Mitchell Levine, DMD, ABDSM, was recently installed as president of the American Academy of Dental Sleep Medicine (AADSM). In an interview with Sree Roy of Sleep Review, he discusses how COVID has changed the practice of dental sleep medicine, the role of telehealth, a consensus statement about oral appliance compliance, oral appliance monitoring sensors, what he wants to see in dental sleep medicine research, and what he hopes will have changed in dental sleep by the end of his 2-year term.

Podcast Transcript

Sree Roy:

Hi, this is Sree with Sleep Review, and I am thrilled to be here with Mitchell Levine, DMD ABDSM, who was recently installed as the president of the American Academy of Dental Sleep Medicine. Could you tell us a little bit about yourself, including how you came to practice dental sleep medicine?

Mitchell Levine:

Sure. Thank you, Sree, and thank you for having me with you today. I’m an orthodontist by training and I’ve been practicing sleep for probably more than a dozen years now. I had a private practice in Florida for more than 30 years, of which about a third of my patients were patients who presented with some sort of sleep disordered breathing. I kind of got involved in postgraduate education about five years ago. The first four years were at the University of Tennessee in Memphis. And in the last 14 months, I’ve been here at St. Louis University.

Mitchell Levine:

And I got involved really because the science of sleep, I found it just overwhelmingly compelling to me. I really hoped that orthodontics would be kind of the missing piece. As I’ve spent the last five years involved in the academic side of this, what I think I’ve found in my mind is that really the physiological burden still seems to be greater than the anatomic burden. But still since there’s a role for anatomy and as an orthodontist, this kind of gives me a sandbox to play in.

Sree Roy:

What motivated you to become involved in AADSM leadership?

Mitchell Levine:

Well, I thought that there could be more to the definition of dental sleep medicine. I really thought that there would be a greater role than just perhaps oral appliance therapy. And I thought that maybe as a specialist, someone who could change anatomy also, that maybe I could help expand the direction of the academy. And I found the collaborative nature, the interdisciplinary nature of sleep in particular to be really important. And I thought that this would be a good segue getting involved with the AADSM.

Mitchell Levine:

And eventually, I came to believe that the Academy could be a leader not only in postgraduate education, but my hope is that we could help it find a place in delivering undergraduate dental education as well. And so I think over these last five to six years that I’ve been involved, I think that we’ve established a good foundational educational program in dental sleep medicine. And accordingly, what we’ve been able to accomplish is increasing the number of qualified dentists who can provide oral appliance therapy. I still think that DSM is pretty much in its infancy, and I think the AADSM can evolve, I hope it can evolve and become a truly integral part, integral necessity to the practice of DSM for all of us, both nationally and internationally.

Sree Roy:

How has COVID changed the practice of dental sleep medicine?

Mitchell Levine:

Well, COVID has probably changed not only the practice of dental sleep medicine, but it’s certainly changed all of our lives. In particular, I think COVID helped us appreciate the fact that treating patients who have sleep apnea is important because many studies have shown us that those who were afflicted by COVID actually had a greater impact as related to that COVID. I think it also helped bring to the forefront how we could integrate telehealth into our dental practices. And I think what we’re going to see is movement that not only just in dental sleep medicine, but I think just dentistry as a whole. And then probably an unintended effect, I guess all these were unintended, but in particular, were the effects of supply chain issues with CPAP, and then compounded by the fact that there was this recall of PAP devices really has resulted in a shortage of available PAP modalities. And accordingly, I think what we’re seeing as a reflection of this is an increased utilization of oral appliances, either in a stop gap mode, or even now as a long term definitive therapy.

Sree Roy:

You had touched on this a little in that last response. I was curious about how, if at all, do you personally use telehealth in your own dental sleep practice?

Mitchell Levine:

Well, in academics, it’s probably a little bit different. I think in in a dental practice, and I know of people who are not only utilizing telehealth to screen patients, but to even actually deliver devices, they’ll hand them the device through a window into their car window and then have an assistant or somebody actually walk the patient through on how to deliver the device to themselves. In an academic environment, I think it’s a little bit different. As a training institution, we really find that for us, the resident to deliver an oral appliance and then help manage the patient through follow up, is really best done in person at this point. And I think we’re probably going to continue doing this until we get a comfort level on both parties on exploring telehealth in a different modality.

Sree Roy:

Do you think that’s because of demographic differences, like the types of patients that you see in an academic setting? Or why is that?

Mitchell Levine:

I think part of it is that I think the there’s not as much an expanded mindset of the resident at this point. And I think a hands-on, being able to see a patient and touch a patient, I think it’s more just that the ability of the resident dentist, as opposed to the practicing dentist, I just don’t think the skill set’s expanded quite as much to utilize that. I do see it happening over time. But like in our clinic, for example, we’ve just been delivering now oral devices over the last six months. And so it’s still new to them. And I think that it’s easier, once you’ve delivered a couple, than to have another process where it’s done remotely, I think it would be more amenable to that direction. But I think as they’re learning to just begin to deliver their first and second devices, it’s more incumbent upon them to be within the confines of a safer space, maybe.

Sree Roy:

That makes sense. I do like the idea of giving patients their device through the car window and then maybe training them on it through a telehealth application on how to put it in, because that’s just kind of meeting patients where they are and keeping it safe for patients who don’t feel like they are comfortable coming in. That’s a cool idea. Switching topics a little bit, the AADSM published a paper that provides a consensus-based standardized and oral appliance specific definition of compliance. It defined it as the appliance being worn for a minimum of at least greater two or equal to 80% of nights, I think it’s 80% of the time per night, for five or more nights a week. How has that definition impacted clinical practice so far? Obviously we’ve had a definition of CPAP adherence for a long time, but this is in a way the first standardized definition of oral appliance adherence.

Mitchell Levine:

Sure. So even the definition for compliance with PAP is evolving to some extent. And this seems to be in response to some outside pressures. In particular, I don’t know yet, I don’t know that we can qualify exactly how it’s impacting clinical practice in particular. But I think we do recognize that some sort of regimented compliance really emphasizes the benefit that it only comes by wearing the device, whether it is an oral device or a CPAP. And in line with the AASM recommendations of sleep duration somewhere being in that seven hours per night, I think the consensus task force, this was a consensus statement that came out, considered the role of things like sleep hygiene and other considerations in coming to this definition of 80% per night for at least five nights per week.

Mitchell Levine:

The guidelines are an ongoing evolving metric that can be improved over time. That is, some patients when they get their devices may struggle for wearing them 80% of the night. And I think the idea is that there’s a goal that we’re trying to achieve, but that if a patient can only manage two to three hours at least initially, that they understand that for an ideal management of their sleep disorder breathing, that the goal is to get to this 80% of time or greater for at least those five nights a week. Ideally, a patient would clearly be wearing this all night and wearing it every night, but I think we have to appreciate that some patients, even with oral devices, just like with CPAP, some patients struggle with compliance. And if they feel like they’re not getting that 80% of wear, then I think we have to explore the potential for alternative therapies beyond what we’re providing right now.

Sree Roy:

What are your thoughts on these sensors currently in development to be embedded into oral appliances that hope to track not only whether the patient is wearing the device, but also metrics such as AHI or even EEG? And again, this is kind of like what we’ve had, at least parts of this, for CPAP for a long time, but now it seems like in the near future, we’ll have these tracking for oral appliances as well.

Mitchell Levine:

Yeah. So it’s kind of interesting. I just came back from the American Academy of Sleep Medicine, and there were a handful, three or four, device manufacturers there, and they’re all now pumping up the idea of using sensors or some sort of compliance modalities. None of them were really able to show those chips or sensors in their devices just yet, but this is all coming around the corner, it would certainly seem. It’s kind of interesting, science and technology are definitely evolving. And I think the AADSM, as an academy, recognizes that it’s important that our guidelines and our resources also reflect these new updated technologies and reflect the new evidence that’s coming around the corner.

Mitchell Levine:

But trajectories themselves really are rarely straight. And so just as we’re beginning to explore the idea of tracking AHI, for example, it’s kind of interesting now that there’s a movement, albeit slow but a movement, of getting away from AHI. So how will this new technology fit in an evolving world where the AHI is becoming more of a compromised metric? It’ll be interesting to see if we can begin to somehow really use these devices other than just figuring out how much time someone’s wearing them, which is important to be sure. But unlike CPAP, we were hoping that we would be able to track really whether there is a management of the AHI or the [inaudible 00:13:17] burden, whatever it ends up being. So, just as these devices are coming on, they’re probably going to have to continue their evolution to meet new definitions as they begin to arise in sleep medicine.

Sree Roy:

I agree. I’m glad to see that these are in development, and I think some are very close, but I think that you’re right, there’s been a lot of talk about is AHI even the best measurement for somebody’s sleep apnea and whether it’s really being treated effectively or not. I was interested that one of the devices says it’s going to be able to measure EEG from inside the patient’s mouth. And so that presumably could measure a lot more things than just the AHI. So maybe that’ll be more useful. But yeah, I agree, those devices when they’re available, they’re going to have to keep evolving too.

Mitchell Levine:

Absolutely.

Sree Roy:

What research would you like to see done in the field of dental sleep medicine?

Mitchell Levine:

Probably because more of where I’m coming from, but I think I’d like to see more on the evidence of the real implications of risk factors as they relate to obstructive sleep apnea. There’s a lot of chatter out there, as you’re probably aware, that risk factors are more cause and effect, and that’s hardly the case. There is no cause and effect relationship. And so that even if we mitigate these risk factors, they don’t necessarily make a whole big difference in controlling the OSA. So what I would like to see truthfully is the beginning of longitudinal studies, longitudinal studies that really look at the real benefit as we attempt to modify dental and facial anatomy. I’m not talking about the severe cranio facial things, right? Those unto themselves, there may be a cause and effect relationship because the discrepancies are just so severe. But I’m talking about really more on the general pediatric dental patient who comes in to an orthodontic office. What are the implications there by really mitigating these supposed risk factors? And what will be the benefit or otherwise of the therapies that we’re providing?

Mitchell Levine:

So to me, that’s where I think the next step really is. And there are challenges. There are challenges because even as we’re doing this therapy in children in particular, these kids are growing. And there’s no doubt that some of the mitigating factors of growth exist at reducing the OSA burden. So, do we attribute it to therapy? Do we attribute it to growth? It’s hard to know at this point, and I think we’d all be better served by some better answers.

Sree Roy:

That’s a great suggestion. What, if anything, do you hope will have changed in dental sleep medicine by the end of your two-year term as AADSM president?

Mitchell Levine:

So I think that obviously this is… We’re just a few days into my presidency, but I think that there’s a lot of opportunity moving forward over the next two years. I think one of the things that we’ve already begun to do is at some levels, begin to ameliorate the burden of OSA by having more qualified dentists engaged in oral appliance delivery. And I think that over the next two years, we’ll educate a good deal number of dentists who feel both confident in their abilities and their skillsets to treat more adults. And I think accordingly we’ll see more adults in a care as well.

Mitchell Levine:

One of the other initiatives that we’ve embarked upon over the last year is through our academic council, where we have efforts at introducing dental sleep medicine into the curriculums of the dental schools. Now, I recognize that CODA, the Council on Dental Accreditation, doesn’t require any education per se right now in dental sleep medicine. But with the role of screening through the ADA and other efforts with our academic council, I think that we’re seeing increased interest, certainly in the dental schools. And I hope that we’ll be able to help enhance the curriculum at the D-one to D-four levels. Even just in postgraduate education here since I’ve been at SLU, we’ve actually been able to… We offer a full semester course in dental sleep medicine with our graduate residents. And they also have a clinical experience where they get to deliver several oral appliances as well. So I think there’s ample opportunity in both postgraduate dental and undergraduate dental education to make a difference as well.

Mitchell Levine:

And then I think over time, I think we can enhance and build upon the somewhat challenging relationships that exist between dentists and physicians. I think that there’s more nurturing that can be done. And I think that will be part of my intent over the next several years. And I think that we’re going to see more of a leveling of the playing field between physicians and dentists. So I don’t think we’re going to see much of a change yet in who does the diagnosing. I think that’s still certainly within the purview of physicians as they diagnose OSA. But I think the management, the care can begin to be relegated to other players and other providers, including dentists. And I think that what we’ll see is a greater capacity to reduce, I hope, this social economic burden that exists and the health inconsistencies that exist with OSA. And I would hope that the AADSM will be the go-to resource to help dentists find their way and navigate their way to making a difference in this pretty exciting field.

Sree Roy:

Thanks for sharing that with us. Those are all my questions. Can you tell our listeners where they can find you, any social media, any live virtual events, anything like that where our listeners can find you?

Mitchell Levine:

Not necessarily to find me per se, but to find better probably the AADSM. I think we can go to the web at aadsm.org, Twitter at AADSMorg, and Facebook at aadsm.org as well. We offer a series of advanced educational opportunities through the mastery program, which can be done both virtually or in person. And you can contact the AADSM for that as well. I think we’re doing a novel job of providing both didactic and clinical experience to the students and dentists who go through this program. And I think there’s a great opportunity to enhance your own skill set and feel comfortable embarking on the solution of oral appliance care through this venue. We also provide, alongside of mastery and within mastery, management and treatment considerations in the pediatric population as well.

Sree Roy:

Excellent. And if you want more from Sleep Review, please visit us at www.sleepreviewmag.com. Thanks so much for tuning in today.

Mitchell Levine:

Thank you for having me.