sensors back to basics · 2018-07-19 · disclosure richard a. bonato, ph.d., m.a., rpsgt ceo and...
TRANSCRIPT
![Page 1: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/1.jpg)
DISCLOSURE
Richard A. Bonato, Ph.D., M.A., RPSGT
CEO and Co-Founder of BRAEBON® Medical Corporation
Has been involved in the study of sleep and its disorders since
1986, has taught courses on Sleeping & Dreaming at Carleton
University, was the director of a sleep disorders laboratory, and
has been an author, co-author, reviewer, and examiner in
various educational organizations within the sleep field,
including the AASM, AAST, BRPT, and has served on the
Executive of the Canadian Sleep Society.
BRAEBON manufactures and sells wearable sleep sensors,
home apnea recorders, and a micro-recorder, DentiTrac, for
tracking oral appliance compliance.
![Page 2: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/2.jpg)
Copyright 2017 BRAEBON
Oral Appliance Therapy for OSA
and Measuring Compliance in
Custom Oral Devices for OSA
![Page 3: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/3.jpg)
Copyright 2017 BRAEBON
Objectives
• How does OAT (and CPAP) work and how do
you know it is working?
• Compliance and why measure it?
• Test Treat Trac®
• Technology: understanding what to use
• Types of patients who may benefit from oral
appliance compliance measurement
• Evaluation of oral appliance success:
compliance reporting
![Page 4: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/4.jpg)
Copyright 2017 BRAEBON
iOS & Droid App – Free Dental Sleep Study Guide
![Page 5: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/5.jpg)
Copyright 2017 BRAEBON
![Page 6: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/6.jpg)
Sleep Disordered Breathing Spectrum
![Page 7: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/7.jpg)
![Page 8: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/8.jpg)
Copyright 2017 BRAEBON
Two key questions for DSM:
1. How does OAT work, how do you
know oral appliance therapy (OAT) is
working for an apnea patient?
2. How do you know if a patient is
wearing their oral appliance?
![Page 9: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/9.jpg)
®
![Page 10: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/10.jpg)
Change….
• Omnipresent
• Very difficult for many people
• Technology change (Test. Treat. Trac.)
• What was life like in the year 1900?
• What was the environmental crisis of
the day?
![Page 11: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/11.jpg)
Technology we use…..
Lab (PSG) vs home (HSAT)
Type 1 PSG Type 2 HST Type 3 HSAT Type 4 HSAT
Sleep Tech in
Sleep Lab
No Tech, Home
(MediPalm/Byte)
No Tech
Home (MediByte)
No Tech,
Home (Oximeter)
16 or more
channels: EEG,
EOG, EMG, EKG,
Legs
7 or more: EEG,
EOG, EMG
4 or more 1 or 2
Thermal airflow,
Pressure airflow,
Ventilatory effort,
Snoring, Body Pos
Thermal airflow,
Pressure airflow,
Ventilatory effort,
Snoring, Body Pos
Thermal airflow,
Pressure airflow,
Ventilatory effort,
Snoring, Body Pos
Perhaps pressure
airflow
SpO2 SpO2 SpO2 SpO2
![Page 12: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/12.jpg)
SCOPER Scale: Collop et al. 2011
![Page 13: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/13.jpg)
Polysomnogram = PSG (full PSG or full poly)
1989: >200 lbs; 6’ high
![Page 14: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/14.jpg)
Full Polysomnograpy (Type 1)
2003: ½ lb; 4.75” x 2.75” x 0.75” (L x W x H)
![Page 15: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/15.jpg)
Polysomnogram = multiple sleep graph recording
EEG EOG
Chin EMG
Legs EMG
SpO2
Chest effort
Abdominal effort
EKG
Body Position
Airflow
![Page 16: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/16.jpg)
Type 1
![Page 17: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/17.jpg)
With in-lab PSG (Type 1)….
• We can evaluate virtually all sleep
disorders (about 90)
• Plus MSLT & MWT
• But PSG is NOT a gold standard for OSA
• There is no anatomical or biological
gold standard for OSA
• Best at the time and we got stuck with it
![Page 18: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/18.jpg)
Home sleep apnea testing (HSAT): Type 2 / 3
2006: 93 grams; 2.75” x 2” x 0.70”
![Page 19: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/19.jpg)
Type 2 Home Sleep Recording
![Page 20: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/20.jpg)
Type 2: EEG, EOG, EMG + cardiopulmonary
![Page 21: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/21.jpg)
Unambiguous Stage REM sleep….
![Page 22: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/22.jpg)
![Page 23: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/23.jpg)
Type 1 or Type 2
![Page 24: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/24.jpg)
EEG During sleep stages
Beta = 16 to 30 Hz EEG
Gamma = > 30 Hz EEG
CNV & DC Potentials
Alpha EEG = 8 to 12 Hz
Theta EEG = 4 to 8 Hz
Delta EEG = 0.5 to 4 Hz
Sleep Spindle = 12 to 14 Hz
NREM REM Sleep Cycle
Copyright 2011 Braebon
![Page 25: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/25.jpg)
OSA SNORING EKG BRUXISM
Different tests are easily configured:
bruxism, EKG, snoring, PLMs (legs), etc.
Copyright 2011 Braebon
![Page 26: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/26.jpg)
ORAL CPAP PAP INDUCED
APPLIANCE AUTOPAP PLMS
Different therapies can be monitored.
Copyright 2011 Braebon
![Page 27: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/27.jpg)
Simultaneously record:
1. EEG
2. EOG
3. EMG
4. EKG
5. Snore
6. Pressure Airflow
7. Flow Limitation
8. Thermal Airflow
9. Chest Effort
10. Abdominal Effort
11. Sum
12. SpO2
13. Pulse Rate
14. Body Position
15. *PPG (Photoplethysmogram)
16. User Events
![Page 28: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/28.jpg)
HSAT Type 3 simpler cardiopulmonary recorder
2008: 91 grams; 2.75” x 2” x 0.70”
![Page 29: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/29.jpg)
BRAEB
ON
Type 3 but with fewer channels
Copyright 2011 Braebon
![Page 30: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/30.jpg)
Simultaneously record:
1. Snore
2. Pressure Airflow
3. Flow Limitation
4. Chest Effort
5. SpO2
6. Pulse Rate
7. Body Position
8. *PPG (Photoplethysmogram)
9. User Events
![Page 31: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/31.jpg)
Type 4: overnight pulse oximetry
![Page 32: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/32.jpg)
Type 4: Pulse Oximetry (+ more?)
![Page 33: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/33.jpg)
Simultaneously record:
1. Snore
2. Pressure Airflow
3. Flow Limitation
4. SpO2
5. Pulse Rate
6. *PPG (Photoplethysmogram)
![Page 34: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/34.jpg)
DentiTrac micro-recorder
2015: 5 grams; ~12 x 11 x 5 mm
![Page 35: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/35.jpg)
What do these devices have in common?
• They are ALL recorders
![Page 36: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/36.jpg)
What do we do with this info?
• SDB: AHI is often focus
• Why?
• Other measures: Arousals, RDI, flow
limitation, RERAs, PRV, etc.
• Goal is successful treatment: CPAP or
OAT
![Page 37: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/37.jpg)
How does CPAP work?
• A CPAP machine blows room air into
your airway so it doesn't collapse when
you breathe in.
• Interface covers nose (maybe mouth,
but nose better)
• Think of CPAP as an air splint
• Effective but usually low compliance
![Page 38: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/38.jpg)
Copyright 2013 Braebon
![Page 39: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/39.jpg)
CPAP (cont’d)
• Bedside blower size is usually not an
issue for people
• Blowers are getting smaller for easier
travel: Travel PAP
• Mask interfaces remain the largest
issue for most people
![Page 40: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/40.jpg)
How does OAT work?
• A device is placed in the mouth and
holds the mandible and / or tongue
forward, usually with increased vertical
opening, which acts as a mechanical
splint to increase airway space so your
airway doesn’t collapse (as much) when
you breathe in
• TRD vs MRD
![Page 41: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/41.jpg)
![Page 42: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/42.jpg)
How does OAT work?
• Custom usually better than boil & bite
• Titratable usually better than non
• Bite registration?
• Phonetic
• George Gauge
![Page 43: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/43.jpg)
86% increase
in anterior-
posterior
area
![Page 44: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/44.jpg)
How does OAT compare to CPAP?
Chan & Cistulli, 2009
![Page 45: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/45.jpg)
Are you better off using something
that works well (i.e., CPAP with AHI &
PSG measures) but using it less OR
are you better off using something
that does not work quite as well (i.e.,
OAT) but using it more?
![Page 46: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/46.jpg)
Copyright 2017 BRAEBON
Amer J Resp Crit Care Med 2013
![Page 47: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/47.jpg)
Copyright 2017 BRAEBON
• Measured cardiovascular (24-h blood
pressure, arterial stiffness), subjective
sleepiness, driving simulator
performance, and quality of life
(Functional Outcomes of Sleep
Questionnaire-36)
• Randomly assigned 126 (108
completed) patients with moderate to
severe OSA
![Page 48: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/48.jpg)
Copyright 2017 BRAEBON
What This Study Adds to the Field
In the short term, health outcomes in patients with moderate
to severe OSA were similar after treatment with
CPAP and MAD. This was likely explained by the greater
efficacy of CPAP being offset by inferior compliance relative
to MAD. These findings strongly challenge current
practice parameters recommending MAD treatment be
considered only in patients with mild to moderate OSA.
Long-term comparative effectiveness studies between
CPAP and MAD that include objectively measured treatment
compliance are needed to better define treatment
strategies for patients with OSA.
CPAP reduced AHI better, but moderate to
severe OSA patients were similar after
treatment with CPAP and oral appliance.
Because patients wear oral appliances
more than they wear CPAP.
Long-term studies needed to compare
CPAP and MAD using objective
compliance measurement [e.g., DentiTrac].
![Page 49: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/49.jpg)
Copyright 2017 BRAEBON
• Why did Philips et al (2013) find this?
• “Mean Disease Alleviation” (later)
![Page 50: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/50.jpg)
Copyright 2017 BRAEBON
![Page 51: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/51.jpg)
Copyright 2017 BRAEBON
• Q/ How do you know if CPAP Tx is
working for the patient?
![Page 52: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/52.jpg)
Copyright 2017 BRAEBON
Pt with Hx of MI, TIA….
![Page 53: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/53.jpg)
Copyright 2017 BRAEBON
![Page 54: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/54.jpg)
Copyright 2017 BRAEBON
![Page 55: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/55.jpg)
Copyright 2017 BRAEBON
![Page 56: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/56.jpg)
Copyright 2017 BRAEBON
![Page 57: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/57.jpg)
Copyright 2017 BRAEBON
• Q/ How do you know if OA Tx is
working for the patient?
![Page 58: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/58.jpg)
Copyright 2017 BRAEBON
![Page 59: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/59.jpg)
Copyright 2017 BRAEBON
![Page 60: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/60.jpg)
Copyright 2017 BRAEBON
Before: AHI 9.5 After: AHI 11.2
![Page 61: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/61.jpg)
Copyright 2017 BRAEBON
Before: AHI 9.5
After: AHI 11.2 Patient feels better now
![Page 62: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/62.jpg)
Pulse Rate Variability from 60 to 120
Overall AHI / RDI = 15.7 / 24.2
![Page 63: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/63.jpg)
But supine this person falls into mild….
![Page 64: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/64.jpg)
Follow-up: Baseline vs OAT Tx
16.3
3.8
![Page 65: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/65.jpg)
CPAP Noncompliant patient using temp appliance (in a tent)
38
11
![Page 66: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/66.jpg)
72
6
Copyright 2012 Braebon
![Page 67: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/67.jpg)
Copyright 2017 BRAEBON
![Page 68: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/68.jpg)
Copyright 2017 BRAEBON
• We’ve talked about technology, we’ve
talked about how CPAP & OAT work,
how to measure their success
• How do you actually know if people
are actually complying or adhering to
treatment?
![Page 69: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/69.jpg)
What is compliance?
• “Extent to which a person’s behavior (taking
meds, following a diet) coincides with medical
or health advice” (Haynes et al., 1979)
• Also, adherence, concordance or cooperation
(not passive terms, suggest more choice, etc.)
• For dental sleep medicine or orthodontics:
extent to which the person is using prescribed
therapy
Copyright 2017 Braebon
![Page 70: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/70.jpg)
Direct or Indirect compliance measurement
• Direct:
• Use physiological measures (airflow, body temp)
• Less subject to bias
• This is where CPAP has been
• Indirect:
• Self-reports are more frequently used and easier
• More subject to bias
• This is where OAT has been
Copyright 2017 BRAEBON
![Page 71: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/71.jpg)
Why is it important to measure?
• Better compliance = better results: reduced
treatment time (ortho)
• Noncompliance = waste of resources =
insurance payers will no longer pay (CPAP)
Copyright 2017 BRAEBON
![Page 72: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/72.jpg)
Achilles heel of CPAP = compliance
CPAP Achilles heel: compliance
• mask is a huge issue
• not size of blower
• not humidity
• not hose
Copyright 2017 BRAEBON
![Page 73: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/73.jpg)
Two Achilles heels of OAT
1. Objective compliance
measurement
2. A priori determination of
successful OAT candidate
![Page 74: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/74.jpg)
Definition of compliance: CPAP
• To qualify to retain funding for CPAP after an
initial 3-month trial, a patient must
demonstrate “continued use of CPAP therapy”:
• > 4 hrs per night for > 70% of all nights
during a 30-day period of the initial 90-day
trial
• Historical def’n is >4 hrs nightly five
nights per week
Copyright 2017 BRAEBON
![Page 75: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/75.jpg)
Europe
Qualifying for continued CPAP funding
• France: > 3 hrs per night 7 days per week
• Germany: > 4 hrs per night
• Italy: > 3 hours per night
• Spain: > 5 hours per night
Which definition is more correct?
Copyright 2017 BRAEBON
![Page 76: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/76.jpg)
CPAP machines & the luxury of size
Copyright 2017 BRAEBON
![Page 77: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/77.jpg)
A CPAP report…..
Copyright 2017 BRAEBON
![Page 78: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/78.jpg)
AHI, Pressure (cm H20), leak, hours of use
Copyright 2017 BRAEBON
![Page 79: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/79.jpg)
Let me tell you about our patient Juan…
• Juan is from Columbia
• Juan is a bit of a round individual
• Juan has a BMI of 32.5
Copyright 2017 BRAEBON
• Mallampati score of 0 (or less)
• Weight = 1.36kg and Height = 8”
![Page 80: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/80.jpg)
Meet Juan….
Copyright 2017 BRAEBON
![Page 81: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/81.jpg)
Juan needs CPAP @ 11 cmH20
Copyright 2017 BRAEBON
![Page 82: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/82.jpg)
Copyright 2017 BRAEBON
![Page 83: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/83.jpg)
Copyright 2017 BRAEBON
![Page 84: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/84.jpg)
Gaming CPAP compliance
• Quick & dirty demonstration of CPAP
compliance deception:
• Cannot guarantee that it is actually
that patient wearing that particular
CPAP
• Could be bedpartner or a simple or
more sophisticated simulation
• This has important implications for the
future
![Page 85: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/85.jpg)
CPAP Compliance / Intolerance
• When adherence is defined as greater than 4
hours of nightly use, 46 to 83% of patients with
obstructive sleep apnea have been reported to
be nonadherent to treatment.
Weaver & Grunstein (2008). Proc Am Thorac Soc Vol 5. pp
173–178, 2008
• CPAP Intolerance is a large target market for
dentists
Copyright 2017 BRAEBON
![Page 86: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/86.jpg)
CPAP is state of the art treatment but…
After about a year 50% of people
stop using it
Copyright 2017 BRAEBON
![Page 87: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/87.jpg)
Copyright 2017 BRAEBON
Kribbs, Pack, Kline, Getsy, Schuett, Henry,
Maislin, Dinges. Effects of one night without
nasal CPAP treatment on sleep and sleepiness
in patients with obstructive sleep apnea.
Am Rev Respir Dis 1993;147:1162–1168.
Sleeping without CPAP for one night
reversed virtually all of the sleep and
daytime alertness gains derived from
sleeping with CPAP.
![Page 88: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/88.jpg)
Copyright 2017 BRAEBON
![Page 89: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/89.jpg)
AASM OA Practice Parameters: 2005
• Adherence data for OAs mostly relies on
subjective reports.
• In contrast, CPAP compliance is
routinely monitored objectively.
• Development of similar capabilities for
OA therapy should be pursued for both
research and clinical purposes.
What about OAT compliance measurement?
Copyright 2017 BRAEBON
![Page 90: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/90.jpg)
Two Achilles heels of OAT
1. Objective compliance
measurement
![Page 91: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/91.jpg)
What is OAT compliance?
1. How compliant are you everyday?
2. How compliant are you on days you are
wearing it for at least 15 min?
3. How compliant are you > 4 hrs daily for 5
out of 7 days for the entire data collection
period? (historical CPAP def’n)
4. How compliant are you > 4 hrs daily during
a 30-day period of the initial 90-day usage?
(this is the new CPAP def’n)
Copyright 2017 BRAEBON
![Page 92: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/92.jpg)
4. How compliant are you if you changed
appliances and now have a new one
(i.e., more than one)?
5. How compliant are you since the last
time we looked (uploaded) at the data?
What is OAT compliance? (cont’d)
![Page 93: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/93.jpg)
• Headgear timer: miniature electronic watch with memory
• Pts increased wearing time when told about monitoring.
• Hours increased from 35-50 / week to 100 / week.
![Page 94: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/94.jpg)
Northcutt, M. E. The timing headgear. J. Clin. Orthod.
V.8, p.321-324, Jun. 1974.
• Timing headgear neckband and timer
• Timing headgear readout monitor
• Neckband placed on monitor for readout
![Page 95: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/95.jpg)
Orthokinetics: Compliance Science System
• Objectively inform orthodontists and patients the
number of hours the headgear is being worn
![Page 96: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/96.jpg)
• Compliance Science System in 46 patients (blind)
• After two months two groups set up:
• uncooperative <16 hrs daily now informed of monitor
• cooperative > 16 hrs daily remain blind to monitor
• 4 months later: statistically significant increase in
usage in the uncooperative group
![Page 97: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/97.jpg)
Creative children found a way around it….
![Page 98: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/98.jpg)
Temperature sensor with periodic sampling
![Page 99: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/99.jpg)
Copyright 2017 BRAEBON
What is an OAT compliance
monitor (DentiTrac)?
Is it a sensor? NO
Is it a chip? NO
Is it a micro-recorder? YES
![Page 100: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/100.jpg)
Copyright 2017 BRAEBON
Both are dataloggers (recorders)
![Page 101: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/101.jpg)
Copyright 2017 BRAEBON
Having a lab embed a recorder into an appliance
is as simple as inserting a label…
•We anticipate most dentists will
check a box when ordering the
appliance
![Page 102: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/102.jpg)
Copyright 2017 BRAEBON
![Page 103: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/103.jpg)
Copyright 2017 BRAEBON
![Page 104: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/104.jpg)
Copyright 2017 BRAEBON
![Page 105: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/105.jpg)
Copyright 2017 BRAEBON
![Page 106: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/106.jpg)
Copyright 2017 BRAEBON
![Page 107: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/107.jpg)
Copyright 2017 BRAEBON
![Page 108: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/108.jpg)
Copyright 2017 BRAEBON
![Page 109: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/109.jpg)
Copyright 2017 BRAEBON
![Page 110: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/110.jpg)
Copyright 2017 BRAEBON
![Page 111: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/111.jpg)
Copyright 2017 BRAEBON
Auxilary can do much of this:
• Data is read by the base station and
uploaded to the cloud portal for analysis
and reporting
• Reading data is as simple as placing the
OA into the base station
![Page 112: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/112.jpg)
Copyright 2017 BRAEBON
![Page 113: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/113.jpg)
Copyright 2017 BRAEBON
![Page 114: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/114.jpg)
Copyright 2017 BRAEBON
![Page 115: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/115.jpg)
Copyright 2017 BRAEBON
DentiTrac processed data
2. CWhenWorn = 91%
1. Ceveryday = 87%
3. C5 of 7 = 95%
4. C90 = 100%
![Page 116: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/116.jpg)
Copyright 2017 BRAEBON
CPAP compliance &
OAT compliance data
![Page 117: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/117.jpg)
Copyright 2017 BRAEBON
![Page 118: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/118.jpg)
Copyright 2017 BRAEBON
![Page 119: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/119.jpg)
Copyright 2017 BRAEBON
CPAP & OAT Compliance Data Detailed View
Pearson r = 0.92, r2 = .85; t-test = NS
![Page 120: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/120.jpg)
Definition of compliance: OAT
Copyright 2017 BRAEBON
![Page 121: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/121.jpg)
Vanderveken et al. 2013: Thorax
• Objective compliance measurement &
OAT
• Compared objective and subjective OAT
compliance
• Introduced “mean disease alleviation”
![Page 122: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/122.jpg)
Vanderveken et al. 2013
• Objective OAT compliance measurement
allows calculation of mean disease
alleviation, defined as a combined function of
efficacy and compliance, being a measure of
overall therapeutic effectiveness
• Effectiveness = compliance x efficacy.
![Page 123: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/123.jpg)
• OA efficacy (%) = baseline AHI minus
AHI with OA (e.g., 10 – 4.4 = 56%)
• Mean Disease Alleviation = product of
adjusted compliance (worn 91.2% of the
time) with therapeutic OA efficacy (56%
above = 51.1%
Vanderveken et al. 2013
![Page 124: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/124.jpg)
Mean disease alleviation
![Page 125: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/125.jpg)
CPAP example…
• If the AHI on CPAP drops from 50 to 2
then it is a 96% reduction
• If the patient only wears the CPAP 50%
of the time then Mean Disease
Alleviation = 50% x 96% = 48%
![Page 126: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/126.jpg)
• Higher compliance with OAT = similar
adjusted effectiveness as compared
with CPAP
• OAT is not as good as CPAP in
reducing AHI, but MDA values might be
comparable with CPAP because of the
higher compliance with OA therapy (and
that’s what Philips et al. 2013 said too)
Vanderveken et al. 2013
![Page 127: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/127.jpg)
More research using objective OA compliance…
51 patients with mild to moderate OSA
![Page 128: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/128.jpg)
Dieltjens et al. 2015 JAMA Oto Head & Neck
• Neither anthropometric & polysomnographic
parameters nor reports of excessive daytime
sleepiness correlated with OAT compliance
• Two parameters which correlated with higher
OAT objective compliance were decreased
snoring and dry mouth
![Page 129: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/129.jpg)
Journal Dental Sleep Medicine: 2015
CPAP & OAT have limitations: CPAP Tx often
has low patient acceptance, poor tolerance and
suboptimal compliance; OAT usually has inferior
PSG efficacy when compared to CPAP
![Page 130: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/130.jpg)
According to MDA concept….
• OSA Tx with CPAP, OAT or other non-
CPAP modalities, as a single treatment,
usually means incomplete elimination of
the disorder with average MDA index,
as a marker of real clinical
effectiveness, ranging from 40 to 59%
![Page 131: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/131.jpg)
Vanderveken 2015….
• Greater CPAP efficacy is offset by its
inferior compliance relative to OAT
• This is not imaginary, and results in a
similar overall effectiveness for both
therapeutic modalities
![Page 132: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/132.jpg)
• Mandibular advancement + tongue
protrusion = effective treatment for
moderate-to-severe OSA: tongue bulb
added to MRD provides further
therapeutic effectiveness.
Vanderveken 2015: Combo Tx
Dort & Remmers
JCSM 2012
![Page 133: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/133.jpg)
• OAT + multilevel upper airway surgery
• OAT + positional Tx
• Recent study reported MDA increased
from 42% to 70% when OAT was
combined with positional Tx
(Dieltjens et al., 2014)
Vanderveken 2015: Combo Tx
![Page 134: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/134.jpg)
But can we game OAT same as CPAP?
• It is much more difficult to deceive OAT
with DentiTrac objective compliance
than to deceive CPAP with Juan
• My OA won’t fit my bedpartner
• My dog luvs my OA as a chew toy
• Juan is not a substitute
• What about a heated water bath?
![Page 135: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/135.jpg)
Copyright 2017 BRAEBON
![Page 136: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/136.jpg)
Copyright 2017 BRAEBON
• Bϋchi heating bath deception
• 2 litres of water warmed to 35 C (95 F)
between 2100 and 0700 to simulate wearing
• Off 0700 to 1400
• On again 1400 to 1600 and 1700 to 1900
• Off 1900 to 2100
• Thus, total of 14 hrs wearing & 10 non-
wearing every 24 hours
Schott & Goz, Journal of Orofacial
Orthopedics, 2010, 79, pp 339-347.
![Page 137: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/137.jpg)
Copyright 2017 BRAEBON
With a simple temp measurement device,
they concluded that the warm water
bath could deceive the temperature
sensing technology and report wearing
when not actually worn
The DentiTrac was not susceptible to
this deception because more than
temperature is being recorded and
anti-deception algorithms are
implemented
![Page 138: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/138.jpg)
To conclude:
• Exciting times for OA Tx
• OAT compliance measurement is a
rapidly expanding frontier of dental
sleep medicine
• New standards evolving
• Modeled after the existing CPAP
compliance paradigm
• Test. Treat. Trac.®
![Page 139: Sensors back to Basics · 2018-07-19 · DISCLOSURE Richard A. Bonato, Ph.D., M.A., RPSGT CEO and Co-Founder of BRAEBON® Medical Corporation Has been involved in the study of sleep](https://reader034.vdocuments.net/reader034/viewer/2022050306/5f6e62f056f91d122e10f770/html5/thumbnails/139.jpg)
Where to go from here?
• Principles & Practice of Sleep Medicine (6th Ed)
• ASBA Diplomate Exam