Obstructive sleep apnea and oral appliances: Vivos Dental Technologies pushes boundaries, transforms lives
When heart palpitations strike, it is no joke. Often, it is dismissed as your typical episode of anxiety disorder or a scenario-based occurrence. However, coupled with memory loss and fatigue, it can be an indication of something far more concerning.
If you ask if someone snores or has sleep apnea, he or she probably tell you to ask their spouse. Despite the fact this person is living with it, it is just not obvious.
Obstructive sleep apnea (OSA) is a disorder in which relaxed tissue in the throat periodically blocks the upper airway during sleep; as a result, the sufferer stops breathing for seconds or minutes at a time. This generally occurs until the brain’s alarm centers rouse the individual enough to tighten the throat muscles once more. This can happen over and over again, even hundreds of times per night. However, the moments are so minor that they are completely unnoticed by the individual.
It is a silent killer, a hidden predator.
You might be thinking, “a killer”? A little melodramatic, perhaps?
What the current science says
However, newer studies indicate that OSA, and sleep disturbance in particular, are related to a slew of medical conditions. Growing evidence suggests that adequate and restful sleep is central to the health of both the mind and body, regulating processes ranging from memory to metabolism.
Sleep apnea and sleep disturbance has been shown to cause cognitive deficits (1), hypertension (1), learning and memory impairment (2,3), headaches (1), obesity (3), mood disorders such as anxiety and depression (2,1,3), cardiovascular disease (1), and allergies. (3)
What if I told you it can even be linked to the development of cancer and Alzheimer’s? Many processes occur during restful sleep, such as immune system repair, hormone regulation, and the breakdown of amyloid in the brain by glial cells. (1)
Yes, that’s right, amyloid buildup and plaque is broken down during restful sleep, hence the Alzheimer’s correlation. Oh, and if you didn’t already know, a strong immune system keeps cancer at bay; weak ones, on the other hand, do not. Additionally, reduced sleep is linked to an increase in widespread systemic inflammation. Yep that’s right, that notorious word—inflammation.
What’s more, there are unique signs in children that paint an even darker picture. Several studies suggest that OSA in children can be directly linked to attention disorders (4), autism spectrum disorders (4), and enuresis (bed-wetting). (3)
Imagine the number of the unfortunate children out there suffering with the embarrassment of bed-wetting while having a sleepover with friends or having continuous classroom reprimands, their parents frustrated to no end, likely blaming themselves, all because of undiagnosed OSA.
A study performed by Cheravin et al. stated that “our data suggests that… 25% of all children with ADHD… could have their ADHD eliminated if their habitual snoring and any associated [sleep-related breathing disorders] were effectively treated.” (2)
What a profound statement. But it gets better. The data speaks for itself.
A study performed in 1998 by pediatric pulmonologist and sleep specialist David Gozal revealed that children with OSA were at increased risk of having learning difficulties. Two hundred and ninety-seven New Orleans first-graders who were performing poorly in school were screened for sleep apnea. Eighteen percent tested positive. Of the group, 24 of the students had their tonsils and adenoids removed, the standard at the time for treating apnea. The parents of 30 other children declined the surgery. Among the treated students, average grades improved significantly the following year, while the untreated kids and the control group with no OSA showed no academic improvement. (1) Unfortunately, some did relapse, as the fundamental problem had not been addressed, as I will discuss below.
According to the National Institutes of Health, up to 70 million Americans have a serious sleep disorder including insomnia, sleep apnea, and other physiological problems that may go undiagnosed. (1) But sadly, there may be barriers to diagnosing apnea among the masses.
Dental-medical conflict
OSA has taken stage in recent years, particularly in the dental community, as the boundaries between general medical care and dental care blend ever more. In fact, it blended so well for a while that it resulted in major litigation between the American Medical Association and the American Dental Association. States where dentists were diagnosing and treating sleep apnea came under fire; a brewing storm had erupted.
Doctors felt dentists were overstepping their legal boundaries. Some dentists agreed.
In my own state of Colorado, several stakeholder meetings took place in 2017 in which board staff highly encouraged the medical and dental boards to adopt a joint policy, as opposed to a rule, which requires greater stakeholder participation and offers greater flexibility in the face of legal challenges in other jurisdictions. The most recent update on the CDA website states, “the primary area of remaining debate in the workgroup appeared to be around the ability of dentists to order and dispense a home sleep study (Rule XXVI (A)(2) in the draft rule), with strong opinions on both sides of this issue among workgroup members.” (5)
This basically states that medical doctors and practitioners (nurses included), believe the diagnosis of sleep apnea should remain within their scope of support only. This is an ongoing issue that has yet to be worked out.
A groundbreaking oral appliance
All of that aside, there are new dental-related technologies that are doing groundbreaking work and changing lives in the process.
One such revolutionary technology is treating airway obstruction and oral-maxillofacial development. It is giving adults and children their lives back in a new and unique way and I was fortunate enough to encounter it, right here in my home city of Denver, Colorado.
So, what is this magical new technology? It’s called Vivos Therapeutics, or “Vivos” for short.
Vivos first came up in conversation with a friend who happens to be a general dentist and colleague. Her journey with Vivos, along with the stories of others, inspired her so much that she is now a Vivos Certified Provider in the Denver Metro Area.
But, Dr. Rowe’s story didn’t begin with OSA at all. It actually started with good ol’ fashioned dentistry and maxillofacial growth and tooth eruption pertaining to her six-year-old daughter, Anna. Young Anna had a severely distal impacted No. 30 that did not have room to grow into her mouth naturally. A consultation with an orthodontist sent Dr. Rowe down a path of conflict. The standard treatment plan meant surgery. The recommendation was to cut into the gingiva above No. 30 and to remove the bone, then to place a distal shoe on tooth T to help the eruption of No. 30 to occur. Anna had, and I quote, “110% overbite, with less than 1mm overjet, practically edge to edge with no spacing between the primary teeth.”
Knowing her daughter’s delicate nature, Dr. Rowe hesitated to take on what seemed like an impossible task. But she had another option—a nonsurgical option, one that she is extremely grateful for.
Anna started wearing the Vivos appliance throughout the day as recommended, and within six weeks her facial profile began to change. It changed so much, that Anna’s grandmother, an untrained eye, even caught notice of her granddaughter’s profile. Anna’s parents also noticed that Anna was better rested, more focused, and the dark circles under her eyes went away. Oh, and in case you’re wondering, No. 30 did finally erupt on its own and in its natural position. The behavior changes were just benefits of her treatment. It was so profound that Anna’s parents decided to get her younger brother Josh into a device as well.
So why does all of this happen in the first place? What’s going on in modern society that so many individuals are inflicted with crowding and OSA?
It starts with tongue placement. The tongue should rest at the roof of the mouth naturally, but in those with retrognathic profiles and vaulted palates, there is not enough room in the mouth. That’s why, as the individual goes to sleep, the tissue of the throat and the tongue relax enough to cause the significant airway obstruction.
There are a few theories about this particular issue, one being that a reduction in breastfeeding—thus the proper development of facial muscles, which would occur during suckling—is the first culprit. Secondly, toddlers in underdeveloped countries are often given root vegetables and dried meats to chew on, adding to the training of these muscles and thus palatal and mandibular bone development. But what do most toddlers today eat in the industrialized world? Soft blended foods, melt-in-your-mouth crackers, ooey gooey gummy snacks, and the one-and-only chicken nugget, all of which deprive the adequate growth and function of the maxilla and mandible.
When I mentioned the relationship to childhood bed-wetting earlier, did you wonder how that one might be remotely related?
As dental professionals, we now know that nighttime bruxing may be a sign of OSA. During this event, the brain sends signals the masseter and other related muscles to clench down in an attempt to keep the jaw positioned in such a way that airway obstruction is reduced to a minimum. Sounds a little bit like the brain is in a state of panic and clenching ensues.
Similarly, as the brain goes without oxygen for any period of time during sleep, the brain will send signals out to the bladder to release its contents. Time to wake up Johnny boy, and awaken he does.
What exactly is it?
So, what exactly is Vivos and how does it work? Because, as we know, oral appliances are a dime-a-dozen. Is it just another glorified snore or bedtime night guard?
The child devices are pliable, plastic mouthpieces that look similar to sport guards, with one exception—there is a small tab that forces the tongue to lift and go up into the roof of the mouth, thus training it where to go. The primary function of the child mouthpiece is to aid in expansion as the child grows, allowing proper placement of the maxillofacial profile and providing room for secondary tooth eruption. This in turn serves as a replacement for orthodontics in many cases, and corrects airway constriction all with one fell swoop.
The adult appliance, created by Dr. Dave Singh and later rebranded by Vivos founder Kirk Huntsman, is different than the child version and includes a specialized crank for tailored expansion. It remodels the dental arch, widening it, allowing the nasal passages to drop down and thus improve airway function, minimizing the need for more extensive treatments and surgical intervention.
On my tour of one of the Vivos’ clinics in downtown Denver, I was able to witness the process firsthand. The children were referred by their general dentist for orthodontic purposes, such as crowding, retrognathic profile, and vaulted palates. The process started with a consultation with the parents, addressing concerns both dental and medical in nature. A clinical and intraoral exam was performed. I was told that Vivos Certified Providers could spot obstruction issues from afar, without yet looking in the mouth clinically. Their extensive training allows them to recognize various facial attributes and jaw placement malalignment, all of it a telling tale. However, that’s not all the diagnostic tools in their arsenal—a standing CBCT provides evidence of airway obstruction. The radiographic images were evaluated, and specialized tools were used to measure the airway.
Depending on their age and severity, the children were usually then fitted for a device and told to wear it at night. This method worked best for ages 3 to 6 years, whereas ages 7 to 10 years require nighttime use plus 2 hours a day. If the patient is 11 to 12 years old, nighttime use plus 4 hours during the day is required. Daytime use also requires exercises, basically meaning the child should try to clench into the appliance off and on throughout the wearing period. This of course requires a level of compliance by the child and the parents.
Eventually the child device may need to be changed out with other standard-sized devices at follow-up appointments as the dentition changes and the maxilla and mandible grow.
The adult Vivos appliance is not only custom fitting, but the process itself requires a different approach. Because most adults are not being treated for orthodontic purposes, but rather sleep apnea, they first require a sleep study. The study must be read and authorized by a medical doctor before an appliance can be fabricated. This process works smoothly, keeping dentists in their own lane and out of that of the medical practitioner, as discussed earlier.
And I haven’t even told you the best part yet. The reshaping done by the Vivos device literally restructures bone and the occlusion in the oral maxillofacial region permanently. It’s palatal and mandibular expansion on steroids! It also eliminates the need for a CPAP machine, which many patients find noisy and restrictive. The device is temporary and does not have to be worn forever.
I repeat, this is not a night time snore guard! It is a one-of-a-kind device that is worn temporarily and does not have to be worn forever and ever, night after night. The change is permanent!
I’ve seen pictures of treated patients from a slideshow that demonstrate just how profound this technology is. Their face is transformed from a shorter profile with dipping under the chin, to a longer, more natural one, a facial profile that promotes a free and open airway. Voila! I did say it was magic!
One caveat to Vivos is that many dental insurances will not cover the cost of the device for adults, however, many medical insurances will. Due to the function of the device as a sleep apnea treatment, as long as a successfully completed sleep apnea study has been performed, health insurance will pick up the bill in many cases.
Imagine if you will, an airway change from 6 cubic millimeters in diameter to an astounding 22 cubic millimeters. That’s the equivalent of going from a piece of angel hair pasta to a garden hose. Simply remarkable.
In my opinion as a clinician, the Vivos system is truly transformative, correcting and treating the root of the problem, and potentially preventing a myriad of OSA-related diseases. It is also giving peoples a new chance at a better life, one that is without embarrassment and shame.
With over 700 nationwide Vivos certified providers, this treatment could be easily accessible for patients suffering from OSA.
Editor’s note: The author has received no compensation from Vivos Therapeutics for the publication of this article, which was written independently.
References
1. Miller K. Getting enough sleep can be a matter of life and death. Discover website. http://discovermagazine.com/2015/april/17-wake-up-call. Published February 26, 2015.
2. Chervin RD, Dillon JE, Bassetti C, Ganoczy DA, Pituch KJ. Symptoms of sleep disorders, inattention, and hyperactivity in children. Sleep. 1997;20(12):2185-1192.
3. Fischman S, Kuffler DP, Bloch C. Disordered sleep as a cause of attention deficit/hyperactivity disorder: recognition and management. Clin Pediatr. 2015;54(8):713-22. doi: 10.1177/0009922814548673.
4. Souders MC, Mason TB, Valladares O, et al. Sleep behaviors and sleep quality in children with autism spectrum disorders. Sleep. 2009;32(12):1566-1578.
5. Update on dental board’s sleep apnea rulemaking. Colorado Dental Association website. https://cdaonline.org/news/latest-news/update-dental-boards-sleep-apnea-rulemaking/. Published August 10, 2017.
Editor's note: This article first appeared in RDH eVillage. Click here to subscribe.
Chris Bustamante, RDH, is a dental hygienist in Denver, Colorado. He has a passion for writing and a love of biomedical research. When he is not at the office helping patients achieve optimum oral health, he spends his time working on several entrepreneurial pursuits. His most recent endeavor is helping his best friend grow an athletic brand Wearbroski.com. He can be contacted at [email protected].
