experience hypopneas rather than complete apneas.

Taking a scoring and grading approach allows dentists and dental sleep specialists to more holistically assess where patients fall within the broad range of OSA presentations. In the long run, this approach also supports more focused and effective treatments compared to using strict cutoffs based on AHI alone as a diagnostic model. 

Itamar Medical is a global medical device company specializing in sleep apnea diagnosis & management with the WatchPAT home sleep apnea test (HSAT).

References:

  1. American Dental Association. Oral health topics – Sleep apnea (obstructive). https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive. Accessed July 22, 2021.
  2. Kapur VK, Donovan LM. Why a single index to measure sleep apnea is not enough. Journal of Clinical Sleep Medicine. 2019;15(5):683–684. https://jcsm.aasm.org/doi/10.5664/jcsm.7746 
  3. Cielo CM, Tapia IE. Diving Deeper: Rethinking AHI as the Primary Measure of OSA Severity. Journal of Clinical Sleep Medicine. 2019;15(8):1075-1076. doi:10.5664/jcsm.7856.
  4. Lamberg, Transcending AHI. Dental Sleep Practice. https://dentalsleeppractice.com/transcending-ahi/. Accessed July 22, 2021
im blog osa nfl

Study Title: Obstructive sleep apnea among players in the National Football League: A scoping review

Authors: April J. Rogers, Kevin Xia, Kyaw Soe, Azizi Sexias, Felix Sogade, Barbara Hutchinson, Dorice Viera, Samy I. McFarlane, Giarardin Jean-Louis

Background:

Obstructive sleep apnea (OSA) – a condition associated with significantly reduced quality of life and chronic health risks – has become increasingly prevalent in the last ten years. As a result, this sleep disorder and its treatment have become a public health concern that needs attention from health care providers from a range of disciplines.

OSA presents as repeated loss of airflow during sleep, which results in disrupted, poor quality rest. People suffering from OSA experience lower metabolism, reduced cognitive function, and excessive daytime sleepiness. Adults with a high body mass index (BMI) and/or a large waist circumference relative to their height have a higher risk of developing OSA.

Often occurring comorbidly, both medical obesity and OSA increase patients’ risk of cardiovascular diseases like hypertension and arteriosclerosis. These conditions can exacerbate one another, even among professional athletes. In the US, OSA affects between 2% and 5% of the general population, while the National Football League (NFL) sees OSA rates of between 14% and 19%.

Historically, NFL players have exhibited higher rates of obesity, which may explain in part the league’s elevated rates of OSA. Many prominent NFL players have been diagnosed with the condition, and additional research could illuminate how OSA has affected current and former players’ health and the long-term effects the condition has had on this unique population.

Study Objective: To conduct a scoping review that assesses current literature on obstructive sleep apnea and its impact on NFL players. This review outlines what associations between OSA and poor health outcomes have been investigated regarding the NFL community and indicates important areas for future research.

Methodology: This study applies a scoping review methodology to evaluate and provide an overview of how OSA impacts the cardiovascular health of professional American football players based on over 30 years of literature. To identify studies to include in this review, researchers defined search terms related to the population of interest (NFL players), cardiovascular health conditions (i.e., hypertension, heart disease, heart failure, or vascular disease), and sleep-disordered breathing. Then, peer-review articles were manually screened for relevance.

Results/Discussion:

  • On average, NHL linemen weigh over 300 pounds, which traces back to obesity trends at the college level. Comparatively, there were 30 times as many players over 300 pounds in 2017 as there were in 1986.
  • Studies on the effect of OSA on NFL lineman specifically are lacking, as this population likely affected even more so than the general population of players.
  • NFL players likely suffer significant negative effects on both their cardiovascular health and daytime performance from OSA, which would impact their short- and long-term quality of life, as well as their overall health.

To better understand how OSA has affected players’ long-term cardiovascular health, clinicians need more peer-reviewed research on these associations.

Conclusion: The results of this literature review show that, although available research shows that NFL players exhibit signs and risk factors of OSA (including obesity, cardiovascular disease, hypertension), there is a significant gap in available research for this population. Health care providers commonly recommend weight loss to OSA patients to reduce their symptoms, but this may not be a viable option for current players, as well as those in other professions that require them to retain a certain physique. For such patients, OSA treatments like CPAP or oral appliance therapy may be the best option to reduce or control their symptoms and improve their quality of life and long-term health.

Reference:

  1. Rogers AJ, Xia K, Soe K, Sexias A, Sogade F, Hutchinson B, Viera D, McFarlane SI, Jean-Louis G. Obstructive sleep apnea among players in the National Football League: A scoping review. Journal of Sleep Disorders & Therapy, 6(5): 279. https://dx.doi.org/10.4172%2F2167-0277.1000278
dental blog

Study Title: Efficacy Versus Effectiveness in the Treatment of Obstructive Sleep Apnea: CPAP and Oral Appliances

Authors: Kate Sutherland, Craig L. Phillips, Peter A. Cistulli

Background: 

Obstructive sleep apnea (OSA) has become increasingly prevalent in recent years, in part due to the rise in obesity. The condition, which involves upper airway obstruction during sleep, causes disrupted sleep and hypoxia. As a result, people with OSA experience a higher risk of all-cause mortality, as well as

  • Daytime sleepiness
  • Reduced quality of life
  • Workplace accidents
  • Motor vehicle accidents
  • Hypertension
  • Cardiovascular disease
  • Type 2 diabetes

People with OSA need effective, long-term treatment options, both to alleviate OSA symptoms and to prevent the serious health risks linked to this dangerous sleep disorder. When treating patients with chronic conditions like OSA, health care providers select treatments that offer the best long-term health outcomes. Providers need to distinguish between treatment efficacy and treatment effectiveness, which are how well treatments work under ideal and real-world conditions, respectively.

Continuous positive airway pressure (CPAP) therapy, which uses pressurized air to open collapsed airways, is the standard OSA treatment because of its high efficacy. However, low compliance from patients often undermines CPAP therapy’s long-term effectiveness. Oral appliance (OA) therapy, which dentists can custom fit for patients, offers an alternative treatment for OSA.

When studying the effectiveness of these 2 treatments, patient compliance can be represented as a ratio of treatment usage to total sleep time. Understanding the impact usage rates have on each treatment’s overall effectiveness helps illustrate their potential outcomes in real-world settings.

Study Objective:

To compare the overall treatment efficacy and effectiveness profiles of CPAP therapy and OA therapy using measures of patients’ apnea-hypopnea index (AHI) versus their Sleep Adjusted Residual AHI (SARAH Index). The objective measurement of OSA treatment effectiveness represents the combined effect of treatment efficacy and patient compliance for patients with OSA. 

Methodology:

This study used objective data downloads from CPAP machines and objective compliance monitors for oral appliances to verify patient usage patterns. The analysis incorporated data from 108 participants with moderate-severe OSA who received 1 month of each optimized treatment: CPAP and OA therapy. Treatment efficacy and effectiveness were calculated and compared using the AHI and the SARAH Index.

Results:

  • Between CPAP and OA therapy, patients with moderate-severe OSA experienced no significant differences in health outcomes, including measures of cardiovascular health, neurobehavioral indicators, or quality of life
  • Hypertensive patients experienced reduced blood pressure during sleep when using each treatment
  • While OA therapy had lower efficacy, CPAP therapy had significantly lower usage rates  

Treatment with OA therapy resulted in residual OSA compared with CPAP therapy (AHI 4.5 ± 6.6 vs 11.1 ± 12.1/h); however, on average, OA therapy users reported an additional 1.3 hours of usage (95% of sleep time) and 50% improvement in AHI.

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Conclusion/Discussion:

The results of this study indicate how OA therapy, despite its lower efficacy, can deliver similar real-world health outcomes as CPAP therapy. In controlled settings, CPAP therapy consistently reduces patients’ AHI. However, the higher usage rates of OA therapy (+1.3 hours per night) increased the overall effectiveness, especially for patients with poor CPAP compliance or longer sleep periods. Median treatment AHI for CPAP therapy was 4.7 hours; however, up to 50% of OSA patients use CPAP therapy for less than 4 hours per night. Additionally, as patients saw similar improvements in daytime sleepiness, nighttime hypertension, and overall quality of life, OA therapy’s real-world effectiveness may outweigh CPAP therapy’s clinical efficacy for patient health.

References:

  1. Sutherland K, Phillips CL, Cistulli PA. Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances. J Dent Sleep Med.2015;2(4):175-181. doi.org/10.15331/jdsm.5120 
dental blog

Study Title: Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing

Authors: Olivier M. Vanderveken, Marijke Dieltjens, Kristien Wouters, Wilfried A. De Backer, Paul H. Van de Heyning, Marc J. Braem

Background: 

Continuous positive airway pressure (CPAP) therapy is considered the gold standard for the treatment of obstructive sleep apnea (OSA) because of its high rate of therapeutic effectiveness. Measuring CPAP compliance has become a routine part of clinical practice, and objective compliance measurements have been built in. Unfortunately, these data indicate that clinical effectiveness of CPAP therapy is often restricted due to low patient acceptance, poor tolerance, and suboptimal compliance.  

Oral appliance (OA) therapy, which can be administered by a dentist, can be used as an alternative to CPAP for sleep-disordered breathing (SDB). And while the effectiveness of OA therapy has been demonstrated in patients with sleep apnea, little has been reported about patient compliance due in part to the lack of objective compliance measurements. 

Study Objective:

To assess the safety and feasibility of an objective measurement of compliance during OA therapy using an embedded microsensor thermometer with on-chip integrated readout electronics. The objective measurement of OA compliance enables the calculation of the mean disease alleviation (MDA) as a measure of OA effectiveness.

Methodology:

This was a 3-month prospective clinical trial that included 51 consecutive patients with an established diagnosis of SDB (apnoea/hypopnoea index [AHI] 18.0 ± 11.9/h; aged 47 ± 10 y; body mass index [BMI] 26.6 ± 4.0 kg/m2; men/women: 31/20). Patients were unaware of the purpose of the study.

Results:

  • No adverse events were reported related to the compliance monitoring illustrating the safety of this device
  • No patients discontinued therapy during the 3-month study period 
  • Oral appliance therapy was used on 91.9% ± 10.8% days per week for an average of 6.7 ± 1.3 hours per day

The use of OA therapy resulted in statistically significant decreases in AHI (P<0.001), oxygen desaturation index  P<0.01, sleepiness, and snoring (P<0.001).

Conclusion/Discussion:

The results of this study illustrate the safety and feasibility of objective measurement of OA compliance. In addition, the high rates of OA use seen in this study illustrate that compliance is likely not a limitation in the use of these devices for the treatment of OSA and SDB. While the effectiveness of CPAP therapy is clinically superior to that of OA, when compliance is considered, the adjusted effectiveness may be similar. 

References:

  1. Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van de Heyning PH, Braem MJ. Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax. 2012;68(1):91-96.
A Closer Look at the Visible Signs of Sleep Apnea

Sleep health has an incredible impact on long-term patient wellness, and dental health is no different1. In honor of National Sleep Awareness Week, March 14-20, dentists should take time to understand what patients’ teeth can reveal about their sleep quality and their overall health. 

This visual guide outlines the visible signs and common symptoms associated with obstructive sleep apnea (OSA). The American Dental Association (ADA) has identified several indicators that patients likely suffer from obstructive sleep apnea2, including:

  • Bruxism
  • Large or scalloped tongue
  • Retrognathia
  • Narrow/obstructed airway

Those suffering from OSA have a higher risk of experiencing heart disease, obesity, and diabetes, among other chronic illnesses2. As OSA is often underdiagnosed, dentists who remain educated on how to identify these visible signs will be able to advocate for and help these patients.

Learn These Four Visible Signs of Sleep Apnea

The characteristics that present the most dramatic visible indicators, their associated.

In recent years, the American Academy of Dental Sleep Medicine (AADSM) has advocated for standardization of diagnostics and treatment in dental sleep medicine3. A large part of that effort focuses on developing consistent dental education materials that show how sleep disorders like OSA may present in patients. 

Practicing dentists should seek continuing education to recognize and manage their patients’ sleep disorders effectively. For OSA specifically, the characteristics that present the most dramatic visible indicators, their associated symptoms, and their typical presentations are as follows.

The characteristics that present the most dramatic visible indicators, their associated.

symptoms, and their typical presentations are as follows.

Bruxism

Bruxism

Bruxism, or teeth grinding, presents as excessive dental attrition, particularly along the incisal and occlusal surfaces of teeth.3 Unlike normal attrition, which occurs from day-to-day wear and tear, bruxism significantly damages dental crowns and exposes the fragile dentin beneath.

Over time, the mandible and maxilla bones, and therefore the upper and lower gums, come closer together as the enamel and dentin wear away and teeth take on a flattened shape3, as shown in this image (data on file). This contributes to the oral obstruction responsible for OSA symptoms.

Bruxism, or teeth grinding, presents as excessive dental attrition, particularly along the incisal and occlusal surfaces of teeth.4 Unlike normal attrition, which occurs from day-to-day wear and tear, bruxism significantly damages dental crowns and exposes the fragile dentin beneath.

Over time, the mandible and maxilla bones, and therefore the upper and lower gums, come closer together as the enamel and dentin wear away and teeth take on a flattened shape4, as shown in this image (data on file). This contributes to the oral obstruction responsible for OSA symptoms.

Over time, the mandible and maxilla bones, and therefore the upper and lower gums, come closer together as the enamel and dentin wear away and teeth take on a flattened shape3, as shown in this image (data on file). This contributes to the oral obstruction responsible for OSA symptoms.

Large or Scalloped Tongue

Large or Scalloped Tongue

Patients with OSA often present with a scalloped tongue5, as pictured here (data on file). A scalloped tongue will appear swollen or puffy. Often, patients unconsciously push their tongues into their mandibular teeth as they strain to breathe while asleep. This leaves visible waves or notches that form uneven ridges on the perimeter of the tongue surface.

Retrognathia

Retrognathia

As the illustration shows (data on file), retrognathia is a specific type of malocclusion in which the maxillary teeth overhang mandibular teeth. This is also known as overclosure6, a form of teeth misalignment that is especially common among patients with bruxism. Retrognathia can worsen the vertical collapse seen in bruxism sufferers, which further constricts patient airways as seen in OSA.7

Narrow or Obstructed Airway

Narrow or Obstructed Airway

The American Dental Association describes this visible sign of OSA as “increased volume of lateral pharyngeal walls, tongue and total soft tissue.”2 As shown in these illustrations and images (data on file), obstructed airways can leave very little room for sufferers to intake full breaths of air, which is why OSA can interrupt patients’ sleep hundreds of times in a single night1.

Conclusion

These four physical characteristics are among the most dramatic visible indicators of obstructive sleep apnea found in the oral cavity.2 When dentists learn to identify these indicators and the symptoms that accompany them, patients with undiagnosed OSA are more likely to receive effective care that improves their oral health, as well as their longevity and quality of life.1

In addition to continuing education, the AADSM recommends that dentists who treat patients with OSA acquire some form of accreditation in sleep medicine3. This can include certification from a non-profit working in dental sleep medicine or an official designation based on clinical experience in the field. Doing so ensures that dentists are providing OSA patient with consistent, high-quality care that adheres to professional and ethical standards.

References:

  1. American Academy of Dental Sleep Medicine. Obstructive Sleep Apnea. https://www.aadsm.org/obstructive_sleep_apnea.php. Accessed March 17, 2021.
  2. American Dental Association. Oral Health Topics – Sleep Apnea (Obstructive). https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive. Accessed March 17, 2021.
  3. Levine M. Bennet K.M. Cantwell M.K. Postol K. Schwartz D.B. Dental sleep medicine standards for screening, treating, and managing adults with sleep-related breathing disorders. Journal of Dental Sleep Medicine. http://dx.doi.org/10.15331/jdsm.7030. Accessed March 24, 2021.
  4. James L. Clinical signs of bruxism. Dentalcare.com. https://www.dentalcare.com/en-us/professional-education/ce-courses/ce485/clinical-signs-of-bruxism. Accessed March 17, 2021. 
  5. Holland K. What causes a scalloped tongue? Updated March 7, 2019. Healthline. https://www.healthline.com/health/scalloped-tongue
  6. James L. Occlusion. Dentalcare.com. https://www.dentalcare.com/en-us/professional-education/ce-courses/ce485/occlusion. Accessed March 17, 2021. 
  7. Jenzer AC. Retrognathia. StatPearls [Internet]. Published July 7, 2020. https://www.ncbi.nlm.nih.gov/books/NBK538303/.. Accessed March 17, 2021.
Dental screening

Experts assert to effectively treat patients, dentists should be aware of chronic conditions that impact overall health. Often, this requires dentists to be prepared to diagnose these conditions themselves.1 In particular, obstructive sleep apnea (OSA) represents a nexus of underdiagnosed disease that compromises overall health and directly relates to dental care.2 As such, dentists could incorporate diagnostic tools like home sleep apnea tests (HSATs) into their practice to improve how patients with this condition can access and experience treatment. And because sleep apnea is a key risk factor for cardiovascular disease and other chronic conditions, OSA screening is a great way for dentists to elevate their role in patients’ overall healthcare.2

How Dentists Can Play a Key Role in Patients’ Overall Health

Due to their knowledge of oral cavity and craniofacial structures, studies say dentists occupy a uniquely qualified position to screen patients for anatomical signs and physiological symptoms of OSA.1,2 Using a combination of clinical examinations and home sleep apnea tests, dentists could potentially recognize the visible signs of undiagnosed OSA as described by the American Dental Association that other health professionals may not have the opportunity to uncover.

Dentists’ involvement in OSA treatment has been shown to deliver improved long-term outcomes and patient satisfaction when compared to medical care alone, through patient education, regular oral examinations, and oral fittings for oral appliances that treat sleep apnea.2,4,5

The Link Between Sleep Apnea and Dental Care

Despite OSA’s disruptive nature, patients may only perceive their symptoms as simple restless sleep, snoring, or daytime drowsiness without a specific cause2. Obstructive sleep apnea is particularly relevant to dental care because of its inherent involvement in oral health and anatomy. Many of the signs and symptoms that potentially indicate an OSA case can be observed while conducting a patient history or a bi-annual oral exam during dental care, including2:

  • Bruxism
  • Scalloped tongue
  • Retrognathia
  • Large tonsils
  • Retrusive jaw
  • Large neck circumference

After taking a clinical exam and administering relevant questionnaires, dentists can provide patients with home sleep tests to put them on a path to confirm a diagnosis of obstructive sleep apnea and show patients whether they are experiencing more than a simple poor night’s rest.2 Home sleep tests like the WatchPAT® One device serve to help a dentist incorporate this additional business stream into their practice very easily, for the dentists themselves, additional staff, and their patients, for whom lab sleep studies may seem a burden.

Dentists Can Act as a Supplement to Medical Care

Left untreated, obstructive sleep apnea poses danger to both patients’ quality and quantity of life. Studies clearly show systemic illnesses like cardiovascular disease and hypertension directly impact oral health, and vice versa, so dentists could consider equipping their practices with appropriate tools to identify dangerous conditions like OSA. Home sleep apnea tests are a useful diagnostic tool that are a cost-effective way to assess potential OSA in patients exhibiting typical symptoms. 

By adopting effective, convenient tools for OSA screenings into their practice, such as a home sleep tests, dentists can refer and treat previously undiagnosed patients early and accurately. This allows patients to receive sleep apnea care that integrates dental expertise when needed.4 Gathering information through clinical exams, sleep apnea devices, and patient questionnaires, dentists are able to fill the role of “oral physicians,” to the benefit of the health of the patient and the community.3

Dental OSA Screenings Improve Long-term Outcomes and Patient Satisfaction

When operating in the role of “oral physician,” dentists have two distinct advantages regarding primary healthcare screenings:

  • Dentists likely see patients more often, as patients are used to making and keeping dental appointments twice a year.1
  • Patients with diagnosed OSA largely prefer oral appliance therapy (which dentists can custom fit for patients) over traditional CPAP therapy.5

Dentists who screen patients for OSA with home sleep apnea tests will be involved in treatment of the condition from the start. Working in conjunction with patients’ medical care teams, dentists can be called upon to provide properly fitted sleep apnea devices that patients prefer over positive airway pressure (PAP) machines.

CPAP Therapy vs. Custom-Fit Oral Appliances

As many as 50% of patients prescribed CPAP therapy either fail to fulfill their prescription or stop treatment before indicating, primarily because of mask discomfort.4 In addition to mask discomfort, OSA patients may also experience oral dryness and nasal congestion. 

These side effects contribute to poor patient adherence and satisfaction with OSA treatment, which is why dentists can make a significant difference in patients’ long-term health. Without consistent treatment, patients with OSA will struggle with chronic exhaustion, poor attentiveness, lowered productivity, and anxiety.4

In contrast, oral appliance therapy often results in greater treatment adherence and success among patients with mild to moderate OSA. For those who struggle with the discomfort of CPAP therapy, their dentists can custom-fit oral appliances that are much easier to sleep with comfortably.2,5

Conclusion

As a result of their specialized expertise, dentists provide a convenient and logical avenue to identify obstructive sleep apnea in patients.1 Unlike other healthcare professionals, dentists are more likely to see patients for frequent follow-up visits, which makes them an accessible source for primary care screenings patients may not otherwise receive.3

In addition to the above advantages that dentists have in being the one to make a difference in a OSA patient’s life, WatchPAT® One, the only fully disposable home sleep apnea test, can integrate into dental practices seamlessly with little to no investment. By monitoring OSA patients and remaining involved in their care, dentists can elevate their role in collaborative healthcare that puts patient health first.

References:

  1. Lavanya R, Gandhi Babu DB, Chavva S, Boringi M, Waghray S, Yeladandi M. The role of oral physicians in predicting the risk of obstructive sleep apnea: A case-control study. Imaging Sci Dent. 2016 Sep;46(3):167-171. https://doi.org/10.5624/isd.2016.46.3.167 
  2. Oral health topic – Sleep apnea (obstructive). American Dental Association. https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive
  3. Gambhir RS. Primary care in dentistry – an untapped potential. J Family Med Prim Care. 2015;4(1):13-18. https://doi.org/10.4103/2249-4863.152239 
  4. Knight V. I’m a CPAP Dropout: Why Many Lose Sleep Over Apnea Treatment. Khn.org. https://khn.org/news/im-a-cpap-dropout-why-many-lose-sleep-over-apnea-treatment/. Published July 17, 2019. Accessed February 2, 2021.
  5. Callender E. Treatments for Obstructive Sleep Apnea. Sleepfoundation.org. https://www.sleepfoundation.org/sleep-apnea/obstructive-sleep-apnea/treatments. Updated September 4, 2020. Accessed February 2, 2021.
Dentist

Dental medicine should always be a part of comprehensive care that puts patient health first according to the American Academy of Sleep Medicine (AASM)4 and the American Academy of Dental Sleep Medicine (AADSM).5 Based on American Dental Association (ADA) recommendations, dentists like you are “ideally positioned to identify oral or craniofacial abnormalities” that impact patients’ overall healthcare1.

These organizations assert that when evaluating new patients, dentists should screen for (and potentially treat) obstructive sleep apnea (OSA), a dangerous sleep disorder affecting many Americans’ overall physical and dental health today1. Just as oral cancer screening has become standard in dental care, the ADA has advocated for OSA screening to become part of dental practice.

Doing so will allow you to provide appropriate, collaborative dental care that supplements ongoing medical treatment and improves long-term health outcomes in your practice.

Obstructive Sleep Apnea Prevalence and Risks

In the US, obstructive sleep apnea represents over 80% of sleep-related breathing disorders2, affecting as many as 54 million American adults today1.

According to the AADSM, sleep dentistry is among the fastest growing specialties in dental medicine1. Providing OSA screening as part of dental practice means you may be helping to provide much needed care for this growing patient population.

In addition to leading to a variety of dental problems, OSA is correlated with several life-threatening comorbid conditions that can impact your patients medical and dental care3, including:

  • Cardiovascular disease
  • Type II diabetes
  • Hypertension
  • Stroke
  • End-stage renal disease

Beyond these chronic conditions, OSA is correlated with a variety of dental and oral health issues4, such as:

  • Bruxism
  • Enlarged or scalloped tongue
  • Periodontal disease
  • Battered uvula

Identifying whether your patients meet criteria for an OSA diagnosis may allow you to offer collaborative care with their medical providers and provide insight into other dental issues they may have down the line.

OSA-related Risk Factors and Symptoms

Dentists looking to incorporate OSA screening into their care should learn signs of OSA as well the condition’s related risk factors. OSA screening may be indicated for patients exhibiting the following features or symptoms2

  • Large tongue or tonsils
  • Large neck circumference
  • Nocturnal choking or gasping
  • Obesity
  • Loud snoring
  • Interrupted breathing during sleep
  • Daytime sleepiness or exhaustion

As OSA is a common and dangerous sleep disorder when left untreated, providing OSA screenings may improve the quality of dental care your patients receive. 

Importance of OSA Screening in Dental Care

Patients may communicate or show some of the above features during standard patient history intake. However, OSA sufferers are often unaware of OSA-related symptoms that are interrupting their sleep and causing them to feel poorly rested over time3

When patients are unaware that they are sleeping poorly due to interrupted breathing while sleep, they are unlikely to seek care, which explains why OSA is underdiagnosed. Screenings that you provide in your dental practice may help undiagnosed OSA sufferers identify an overlooked and dangerous threat to their health.

Using at-home diagnostics like the WatchPAT® ONE or WatchPAT® 300 sleep apnea monitor can make these screenings accessible and cost effective, not only for you and your practice, but for your patients as well. In addition to the above benefit, choosing to recommend a home sleep apnea test (HSAT) to a patient showing visible signs prevents additional steps, time and confusion. Patients tend to prefer the notion of being able to utilize an HSAT over a study that must be performed in a lab or facility. 

While in-lab screenings may be necessary for complex cases3, home sleep apnea testing devices are a preferrable option for many patients, saving time and money. Providing HSAT options in your practice will allow you to integrate this important step into your practice quickly and with ease.

Integrating Home Sleep Apnea Tests into Your Practice 

Those trained in sleep dentistry are uniquely qualified to help identify and care for dental patients with OSA. Although it is estimated that a staggering 1 in 15 Americans suffer from OSA, the majority of these patients remain undiagnosed2.

Dental patients seeking care may not know that their OSA diagnosis impacts their dental care or even that they have OSA at all. But, once you integrate OSA screenings into your practice, not only is it possible for you to work with other medical care providers, but you may also be able to offer specially fitted oral appliances that could serve as a more patient-friendly alternative to CPAP therapy, as recommended by the AASM4 and the AADSM.5

Providing OSA-diagnosed patients with this option could simultaneously benefit your practice and your patients by expanding your patient pool and revenue stream while maybe offering OSA patients a sleep apnea treatment option that they may find more comfortable and less noisy to use while sleeping. And, as sleep dentistry has become more prevalent, you have a variety of oral appliance companies with which your practice can partner and offer this kind of care.

Conclusion

According to leading field experts, integrating sleep dentistry into your practice can improve the specialized dental care available for the large number of patients suffering from OSA5. With disposable home sleep apnea test devices like WatchPAT® ONE, you can integrate OSA screening into your practice with a seamless solution that is accessible and super easy to use for your practice and patients.

References:

  1. Obstructive Sleep Apnea. American Academy of Dental Sleep Medicine. https://www.aadsm.org/obstructive_sleep_apnea.php
  2. Oral Health Topics – Sleep Apnea (Obstructive). American Dental Association. https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive
  3. Motamedi KK, McClary AC, Amedee RG. Obstructive sleep apnea: a growing problem. Ochsner J. 2009;9(3):149-153.
  4. Padma A, Ramakrishnan N, Narayanan V. Management of obstructive sleep apnea: A dental perspective. Indian J Dent Res. 2007;18(4):201-209. doi:10.4103/0970-9290.35833 
  5. Oral Appliance Therapy Should be Prescribed as a First-Line Therapy for OSA during the COVID-19 Pandemic,  Schwartz, et al.,  JDSM, Vol. 7, No.3 2020