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Little man studies the word "DATA"

Bernard MarrForbes

If you want to find out how Big Data is helping to make the world a better place, there’s no better example than the uses being found for it in healthcare.

The last decade has seen huge advances in the amount of data we routinely generate and collect in pretty much everything we do, as well as our ability to use technology to analyze and understand it. The intersection of these trends is what we call “Big Data” and it is helping businesses in every industry to become more efficient and productive.

Healthcare is no different. Beyond improving profits and cutting down on wasted overhead, Big Data in healthcare is being used to predict epidemics, cure disease, improve quality of life and avoid preventable deaths. With the world’s population increasing and everyone living longer, models of treatment delivery are rapidly changing, and many of the decisions behind those changes are being driven by data. The drive now is to understand as much about a patient as possible, as early in their life as possible – hopefully picking up warning signs of serious illness at an early enough stage that treatment is far more simple (and less expensive) than if it had not been spotted until later.

So to take a journey through Big Data in healthcare, let’s start at the beginning – before we even get ill.

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A new way of classifying gum disease may speed detection of serious periodontitis before patients lose teeth and bone.

Today, periodontal disease is classified as either chronic or aggressive, based on the severity of clinical symptoms and signs including gum swelling and the loss of facial bone structure. But those designations do little for diagnosis and treatment, given significant overlap between the two.

“Many patients with severe symptoms can be effectively treated, while others with seemingly less severe infection may continue to lose support around their teeth even after therapy, study leader Panos P. Papapanou, a dental professor at Columbia University Medical Center, said in a statement. “Basically, we don’t know whether a periodontal infection is truly aggressive until severe, irreversible damage has occurred.”

To improve the disease classification system, Papapanou followed the lead of oncologists who’ve found that indications of a cancer’s aggressiveness — as well as its response to treatment — may be found in its genetic material. In the lab, the Columbia researchers performed genome-wide expression analyses of diseased gum tissue samples taken from 120 age-diverse patients with either “type” of periodontitis.

Based on the genetic analysis, the researchers found that periodontitis may indeed be classified into two groups. However, “the [groups] did not align with the currently accepted periodontitis classification,” Papapanou said.

Moreover, the researchers also found higher levels of infection by two known oral pathogens, as well as greater severity of disease, among one group. That higher-risk group also included more men than women, which researchers said validated previous observations about the disease.

“Our data suggest that molecular profiling of gingival tissues can indeed form the basis for the development of an alternative, pathobiology-based classification of periodontitis that correlates well with the clinical presentation of the disease,” Papapanou said.

Although performing genomic testing on patients would be impractical, the Columbia team hopes to discover biomarkers for the two different types of periodontitis, potentially improving treatment. “If a patient is found to be highly susceptible to severe periodontitis, we would be justified in using aggressive therapies, even though that person may have subclinical disease,” said Papapanou said. “Now, we wait years to make this determination, and by then, significant damage to the tooth-supporting structures may have occurred.

The Mayo Clinic says periodontitis is “common but preventable” — the result of improper dental hygiene.

Source: Papapanou, Panos N., Kebschull, M., Demmer, R.T., Grun, B., Guarnieri, P., Pavlidis, P. Gingival Tissue Transcriptomes Identify Distinct Periodontitis Phenotypes. Journal of Dental Research. 2014.

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Published: February 2, 2009
New York Times


One person gets migraine headaches, another ringing in the ears, a third clicking and locking of the jaw, a fourth pain on the sides and back of the head and neck. All are suspected of having a temporomandibular disorder.

Popularly called TMJ, for the joint where the upper and lower jaws meet, temporomandibular disorders actually represent a wider class of head pain problems that can involve this pesky joint, the muscles involved in chewing, and related head and neck muscles and bones.

But too often, experts say, patients fail to have the problem examined in a comprehensive way and undergo costly and sometimes irreversible therapies that may do little or nothing to relieve their symptoms. As scientists at the National Institute of Dental and Craniofacial Research wrote recently, “Less is often best in treating TMJ disorders.”

Up to three-fourths of Americans have one or more signs of a temporomandibular problem, most of which come and go and finally disappear on their own. Specialists from Boston estimate that only 5 percent to 10 percent of people with symptoms need treatment.

A New Understanding

The TMJ is a complicated joint that connects the lower jaw to the temporal bone at the side of the head. It has both a hinge and a sliding motion. When the mouth is opening, the rounded ends, or condyles, of the lower jaw glide along the sockets of the temporal bones. Muscles are connected to both the jaw and the temporal bones, and a soft disc between them absorbs shocks to the jaw from chewing and other jaw movements.

TMJ problems were originally thought to stem from dental malocclusion — upper and lower teeth misalignment — and improper jaw position. That prompted a focus on replacing missing teeth and fitting patients with braces to realign their teeth and change how the jaws come together.

But later studies revealed that malocclusion itself was an infrequent cause of facial pain and other temporomandibular symptoms. Rather, as the Boston specialists wrote recently in The New England Journal of Medicine “the cause is now considered multifactorial, with biologic, behavioral, environmental, social, emotional and cognitive factors, alone or in combination, contributing to the development of signs and symptoms of temporomandibular disorders.”

According to the American Academy of Orofacial Pain, the disorder “usually involves more than one symptom and rarely has a single cause.”

Among the “mechanical” causes that are now recognized as distorting the function of the TMJ are congenital or developmental abnormalities of the jaw; displacement of the disc between the jaw bones; inflammation or arthritis that causes the joint to degenerate; traumatic injury to the joint (sometimes just from opening the mouth too wide); tumors; infection; and excessive laxity or tightness of the joint.

But the most common TMJ problem is known as myofacial pain disorder, a neuromuscular problem of the chewing muscles characterized by a dull, aching pain in and around the ear that may radiate to the side or back of the head or down the neck. Someone with this disorder may have tender jaw muscles, hear clicking or popping noises in the jaw, or have difficulty opening or closing the mouth. Simple acts like chewing, talking excessively or yawning can make the symptoms worse.

Jaw-irritating habits, like clenching the teeth or jaw, tooth grinding at night, biting the lips or fingernails, chewing gum or chewing on a pencil, can make the problem worse or longer lasting. Psychological factors also often play a role, especially depression, anxiety or stress.

Proper Assessment

The overwhelming majority of people with TMJ symptoms are women. Women represent up to 90 percent of patients who seek treatment, Dr. Leonard B. Kaban, chief of oral and maxillofacial surgery at the Massachusetts General Hospital in Boston, said in an interview. Most patients are middle-age adults, he and two dental specialists, Dr. Steven J. Scrivani and Dr. David A. Keith, wrote in the journal article.

Dr. Kaban urged patients to obtain a thorough assessment of the problem before choosing therapy, especially if they have symptoms like tinnitus (ringing in the ears) and migraine headaches.

He said doctors and dentists should “start with a thorough history — you can get 80 to 90 percent of the needed information just from talking to the patient about their habits.” This should be followed by a physical examination, checking for signs like muscle tenderness and pain in the jaw, limited jaw opening and noises.

“Among the biggest advances in diagnosis has been imaging studies, especially by M.R.I. and occasionally by CT scan with a cone-beam image,” Dr. Kaban said.

For those with complicated problems, he suggested visiting a multidisciplinary temporomandibular clinic, found at many leading hospitals and dental schools.

Therapy Options

Resting the jaw is the most important therapy. Stop harmful chewing and biting habits, avoid opening your mouth wide while yawning or laughing (holding a fist under the chin helps), and temporarily eat only soft foods like yogurt, soup, fish, cottage cheese and well-cooked, mashed or pureed vegetables and fruit. It also helps to apply heat to the side of the face and to take a nonsteroidal anti-inflammatory medication, for up to two weeks.

Other self-care measures suggested by the orofacial academy include not leaning on or sleeping on the jaw and not playing wind, brass or string instruments that stress, strain or thrust back the jaw.

Physical therapy to retrain positioning of the spine, head, jaw and tongue can be helpful, as can heat treatments with ultrasound and short-wave diathermy.

Some patients are helped by a low-dose tricyclic antidepressant taken at bedtime, or antianxiety medication. Stress management and relaxation techniques like massage, yoga, biofeedback, cognitive therapy and counseling to achieve a less frenetic work pace are also helpful, according to the findings of a national conference on pain management.

If you clench or grind your teeth, you can be fitted with a mouth guard that is inserted like a retainer or removable denture, especially at night, to prevent this joint-damaging behavior.

But Dr. Kaban cautioned against embarking on “any expensive, irreversible treatment” before a thorough diagnosis is completed and simple, reversible therapies have been tried and found wanting.

As with other joints, he said, surgery is a treatment of last resort, when medical management has proved ineffective. As he and his colleagues wrote, surgery is primarily for patients who are born with or develop jaw malformations and patients with arthritis who have loose fragments of bone or require condyle reshaping.

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What is my leadership style?

What leadership style actual boosts results in my organization or practice?

How can I know what leadership style works best for my situation?

Such questions may arise in trying to lead a business or practice. Discovering the right leadership style improves results. However, there is more to the story. It takes the right leadership style coupled with the right systems implemented into a practice that drives results. Yet, a practice owner must realize that there is not a magic bullet in regards to the right leadership style. What may work in one practice may not work in another. Leadership style must not only be right for the practice, team, community, patients, etc., but the practice owner’s leadership style must compliment and enhance the types of programs implemented into the practice. Considering then what leadership style works, a practice owner may consider the concept of “situational leadership.” The concept of situational leadership is that different situations, circumstances, people etc. require different leadership styles at differenct times. Such styles may include transformational, transactional, servant-leader and many more.

Follow the link for additional information on situational leadership



As documented in other articles in this series, obstructive sleep apnea is widespread, negatively impacts quality of life, increases susceptibility to accidents, decreases productivity, and has a wide variety of serious, negative medical consequences, many of which can be life threatening. The standard of care for treating obstructive sleep apnea is continuous positive airway pressure (CPAP). However, many patients are unable or unwilling to comply with long-term CPAP use. In addition, CPAP is difficult to use when traveling. The use of an oral appliance provides an effective treatment that many patients prefer to either CPAP or to the third alternative, surgical modification of the upper airway.

Reviews of older studies

An article [1] published in the Journal of the American Dental Association in 2003 reviewed a couple dozen studies done during the previous eighteen years and concluded that oral appliances have been shown to offer an alternative treatment to CPAP and surgery for treating sleep apnea patients. Of the two main types of oral appliances—tongue repositioning devices and mandibular repositioning appliances (MRAs)—only studies using MRAs are discussed. Tongue repositioning devices are, however, useful for patients with inadequate dentition to qualify for MRA therapy. Among the results reviewed, the use of an MRA was documented by upper airway imaging techniques to increase the openness of the upper airway and decrease the average number of respiratory events per hour from thirty-four (severe sleep apnea) to ten (mild sleep apnea). Another study found reductions from forty-eight to twelve, with 52 percent of the patients still successfully using the MRA at thirty-six months. Two randomized controlled trials (in which the control was a device that was not adjusted to reposition the mandible forward to open the airway) showed significant reductions in respiratory events and significant improvement in daytime sleepiness. Several trials comparing CPAP with MRA showed both to significantly reduce the number of respiratory events. While CPAP was more effective, patient compliance was better with MRA. Summarizing the studies reviewed, the authors conclude that the ideal MRA candidate has symptoms of daytime sleepiness, is not obese, has mild-to-moderate sleep apnea, has an adequate range of protrusion of the mandible, and has adequate dentition to anchor the MRA. In at least one study, however, even patients with severe sleep apnea achieved a 53 percent reduction in the number of respiratory events per hour. Complications of treatment were usually minor and transient, but the authors note the need for studies with longer duration follow-up.

Another systematic review published in 2004 also reviewed published studies using MRAs [2]. Several studies are cited showing that MRA therapy decreases snoring and daytime sleepiness in a high proportion of patients, improves work performance, and improves sleep quality for both the patient and the bed partner. Numerous studies are cited to demonstrate effectiveness in different patient populations (such as greater effectiveness in leaner patients with less severe sleep apnea), side effects and complications (generally mild and transient) and patient compliance (generally good). In one study thirty-four of one-hundred consecutive sleep apnea patients were found ineligible for MRA therapy due to insufficient number of teeth, serious periodontal disease, active temporomandibular joint disorders, or restrictions in mandibular protrusion or opening. The recommendation is to consider oral appliance therapy in patients with simple snoring or mild sleep apnea who are not candidates for conservative treatments, like weight reduction, etc., and in patients with moderate to severe sleep apnea who do not tolerate or have refused CPAP, or who are not candidates for or who refuse surgery. A systematic search for studies on efficacy and complications of oral appliance therapy meeting detailed pre-specified criteria yielded, from 289 relevant articles, sixteen studies that were selected for appraisal of efficacy and thirteen for appraisal of comorbidities (side-effects or complications of treatment). Among the conclusions: compared to control devices that did not advance the mandible, MRA treatment was significantly more effective in reducing the number of respiratory events and daytime sleepiness in all trials studied. Compared to CPAP, MRA was less effective in reducing the number of respiratory events. Higher MRA success rates were observed with greater mandibular protrusion. Some adverse (but generally not serious) effects of oral appliance therapy were identified, and minor orthodontic side-effects and changes in dental occlusion were common. The authors recommend that follow-up be conducted on a regular basis to guarantee long-term efficacy and safety.

The Standards of Practice Committee of the American Academy of Sleep Medicine reviewed eighty-seven articles published from 1995-2006 [3]. Comparing all of these studies was complicated by the variety of approaches used and variables studied. For example, some studies only considered treatment to be effective if the number of respiratory events was reduced to less than ten per hour, while others required only that the number of events be reduced from the pre-treatment baseline by 50 percent or more. Usually studies focused on patients with mild to moderate disease (thirty or less events per hour), but some included patients with more severe sleep apnea (forty or more events per hour). Most of the devices tested were designed to hold the mandible forward during sleep (MRAs), but a few studies used appliances that only held the tongue forward. Some MRAs were prefabricated while others were custom-made. Some appliances were single position while others were adjustable. Variables that emerged as important for the effectiveness of oral appliances include the severity of the sleep apnea, the amount of mandibular protrusion of the MRA, and the body mass index of the patient. Conclusions from all of these studies that the authors cite include, first of all, the observation that overall oral appliances are effective for treating obstructive sleep apnea. Defining successful treatment as no more than ten respiratory events per hour, successful treatment was achieved with in an average of 52 percent of patients. CPAP was more successful at lowering the number of respiratory events per hour, but many patients preferred oral appliances to CPAP for long-term use. Oral appliances were less effective than CPAP in patients with severe sleep apnea and in patients with higher body mass index (more obese). Therefore, oral appliances are not indicated as first line therapy for those with severe sleep apnea or severe daytime sleepiness, but may be indicated if these patients have failed other treatments. In a randomized study, oral appliances performed at least as well as surgery. In the small number of studies comparing MRAs with other oral appliances, MRAs were generally effective in reducing snoring and obstructive sleep apnea, and were more easily used and more effective than other oral appliances. No comparisons were done of different types of MRAs, but most studies were done with fixed position appliances that did not allow adjustment to optimize treatment. Thus the results of these studies, although positive overall, did not represent current best practices and so may underestimate the effectiveness of MRAs. Oral appliances are well-tolerated by most patients (a median appliance use of 77 percent of nights after one year). Side effects are common but minor, and usually improve with time, but tooth movement and malocclusion can occur in some patients and are frequently irreversible.

A study published in 2007 [4] reviewed eighty-nine oral appliance sleep studies focusing on reduction in respiratory events, reduction in snoring, effect on daytime function, comparison with other sleep apnea treatments, side effects, dental changes, and long-term compliance. The success of oral appliance therapy in reducing respiratory events to less than ten per hour was 54 percent; an additional 21 percent achieved at least 50 percent reduction in respiratory events, although they still remained above ten. Snoring was reduced by 45 percent and daytime function was improved somewhat. CPAP produced a greater reduction in the number of events than did oral appliances, but the majority of patients preferred using oral appliances over using CPAP. Follow-up studies at thirty months showed 56 to 68 percent of patients still using the oral appliance. The most common minor side effects encountered were excessive salivation and teeth discomfort.

Fixed vs. adjustable devices

A study published in 2011 [5] compared fixed with adjustable (the degree of mandibular advancement can be optimized) mandibular repositioning appliances. Both fixed and adjustable oral appliances were individually fabricated from impressions of the individual patient’s teeth. Fixed oral appliances are typically molded to advance the mandible by 50 to 80 percent of the patient’s maximal protrusion. Adjustable devices include a mechanism for the patient to increase or decrease protrusion to obtain the optimum balance between effectiveness and side effects. On the other hand, adjustable devices are more expensive. This paper presents the results of a review of consecutive adult patients treated with an oral appliance for obstructive sleep apnea between January 2003 and December of 2009 at the authors’ institution, and who underwent polysomnography before and after treatment. As military service members comprise a large fraction of the patients at this institution, many patients chose oral appliances because electricity to use CPAP is not reliably available during worldwide deployment. Choice of fixed or adjustable oral appliance was made according to resource availability—not by pre-established clinical criteria. Successful treatment was defined as less than five respiratory events per hour. A secondary endpoint for success was reduction of events to less than ten per hour with concurrent resolution of excessive daytime sleepiness. The sample cohort included 805 patients, of whom 74.8 percent used adjustable appliances and 25.2 percent used fixed appliances. Of the cohort, 86.7 percent were men and 38.8 percent were obese. Sleep apnea was mild in 34.1 percent, moderate in 29.2 percent and severe in 36.8 percent. Both devices provided a substantial decrease in events per hour, but the adjustable devices produced significantly greater reductions (74.4 percent versus 64.9 percent decrease) and more patients achieved successful therapy with adjustable devices (57.2 percent versus 46.9 percent).  In terms of whether sleep apnea at baseline was mild, moderate, or severe, adjustable devices produced a greater reduction in events for all three groups. Fixed devices were frequently successful in patients with mild disease, but adjustable devices performed better across all levels of disease severity. A multivariate statistical analysis showed that patients who were older, had a higher body mass index, or were using a fixed device were less likely to achieve less than five events per hour.

Adjustable oral appliances give superior results to fixed oral appliances; however, most of the older comparisons of CPAP to oral appliances compared CPAP titrated to optimally effective pressure with fixed oral appliances not adjusted to maximally effective mandibular advancement. A recent study compared CPAP and oral appliances that were both titrated to optimize settings [6]. Sixty-four patients with mild to moderate sleep apnea were randomly assigned to therapy with an MRA, CPAP, or a placebo device. Polysomnography was obtained before treatment and after six months treatment to measure the number of respiratory events per hour. No differences were found between the MRA and CPAP groups in reductions in the number of events between baseline and after treatment. The reductions seen in the placebo group were much smaller. In terms of the number of patients who were successfully treated, statistical analysis indicates no difference between the MRA and CPAP groups.


Oral appliances provide effective treatment for obstructive sleep apnea. Although a variety of oral appliances have been investigated, most studies have used mandibular repositioning appliances (MRAs), which position the mandible forward during sleep. These can either advance the mandible a fixed fraction of the maximum distance the patient can advance his or her mandible, or they can be adjustable to determine what advancement gives the greatest reduction in respiratory events per hour. Fixed MRAs are frequently optimal for patients with mild disease, but adjustable devices work better for moderate to severe disease. Comparisons with CPAP often show better results with CPAP for more severe disease, but even in this case, MRAs provide effective therapy for the many patients unwilling or unable to tolerate CPAP.


[1] “The role of oral appliances in treating obstructive sleep apnea.” N Mohsenin, MT Mostofi, V Mohsenin. J Am Dent Assoc. 134: 442-9 (2003).

[2] “Efficacy and co-morbidity of oral appliances in the treatment of obstructive sleep apnea-hypopnea: a systematic review.” A Hoekema, B Stegenga and LGM de Bont. Critical Reviews in Oral Biology & Medicine 15: 137-155 (2004) DOI: 10.1177/154411130401500303.

[3] “Oral appliances for snoring and obstructive sleep apnea: a review.” KA Ferguson, R Cartwright, R Rogers, W Schmidt-Nowara. SLEEP 29: 244-262 (2006).

[4] “Review of oral appliances for treatment of sleep-disordered breathing.” V Hoffstein. Sleep Breath 11:1–22 (2007). DOI 10.1007/s11325-006-0084-8.

[5] “Comparison of adjustable and fixed oral appliances for the treatment of obstructive sleep apnea.” CJ Lettieri, N Paolino, AH Eliasson, AA Shah, AB Holley. J Clin Sleep Med 7:439-445 (2011). DOI: 10.5664/JCSM.1300. concept

[6] “Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial.” G Aarab, F Lobbezoo, HL Hamburger, M Naeije. Respiration 81: 411-419 (2011). DOI: 10.1159/000319595.

Courtesy of

Fred Reichheld

Bain Fellow, Author/Speaker on Loyalty, Creator of the Net Promoter System

Given how little time your doctor spends with you during an appointment, don’t you want yours to be fully engaged when you’re on the examining table? I know I do.

So I had both personal and professional reasons to take note when my colleagues at Bain issued a new report noting that the increasing systemization of US healthcare was creating some very unhappy doctors. My personal interest is obvious: The report identifies a large and growing group of doctors who are less engaged and inspired. Who wants one of those when your health is on the line?

My professional interest stems from the way my colleagues used Net Promoter Scores to measure doctor engagement—and uncover a root cause of their unhappiness. Here’s what they found:

Click here for rest of article.

Obstructive sleep apnea has been associated with cardiovascular diseases in general and with hypertension, coronary artery disease, and heart failure. It is also strongly associated with stroke. Because stroke is the number three killer in the US and a leading cause of long-term disability1, untreated obstructive sleep apnea can have major public health implications.

 Association between obstructive sleep apnea and stroke 

Based on earlier reports that obstructive sleep apnea might be a risk factor for stroke, a study2 compared twenty-four recent stroke patients and twenty-seven age and sex-matched controls with no major medical problems. Study subjects were assessed for obstructive sleep apnea using overnight polysomnography in a sleep center, and information was collected concerning known risk factors for both stroke and sleep apnea. Respiratory events recorded by polysomnography were classified as apneas or as hypopneas if airflow was respectively absent or reduced by more than 50 percent. Apneas were classified as obstructive if respiratory effort continued, and central if respiratory effort was absent. An individual with ten or more obstructive events per hour was diagnosed with obstructive sleep apnea. A statistical analysis was performed to assess the association between stroke and the presence of obstructive sleep apnea and other known risk factors.

Central sleep apnea was not found among either stroke or control subjects. Obstructive sleep apnea was found in 77 percent of male stroke subjects and 23 percent of male control subjects, and in 64 percent of female stroke subjects and 14 percent of female control subjects. The mean (average) number of events per hour for men with stroke was 21.5, while for male control subjects it was 4.8. For women, the mean number of events per hour was 31.6 for stroke patients and 2.9 for control subjects. The median (middle value of the range) number of events per hour was 16.8 for male stroke patients, 1.4 for male controls, 38.4 for female stroke patients, and 0 for female controls. During a four-year follow-up period, only stroke patients with obstructive sleep apnea died. The mean number of events per hour for the five patients who died was 41.3, while for the stroke patients who did not die the mean was 22.1 events per hour. The authors conclude that patients with stoke have a high incidence of sleep apnea compared to age- and sex-matched normal controls.

In another study3, fifty-nine patients with either transient ischemic attack (TIA) or stroke were assessed for sleep apnea and compared with nineteen age and gender-matched controls. From among patients admitted to a hospital during a sixteen-week period for either acute TIA or stroke, fifty-nine were eligible for the study and were evaluated for obstructive sleep apnea by questionnaire concerning habitual snoring and daytime sleepiness. Of these, thirty-six patients were further evaluated by overnight polysomnography, as were the nineteen normal controls. The twenty-three patients not evaluated by polysomnography did not differ significantly from the thirty-six who were evaluated in terms of age, gender, body mass index, cerebrovascular risk factors, stroke severity, habitual snoring, or daytime sleepiness. Sleep apnea was found in 69 percent of patients versus 15 percent of normal controls. Controls and patients were similar in age, body mass index, and gender, but differed in the prevalence of habitual snoring and in the average number of respiratory events per hour. The thirteen patients with TIA and the twenty-three patients with stroke were similar in age, gender, body mass index, most cerebrovascular risk factors, sleep history, and polysomnography results, except that there was a trend toward more events per hour in those with stroke. Thus, clinically significant sleep apnea is present in many patients with stroke and acute TIA, and does not differ significantly in prevalence between stroke and TIA patients. Based on these results, the authors conclude that sleep apnea precedes the stroke and is a probable risk factor for stroke.

Sleep apnea and the risk of developing stroke 

To determine whether the association between obstructive sleep apnea and stroke arises because sleep apnea increases the risk of stroke, a large group of state employees in Wisconsin was assessed by polysomnography and other tests at the beginning of the study and then again after four, eight, and twelve years4. Of the 1,475 participants at baseline, 76 percent did not have sleep apnea, 17 percent had mild, and 7 percent had moderate to severe sleep apnea. The latter group was predominantly male and had a significantly higher body mass index. Those subjects in the moderate to severe sleep apnea group were about four times more likely to have had a stroke than those without sleep apnea. Similarly, those subjects in the moderate to severe sleep apnea group were about four times more likely to experience a stroke during the following four years than those without sleep apnea. In both cases, the occurrence of stroke in the group with mild sleep apnea did not differ significantly from the group without sleep apnea. This study provides evidence of a significant link between moderate to severe sleep apnea, and both the prevalence of stroke in the general population and an increased probability of suffering a stroke within the next four years, proving that in many cases sleep apnea precedes stroke. These links were independent of obesity. The authors conclude that sleep apnea may contribute to the development of stroke.

To determine if obstructive sleep apnea patients have an increased risk of stroke or death from any cause that is independent of other cerebrovascular risk factors, a cohort of sleep center patients fifty-years-old or older and without a history of stroke were followed for four years for incidence of stroke, transient ischemic attacks, or death5. Sleep apnea was defined as five or more events per hour determined by polysomnography; the control group had less than five events per hour. Event-free survival of patients with sleep apnea was compared to that of those without. Among the study participants, 697 of 1,022 had sleep apnea, with a mean of thirty-five events per hour. The 325 controls had a mean of 2.0 events per hour. The sleep apnea patients had higher prevalence of diabetes and hypertension and were more obese than the controls. Among the 842 subjects for whom follow-up data were available, there were 3.48 events per 100 person-years in the sleep apnea group and 1.60 events per 100 person-years in the control group. The association of sleep apnea with TIA, stroke, or death was still statistically significant after adjustment for age, sex, body mass index, diabetes, hypertension, and several other risk factors. Further, the risk of stroke or death increased with the severity of the sleep apnea.

With increasing evidence of a link between sleep apnea and stroke in middle-aged populations, another study6 focused on stroke risk in a general population of elderly individuals since, in general, stroke risk is highest in the elderly. Initially ischemic event-free and noninstitutionalized, 394 seventy to one-hundred-year-old subjects were assessed by overnight polysomnography and then followed for up to six years (mean 4.5 years). During this period, twenty ischemic strokes occurred; moreover, these were about 2.5 times more prevalent in those with severe sleep apnea at baseline than in those without or with mild or moderate sleep apnea.

A recent study was large enough to determine in the general population (rather than in patients referred for sleep studies) the effect on the risk of stroke of obstructive sleep apnea, even mild obstructive sleep apnea7. Baseline overnight unattended polysomnography was performed between 1995 and 1998 on a total of 5,422 participants (2,462 men and 2,960 women) without a history of stroke and who were untreated for sleep apnea. The participants were followed for a median of 8.7 years for the occurrence of an ischemic stroke. Over this period, 193 ischemic strokes occurred (4.4 per 1,000 person-years in men and 4.5 in women). A baseline classification of moderate to severe obstructive sleep apnea was about 30 percent more common in men and women who subsequently had an ischemic stroke than in those who remained stroke-free. After statistical adjustment for age and other risk factors, men in the highest quartile of sleep apnea (more than nineteen events per hour) had 2.86 times the risk of stroke of men in the lowest quartile (less than 4.05 events per hour). In men, the stroke risk also increases across the lower to middle quartiles, indicating that even relatively mild levels of sleep apnea can put men at increased risk for ischemic stroke. In women, the risk of stroke was not significantly associated with the sleep apnea quartile, but increased risk was observed at more than twenty-five events per hour. The authors conclude that the strong association between obstructive sleep apnea and stroke risk among community-dwelling men indicates that sleep apnea is an appropriate target for future stroke prevention trials. In an NIH News release dated April 8, 20108, National Heart, Lung, and Blood Institute Acting Director Susan B. Shurin, M.D. said “This is the largest study to date to link sleep apnea with an increased risk of stroke. The time is right for researchers to study whether treating sleep apnea could prevent or delay stroke in some individuals. ”

Sleep apnea and the clinical outcome of a stroke 

Given the prevalence of sleep apnea in stroke patients, does the presence of this potentially treatable condition correlate with greater disability or longer recovery times? Sixty-one consecutive stroke patients not previously diagnosed with sleep apnea or dementia and admitted to a stroke rehabilitation unit were assessed to determine their level of functional and mental disability9. Overnight polysomnography was done to determine sleep apnea status, with less than ten respiratory events per hour classified as non-sleep apnea and ten or more as denoting the presence of sleep apnea. The primary outcome to be measured was the length of hospitalization. Of sixty patients admitted to the study, forty-eight had ischemic stroke and twelve had hemorrhagic stroke. Sleep apnea was diagnosed in 72 percent of the patients (obstructive sleep apnea in 60 percent and central sleep apnea in 12 percent). The severity of the stroke did not differ significantly between those patients with and without sleep apnea. There was a tendency for patients with sleep apnea to have fewer of the other stroke risk factors, although only in the case of heart failure was this difference statistically significant. This observation provides circumstantial evidence that sleep apnea by itself is a risk factor for stroke.

Stroke patients with sleep apnea spent 40 percent more days in the stroke rehabilitation unit and 30 percent more total days in the hospital than did patients without sleep apnea. Length of hospitalization increased with the number of obstructive sleep apnea events per hour but was not correlated with central sleep apnea events. Patients with sleep apnea showed greater functional impairment than did patients without sleep apnea, both at admission and at discharge. There were also significant correlations between functional impairment and the average number of obstructive sleep apnea events per hour. There was no correlation with central sleep apnea events. These results indicate that not only is sleep apnea very prevalent among patients admitted to a stroke rehabilitation unit, but also that obstructive sleep apnea contributed to functional impairment and the length of rehabilitation. Thus sleep apnea may be increasing the social and financial burden imposed by stroke disability and rehabilitation.

Another study of patients admitted for in-hospital stroke rehabilitation examined the correlation between sleep apnea (both obstructive and central) and survival over a ten-year period10. Patients were initially evaluated three weeks after the onset of stroke. Of 151 consecutive patients, 132 who consented to and successfully completed overnight polysomnography in the hospital were included in the study. Sleep apnea was defined as fifteen or more events per hour; those patients with less than fifteen events served as controls. Of the enrolled patients, 11.2 percent had experienced a hemorrhagic stroke and 37.1 percent had experienced two or more strokes. Further, 17.4 percent of the patients had obstructive sleep apnea and 21.2 percent had central sleep apnea. (Two patients with both obstructive and central sleep apnea were excluded from further analysis.) At baseline the mean age of the control, obstructive, and central sleep apnea groups varied from seventy-seven to seventy-nine. At follow-up 87.9 percent of the patients had died, including all of the obstructive sleep apnea patients, 96.4 percent with central apnea and 81 percent of the controls. After statistically correcting for age and other factors, the adjusted risk of dying was not significantly different between the central sleep apnea and control groups, but was 1.76 times as great in the obstructive sleep apnea group compared to the controls. The authors conclude that stroke patients with obstructive sleep apnea face an increased risk of early death.

Conclusion: Stroke patients have a very high prevalence of obstructive sleep apnea compared to age- and sex-matched controls. Sleep apnea was found among 69 percent of a population of hospital patients admitted for either transient ischemic attack or stroke, compared to 15 percent of age and gender-matched controls. In studies of the general population, individuals with sleep apnea were more likely to have experienced stroke, and were also more likely to have a stroke within the following years, than were those without sleep apnea—this was two to three times more likely in the case of those with the most severe sleep apnea. Stroke patients with obstructive sleep apnea face longer hospitalization times, greater functional impairment, and an increased risk of early death compared to stoke patients without sleep apnea.

Four lakes

Recently I experienced a week long excursion with my son and friends into the Four Lakes Basin of the Uinta Mountains, a subrange of the Rocky Mountains. After a strenuous hike to the basin, we set up camp and experienced the next five days of erratic weather consisting of sunshine, rain, snow, and hail. We hiked, explored, and fished. I was impressed not only by the beauty of the area, but in thinking retrospectively, I was equally impressed by the vibrant ecosystem that functioned in that region. Now I am not a ecologist by any stretch. However, I did observed a system of rivers, ponds, and many small streams dually functioning as trails connecting each lake within the basin and even peripheral lakes outside of the basin. Though each individual lake consisted of a unique ecosystem, the four lakes were a whole interconnected by pathways and streams. The interrelated system provided a efficient and high quality area where wildlife, trees, plants, and grass thrived.

Systems Thinking

This notion of separate systems interrelated can be found in the concept of systems thinking. The systems thinking concept was built upon by the work of Jay Forrester and others at MIT and perpetuated and popularized by Peter Senge in the early 90s from his book entitled The Fifth Discipline. The systems thinking concept has been utilized with successful outcomes repeatedly throughout organizations. The process of systems thinking is understanding how individual systems influence one another within a complete entity, or larger system. This concept has been researched in various contexts. My focus is to provide an insight into an area of the healthcare industry today regarding dentistry and its relation with dental sleep medicine.

A Disjointed Healthcare System

It is no secret that the United States healthcare system, though the best on many levels, lacks some vital elements that engender a thriving system for patients. I would suggest that a majority of people working in the healthcare field were drawn to the field because they want to help others. Even many healthcare organizations such as hospitals have a priority to increase patient satisfaction. However, the healthcare system lacks a strong cohesiveness and interrelatedness with many of the subsystems that would actually propagate higher levels of patient satisfaction and business success for healthcare professionals.

Working with many physicians and dentists over the years, I have observed that the unfortunate reality is that the subsystems are not only fractured, but are many times disjointed. One such example of this disconnect of systems is sleep diagnostics and treatment processes. Case in point is a physician who identifies a patient that needs a sleep test and subsequently testing is ordered. The patient is then referred to another entity. The result of the patient referral is either the conversion for testing is low and or the physician never knows what happens to their patient. Or even worse, the patient suffers a debilitating health effect and or dies. This example demonstrates three systems at work. First is the physician system. Second is the ancillary service system. And third is the patient system. These three must work together to optimize healthcare goals. Unfortunately, the three systems are disconnected and often fail in achieving the goal of quality patient care.


Individuals Systems and the Challenges

With the evidence of healthcare lacking a systems thinking approach, we need to look further at some of the critical subsystems. The first is the physician system and his/her ability to have the right tools to screen and identify their patients. Second, is the right type of ancillary services that is interrelated properly with the first system. Third is the patient system and the process by which patients are educated and put through the system efficiently. The fourth system is the treatment system. Part of that treatment system is the dentist who provides oral appliance therapy for those patients diagnosed with mild to moderate sleep apnea; therein becomes a major challenge for many dentists

Challenges to the Dental Sleep Medicine System

Dentists trying to enter into dental sleep medicine have found it to be very difficult. There are two common challenges dentists face.

  1. They find it difficult to treat patients and get paid. There are many ways to overcome that. Nonetheless, such a barrier creates difficulty for many dentists and subsequently they lose steam and either quit it all together or minimize it significantly in their practice.
  2. The other problem for dentists is the integration of such a system into their practice. Dentists most of the time treat their dental sleep medicine as a stand alone system. Doing so creates a disconnected subsystem within their own practice that diminishes their ability to succeed.

Interrelated Dentistry Systems

For a dentist who is practicing dentistry regularly, it becomes very difficult to integrate a system that is inherently different to what the dentist is already doing. A dentist must understand that in order for the dental sleep medicine system to blossom it must be interrelated with general dentistry practices or systems such as TMJ, headache, migraine, and more that creates “the whole [that] can exceed the sum of its parts” (Senge, p. 12). To consider if the dentist is using a systems thinking approach in their practice, there are five simple questions to answer as a dentist:

  1. What difference would having a dental sleep medicine program have on my existing dental systems?
  2. If I already have a dental sleep medicine program, do I effectively integrate it with other dentistry procedures I practice daily.
  3. What of my practice staff? Are they engaged in the systems to ensure interrelatedness?
  4. What metrics and accountability processes am I using in my practice to determine the effectiveness of my dental sleep medicine integration and dentistry practices?
  5. Am I effectively using a systems thinking approach to optimize my patient care and my business?

Answering such questions and implementing new solution pathways by which each of the dentistry systems can influence one another, enables a practice to thrive.

I was in a meeting recently with golf legend Johnny Miller. He shared something that resonated with me. He explained an experience he had with Jack Nicklaus years ago. Johnny, in so many words, asked Jack why he was so good. Jack explained that every year he returns to a coach. Jack asks the coach to teach him as if he didn’t know anything. That forced Jack Nicklaus to focus on the basics every year without getting too fancy. I think it’s safe to say this strategy worked out well for Jack. This leads to what my colleague Joe said to me the other day about the Doctor Alliance Group (DAG) Systems Framework. What Joe said is vey simple, yet powerful. Now what I am about to repeat from Joe may seem commonplace, cliché, trite, overused, obvious “fundamentals,” or whatever you want to call it. However, oftentimes the old wives’ tales, motherly wisdom, adages, or repeated basics contain the most enduring and effective concepts we know. When it comes to our businesses where our livelihood is at stake, nothing is too worn out if it enhances our business and provides the life style we want. The secret to any organizational success is doing the small things well over and over. Now let me relay what Joe said about the DAG Systems Framework. He compared it to a recipe. Now usually any food or beverage product has the list of ingredients, but, as Joe said, “it the right combination of the ingredients at the right time that makes the recipe good.” The core concepts of the DAG Systems Framework was founded after our years of experience enduring trial and error coupled with research have proven to be a successful formula. The right combination of these core components have been implemented by our clients resulting in tremendous success. The DAG Systems Framework contains four core concepts that I will touch on: (1) Fundamentals of Excellence, (2) Communication, (3) Accountability, and (4) Systems Thinking.

The Fundamentals of Excellence

The core concept of Fundamentals of Excellence is broken into three sub parts, (a) patient satisfaction, (b) focused strategy, and (c) leadership.
The first fundamental of excellence is patient satisfaction. We have developed multiple proprietary tools over the years that have added significant value to practices in regards to patient satisfaction. However, for the sake of brevity, let me share some important statistics in regards to patient satisfaction. A recent study of healthcare organizations indicated that “negative word of mouth can cost the organization $6,000-$400,000 in lost revenues over one patient’s lifetime”(1). Another study reported that there was a 64% operating profit margin for organizations with high patient satisfaction levels as opposed to a -27% operating profit margin for organizations with low patient satisfaction levels (2). The degree of excellence is associated with the level of patient satisfaction in your practice.

The second fundamental of excellence is focused strategy. It’s one thing to have a strategy for your practice, but it’s entirely another thing to keep focused on it. Integrating any program in your practice requires the right people working in the right way. Sadly, organizations and private practices alike have good plans, but 60-80 percent of them “fall far short of the targets expressed in their strategic

plans” (3). Why do they fall short? Because the right people are not in the right place and are not focused on plans, at least not long enough. The strategic planning process is nice and successful, but the execution of the plan is often where everything falls off the end.

The third fundamental of excellence is leadership. This is a big topic and obviously impossible to cover at this point. However, it is essential to understand that there are three leadership processes occurring within a practice, (1) doctor- staff, (2) doctor- patient, and (3) doctor-community. It requires a leader to manage change, instill certain behavioral practices, and lead by engagement and example. Such desirable attributes and behavioral practices activate a flourishing environment of success.


The second core concept of the framework is communication. The deficiency of the “right” communication processes in healthcare organizations is replete in the research. Those organizations practicing the right communication behaviors report outcomes of higher performance and financial success. In looking at the micro level in a dental or medical practice, we can see the vital importance of proper communication between doctor and team, patient, and community. There are multiple communication behavior processes that enables a practice to work at an optimal level. The right communication processes, similar to the leadership processes of doctor-team, doctor-patient, and doctor-community, engenders practice success.


The third core concept is accountability. At times this concept seems ominous and people tend to veer away from it because, well let’s admit it, we typically don’t like to be held accountable. As a remedy, there are systems we have built that are anchored on accountability and those who have properly applied our principles are seeing tremendous success in their career. In short, a culture built on accountability is a culture that fosters success.

Systems Thinking

The last core component of the DAG Systems Framework is the concept of systems thinking. The process of systems thinking understands how individual systems influence one another within a complete entity, or larger system. After an analysis of the various systems occurring in your dental practice, you will find multiple independent processes. A practice then must evaluate whether or not the various systems are working together in way to enhance success. Also, it must be determined if the practice is missing any additional systems that would optimize the existing systems and practice overall.

These four core components of the DAG Systems Framework provide a comprehensive model that is synergistic in nature and have proven to cultivate success and elevate your dental practice.

Oral Appliances Can Help Relieve Snoring and Sleep Apnea In Children

Snoring and sleep apnea can affect anyone of any age.  For children, who frequently sleep alone, grinding of the teeth or reflux disease may be the first signs of the condition, and may first be noticed by a well-trained dentist.

Snoring and other signs of disturbed sleep, such as long pauses in breathing, tossing and turning in bed, chronic mouth breathing during sleep, and night sweats are possible signs of sleep apnea.  The website states that studies suggest that as many as 25% of children diagnosed with attention-deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea, and that much of their learning difficulty and behavioral issues can be the result of chronic fragmented sleep.

Snoring occurs when the flow of air through the mouth and nose is physically obstructed.  Blocked nasal passages, poor muscle tone in the throat and tongue, bulky throat tissue (common in overweight patients), and a long soft palate or uvula can contribute to airflow obstruction.

Oral appliances for treatment of pediatric obstructive sleep apnea (OSA) can be helpful, especially in adolescents whose facial bone growth is largely incomplete.  One device, which rapidly expands the transversal diameter of the hard palate over a six-month to one-year period, has been successfully used in patients as young as age six.

In the United States, oral devices to treat OSA can’t be sold over the counter. They must be prescribed by a physician and fitted by a dentist.  An oral breathing device used to treat pediatric OSA must be refitted periodically as the child grows.

To read the article at original location: Click here

DAG Blog

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