Mayoor Patel, DDS, MS, articulates the links between sleep and pain.
Enthusiasm radiates from Mayoor Patel, DDS, MS, when the topic turns to dental sleep medicine, and it’s clear that the owner of Atlanta-based Craniofacial Pain and Dental Sleep Center of Georgia has found his calling. While all that optimism serves him well as an educator and clinician, the positive mindset does not cloud his realism.
“There is a lot of work to be done,” Patel says. “Many general practitioners [GPs] with CPAP noncompliant patients are dealing with their patients’ hypertension and diabetes with only medication. We feel resistance to oral appliance therapy from primary care medicine, but we are merely trying to get primary care docs to see that there are viable alternatives to CPAP.”
Far from disparaging CPAP, Patel’s aim is to educate and increase options for patients who ultimately care nothing for medical turf wars. If and when patients go the oral appliance route, the 47-year-old Patel is quick to remind his colleagues to do thorough follow-up.
“Too often patients will get a device, and as long as patients say they are good, clinicians will let them float. Patients must have oversight because complications can arise with oral appliance therapy,” says Patel, who is also coauthor of the books Sleep Apnea Hurts—The Cure Doesn’t Have To and Take a Bite Out of Pain. “Dentists need to have a system to bring patients back and make sure devices are intact and there are no negative consequences of the oral appliance therapy.”
In the realm of traditional dentistry, Patel learned proper follow-up as a dental student at the University of Tennessee. After working at general practices in Norcross and Duluth, Ga, he went on to receive his Certification in Orofacial Pain at Rutgers in New Jersey in 2004.
From the early 2000s to about 2008, education for dentists who wanted to learn about oral appliances was essentially a “hodgepodge of courses” all with different speakers. “I had the opportunity to get a master’s degree at Tufts University on orofacial pain and dental sleep medicine,” Patel says. “I took a distance learning accredited program, and it really opened my eyes to many different avenues of sleep and pain.”
Patel has also earned Diplomate status from many organizations, including the Academy of Integrative Pain Management, American Board of Craniofacial Pain, American Board of Orofacial Pain, American Board of Craniofacial Dental Sleep Medicine, and the American Board of Dental Sleep Medicine—the latter being the most critical to his dental sleep medicine practice. He is also a registered polysomnographic technologist.
Along with Terry R. Bennett, DMD, DABCP, DABDSM, from Tulsa, Okla, Patel developed a sleep mini residency that has been adopted by various organizations. “We basically offer a 4- and/or 8-day session,” Patel says. “In the past we have done them in Canada and several at ResMed in San Diego. The idea was to create a structure: Start with basic science; then on to sleep medicine, where we have our medical colleagues lecture; an ENT discusses nasal passages; and of course, there’s an entire dental component.”
“Dr Patel and I have presented this program 13 different times,” says Bennett, who has two practices in the Sooner state. “We also developed a 5-and-a-half day TMD course and have given this course three different times. Mayoor understands the two disciplines thoroughly and is able to articulate the problems and solutions to his patients and to students. He is a compassionate person, and he is the consummate teacher at heart.”
Patel accepts the “teacher at heart” mantle willingly and dedicates a portion of each week to lecturing. A typical routine goes something like this. “I work three days a week in clinical practice—Monday, Tuesday, and Wednesday,” Patel says. “That gives me Thursdays to travel so I can be at a destination to lecture on Friday, Saturday, and in some cases even Sunday.”
Three years ago, Patel moved into a 2,200-sq-ft office in Atlanta that includes a 24-student capacity lecture hall. It’s a highly convenient space that occasionally motivates students to come to him. “If I’m not traveling for work, then it’s happening here in town. I can actually see my family and not travel as much,” Patel quips.
The huge emphasis on education is a direct result of Patel’s own lengthy journey to the sleep medicine side of dentistry, a time he says that “took longer than it should have.”
Patel opens his office to colleagues who wish to “shadow” and watch him work. “Since formally there are no fellowships or residencies that one can do, we try to didactically provide that education, and clinically they can visualize the whole process,” Patel says. “Education is my next forte, and it’s time for me to give back so this knowledge base can move on and we can provide better care for our patients.”
Educating colleagues and patients is one thing, but clinicians in other areas of medicine can occasionally be a harder sell. Patel and Bennett are doing their best to expand the understanding.
“Sleep doctors in my area weren’t really very accepting to the idea of dentists trying to treat sleep problems and also infringing on their turf,” Bennett says. “They didn’t understand the oral devices well, thought they were too expensive, and I had a hard time getting through to them. Times are now changing and we are starting to become more respected by our peers in the medical world. We are working toward a collaborative effort with physicians to treat all these patients.”
Ultimately, Patel wants more private sector courses to be offered in the university setting where students who are already in school can benefit. “When they graduate, they will have at least some foundational knowledge as opposed to graduating from dental school and having to seek out this knowledge,” he says. “We do have a joint program with the University of North Carolina in Chapel Hill with Dr Greg Essex. We would like similar programs at the institution-level to get better exposure for the students.”
Orofacial Pain Background
Patel readily admits that burnout is a “big problem” in the field of general dentistry, with practitioners experiencing back and neck issues, in addition to a “drill and fill” routine that can get tiresome. In addition to being a new and invigorating challenge, dental sleep medicine presents some less well known advantages, he says.
For example, when Patel broke his wrist in a car accident earlier this year, he did not have to stop working. His knowledge was more important than his dexterity. He explains, “The beautiful thing about dental sleep medicine is that once patients understand the benefits of oral appliances, everything from that point is passed to assistants to get the impressions. When devices come back from the lab, assistants fit them, and dentists verify that everything is fitting properly. Even with the necessary follow-up visits, there is little physical contact.”
Patel’s orofacial pain background laid the foundation for a firm understanding of what it takes to move the jaw forward and open the airway. More importantly, knowing the anatomy and physiology of the temporomandibular joint (TMJ) helps considerably when determining possible complications that can arise from oral appliance therapy.
“TMJ issues, muscle, and sleep are three things that go hand in hand,” Patel says. “Even though we move the tongue forward by using oral appliances, we’re going to have an indirect effect on the jaw itself. Since I came from the pain background and understand the joints and the joint pathology, I know how to defuse possible problems [from oral appliance therapy] and how to minimize the complications. We need to understand the jaw because the tongue attaches to the lower jaw.”
Greater understanding has led to better results throughout the years. For example, a woman in her mid 40s was referred to Patel with dizziness, ringing in the ears, and right jaw pain while chewing food. She had seen numerous practitioners, from chiropractors to acupuncturists to traditional medicine, but the root cause remained maddeningly unaddressed.
After a diagnosis of severe sleep apnea, followed by CPAP dissatisfaction (leaking and discomfort), she emerged more fatigued than ever. Patel recalls, “Her right joint disc had slipped and she was a significant grinder, which contributed to her pain. Being that she was apneic and noncompliant to traditional treatment, our choice was to manage the joint and find a way to oxygenate a bit better. We did splint therapy to re-support the jaw and try to recapture the tissue and the right jaw joint.”
In addition, Patel and his team “fitted a dorsal appliance to manage her sleep, but we modified the dorsal device to also act like a night guard. However, we did not advance it as much as we would advance a typical appliance if we were only managing it for sleep apnea. We wanted something in there to prevent the jaw from falling back, but at the same time we did not want to strain the jaw until it was healthy enough to move that jaw forward.”
Her first follow-up after receiving the devices showed significant reduction in her symptoms and reduced fatigue. “She did have light snoring but nothing loud or aggressive,” Patel remembers. “It was about 4 to 6 weeks for the jaw joint to calm down, and at that point we started advancing her lower sleep appliance to the point where subjectively she felt great and the bed partner had no snoring complaints.”
She was eventually tested with the dorsal device in her mouth, and the numbers showed that the apnea had reduced more than 50%, while her oxygen saturation remained above 90%. The physician agreed that the appliance therapy was working, even though the patient had residual apnea. “She was not fatigued and jaw issues were no longer a concern,” Patel says. “For her, it was back to living a healthier life and being a mom, which were her goals.”
On the strictly pain side, Patel uses appliances for clenching/grinding, in addition to splints and orthotics. Specifically, he favors Glidewell Laboratories, Great Lakes Dental Technologies, True Function Laboratory, and Apex Dental Sleep Lab. “Bio Research is a company that sells lasers for pain,” Patel adds. “Whip Mix has a Gem Pro, an ambulatory unit that looks at bruxism/snoring/pulse ox, to see if there’s an underlying sleep issue that will require a referral to a sleep physician. I also recommend pharmaceuticals such as over-the-counter NSAIDS and prescription antiinflammatories.” For injection therapy, he buys anesthetic from a dental distributor. For software to manage his TMJ and sleep practice, he prefers Nierman Practice Management for its clinical data capture, letter writing templates, and medical claim forms. (Patel also lectures for Nierman Practice Management.)
With pharmaceuticals, oral appliances, splints, and orthotics as possible solutions, Patel cultivates a continuum that is entirely dependent on patient needs.
While so-called “turf wars” are not a thing of the past, Patel seems confident that day will come, preferably sooner than later. “The level of respect for dental sleep medicine has come a long way,” he says. “Today there is a lot of awareness and we have a lot of medical practitioners who are oral appliance-friendly and understand that many patients are not able to tolerate CPAP. They understand that when that happens, they need to offer alternatives. I look forward to a time when respiratory therapists, nurse practitioners, physician assistants, and MDs all have a firm understanding of oral appliance therapy.”
[sidebar] Continue this discussion in person at an industry supported event at the American Academy of Dental Sleep Medicine annual meeting. Patel is doing a clinical Q&A on dental sleep medicine and pain on June 7 at 7 pm at the Marriott Rivercenter in San Antonio. Contact host Nierman Practice Management for details. [/sidebar]
Greg Thompson is a Loveland, Colo-based freelance writer.