Dental Sleep Medicine in the 21st century
Recent advances in sleep technology, 3D digital imaging and molecular genetics have given new insights into the role that dentists play in dental sleep medicine. It is important to appreciate that dental sleep medicine is a multi-disciplinary endeavor with a team of professionals that aim to achieve maximum medical benefit for their patients. Another important concept is to understand that obstructive sleep apnea is one slice in the broad spectrum of sleep medicine, so professional collaboration and cooperation with sleep specialists is the key to successful patient outcomes. There are other historic examples of professional multi-disciplinary teams. For example, patients with craniofacial pain, and children born with cleft lip and/or palate, are best managed by a team that includes both medical and dental personnel. Therefore, this article provides a brief overview of some new concepts that lie in the hands of dentists working towards improved systemic health of their patients by addressing the putative root causes of OSA.
It is now firmly established that OSA is a relatively common, serious, medical condition that can affect both the quality and quantity of life of patients. But many patients are unaware of this life-threatening condition until a serious medical complication, such as a stroke or heart attack, suddenly occurs; while others believe that CPAP is the only solution. However, research is showing that oral appliances can play a significant role in treating this condition in both adults and children. On the other hand, apart from the unwanted side effects of mandibular advancement devices (MADs), such as occlusal changes and TMJ issues, life-time wear of MADs during sleep is mandatory, similar to CPAP, if the condition is to be managed. Alternatively, a biomimetic approach might be adopted.
Biomimetics (biomimicry) is a science that studies natural models and uses these designs and processes to solve human health issues. For example, in modern humans (homo sapiens sapiens), the natural design includes 32 teeth symmetrically-arranged within the craniofacial architecture. This pattern is achieved through developmental processes (e.g. temporo-spatial patterning) that are encoded within the human genome, including growth and development of the jaws and eruption of the teeth. Figure 1 shows an adult patient who underwent biomimetic appliance therapy using an FDA-cleared device (mRNA appliance®). This biomimetic approach remodels the upper airway  and provides combined maxillo-mandibular correction . The appliance is worn in both the evening and at night, and this protocol allows the body to redevelop the midface , as well as remodeling the upper airway in adults , while gently correcting the positions of the teeth and mandible into a more natural position . Note that in Figure 1 the upper airway volume is significantly increased, from 2.2cm3 pre-treatment to 12.6cm3 with no appliance in the mouth when the post-treatment CBCT CT scan was taken. In addition, the minimum retroglossal surface area increased from 41mm2 to 306mm2 after treatment. Therefore, these innovative solutions might provide a more natural way to improve snoring, the upper airway and OSA in various patients.
It is known that other oral appliances can also be used to manage snoring and OSA but these are predominantly MADs that are typically titrated to protrude the lower jaw. However, mandibular advancement might not always be appropriate for African-American and Asian patients  and other patients with Class III malocclusions that have been diagnosed with OSA. In addition, MADs are worn over a lifetime, but do not address the underlying etiology of the condition, similar to CPAP. The biomimetic technique is different from other appliance protocols because instead of simply repositioning the mandible, the devices are worn during the evening and at nighttime while asleep, to allow the body to gently increase midfacial bone volume , increase the volume of the upper airway , including the nasal airway , and re-coordinate the lower jaw, sometimes to the extent that the underlying issues appear to be eliminated in some cases  by the end of active treatment with no device in the mouth when the post-treatment sleep studies are performed [1, 9]. The biomimetic protocol is painless and does not involve surgery, drugs or injections. Somewhat similar to the way that orthodontics moves teeth and orthopedics reshapes bone, a biomimetic technique for upper airway remodeling (Pneumopedics®) is used to re-develop the upper airway (Figure 3) so that the underlying OSA can be resolved. This pneumopedic procedure typically lasts about 18-24 months, although some cases can take longer and some cases respond faster, but the initial effects can be felt in the first few nights.
Pneumopedics® and Craniofacial Epigenetics, includes epigenetic orthodontics. In adults and children, both tooth alignment and facial appearance can be improved , using the concepts noted above. The craniofacial region includes the face, the teeth, the jaws and the upper airway. Craniofacial epigenetics is used to improve these structures, by using biomimetic appliances that utilize a patient’s natural genes; their genetic potential. Here, I define genetic potential as “achieving an optimized outcome in the prevailing conditions, subject to a viable population of stem cells”. In other words, as long as undifferentiated (adult, mesenchymal) stem cells are available, a biomimetic protocol might be able to address human craniofacial health issues. Figure 2 shows an adult patient who underwent biomimetic appliance therapy using an FDA-registered Daytime-Nighttime Appliance® (DNA appliance®). This device is worn during the late afternoon, early evening and all night during sleep. It is not worn during the day and not while eating. This biomimetic device allows the body to gently realign the teeth [4, 5], increase the size of the jaws , improve facial symmetry [4, 5] and increase the volume of the airway  even it adult patients.
In addition, the DNA appliance® protocols are effective in addressing issues such as TMD/TMJ and headaches  in adults through natural, craniofacial enhancement, utilizing these new protocols that harness a patient’s genetic potential to improve their craniofacial and system health. Guilleminault and Stoohs  regard OSA as a craniofacial issue. Therefore, Pneumopedics® and Craniofacial Epigenetics might represent a craniofacial solution for dental sleep medicine in the 21st century.
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