Welcome to GoodSleepSeattle.com. We are an advanced state-of-the-art facility dedicated to TMJ and sleep apnea treatments. Dr. David Buck is a recognized expert in the treatment of these disorders. Dr. Buck and his team can work with you to manage the serious disease of sleep apnea. Dr. Buck is part of a collaborative team consisting of sleep physicians, sleep techs, sleep centers, ENT physicians and pulmonologists who all combine their expertise where needed to maximally manage obstructive sleep apnea and snoring. The use of medically-approved oral appliances often are critical to the best control of sleep apnea. The oral appliances can be used, at times, when CPAP or other positive pressure devices are not tolerated well by the patient. Oral appliances also can be used when it is inconvenient to travel with a CPAP. We see patients who have not been diagnosed for sleep apnea, and we can coordinate appropriate diagnosis with qualified physicians. We also see patients who are referred by sleep doctors for the specific creation of a custom fitted oral sleep appliance. Additionally, we see patients who are not able to use their CPAP and, essentially, are going untreated. Dr. Buck believes in co-therapy whereby the use of a properly titrated oral appliance can be used in conjunction with a much-reduced pressure setting for CPAP, making it tolerable for patients once again.

Dr. Buck believes obstructive sleep apnea is one the most serious disorders affecting upwards of 100 million Americans. This disease is often accompanied by problem snoring, however it is possible to have serious apnea without snoring at all. Snoring once was thought of as a nuisance problem, but now over the last 10-15 years the medical establishment recognizes that snoring is not a harmless issue. The reduction of oxygen to the body that accompanies sleep disordered breathing disrupts many vital body functions, most notably is a root cause for hypertension (high blood pressure); independent risk for stroke; independent risk for adult onset diabetes; accelerates obesity problems; independent risk for impotence; can cause TMJ and headaches; can increase memory problems. Many other diseases are adversely affected by untreated sleep apnea.

The Greek word "apnea" literally means "without breath." There are three types of apnea: obstructive, central, and mixed; of the three, obstructive is the most common. Despite the difference in the root cause of each type, in all three, people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer.

Sleep apnea is very common, as common as adult diabetes, according to the National Institutes of Health. Risk factors include being male, overweight, and over the age of forty. However, sleep apnea can strike anyone at any age, even children. Yet still because of the lack of awareness by the public and healthcare professionals, the vast majority of suffers remain undiagnosed and therefore untreated, despite the fact that this serious disorder can have significant, and deadly consequences.

Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. In central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Mixed apnea, as the name implies, is a combination of the two. With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality.

Two Appliances are used The Somnodent and Herbst

SomnoDent® MAS the right treatment option for me?

If you suffer from obstructive sleep apnea (OSA) or snore, the SomnoDent® MAS should benefit you. It will almost certainly put an end to your snoring and will most likely eliminate or significantly reduce your OSA. For your bed partner this means peace and quiet again and a better night's sleep. For you, it will mean better quality sleep. As a result, you will be less likely to suffer from headaches and daytime sleepiness and your ability to concentrate will improve.

If you have tried CPAP and found it uncomfortable, wake up to a brilliant alternative treatment for OSA. The difference in comfort and tolerance will astound you.

A study conducted by Dr Edmund Rose at the University of Freilberg 2004 proposed that the ideal patient for MAS therapy is one with a AHI < 25 and BMI < 30 with good dentition. Therefore, when identifying how effective the SomnoDent device is going to be for you, we recommend looking at 3 key areas:

Severity of OSA.

The American Academy of Sleep Medicine recommend the use of oral devices such as the SomnoDent® MAS for mild-to-moderate OSA (AHI < 25), or for patients with severe OSA who either are unable to tolerate CPAP or refuse treatment with CPAP.

Body Mass Index.

If BMI is below 30 (which means that a person is not obese) the probability that the device will work is higher. To calculate your BMI please use this chart.

Your dentition.

SomnoMed defines good dentition as at least 6 teeth on the lower mandible with no periodontal disease.

These three indicators offer a good guide to screening patients for oral device therapy and may increase the efficacy outcome of the treatment.

The Herbst for Snoring and Obstructive Sleep Apnea (OSA)

The Herbst appliance has been used for many years in the treatment of Class II malocclusions in children. With minor modifications, the Herbst appliance has been proven to be effective in the treatment of snoring and mild to moderate OSA. "Adjustability" is the primary advantage of the Herbst appliance in snoring and OSA cases. The post and sleeve mechanism advances the jaw into a forward position. If desired relief is not immediately achieved, this unique appliance design allows for additional forward movement of the mandible. With standard hardware, the mandible is advanced in 1mm increments by adding advancement shims onto the posts. The clinician crimps the shims to secure them so the patient will not lose the shims or the advancement position. The telescopic version of the Herbst allows the clinician to advance the mandible more precisely. One turn of the advancement collar, until the next hole appears, advances the mandible in 1/4 increments.

Please be aware that the arrows indicate the directions of advancement, ie: right side-up, left side-down.

Herbst Material Options

The Herbst appliance can be fabricated from three material options including hard acrylic, thermal active, or soft mouthguard material. Opposing ball hooks located in the upper and lower canine area are joined by elastics to maintain the vertical dimension. The standard elastic samples provided are #64, 5/16"-8oz. They will need to be replaced periodically. Any size elastic can be substituted as long as the mandible is maintained in the forward, closed bite position. Although the soft material may be viewed as more comfortable, periodic replacement may be necessary due to the nature of the material. For this reason, it is not recommended for clenchers or bruxers. If cared for properly, the metal framework can be reused in most cases. The hard acrylic is ideal for patients with normal dentitions. The thermal active material is suggested for patients with short clinical crowns and dental types that do not have an ideal complement of teeth.

Telescopic Hardware

Telescopic hardware for the Herbst permits the clinician to advance the mechanism without the use of shims. The unique threaded system will not separate, and provides for advancement in more precise 1/4 mm increments. The adjustment collar, on the lower portion of the arm near the
bicuspids, will gradually allow up to 5mm of movement.

Additional custom services provided by Dr. Buck at TMJ and Sleep Center of Seattle
A "chew toy" is a used to allow the patient in the morning to work to allow back teeth to fit together if it is difficult to do so after wearing the appliance through the night. This is worn for up to thirty minutes in the morning to allow muscles to accommodate to bring the teeth back together. This is a part of the comprehensive service Dr. Buck uses.

A thorough intake consultation, clinical exam and history review will determine the likelihood of sleep apnea. Dr. Buck may administer an "ambulatory" or take home sleep study to gather important data to further understand the scope and severity of the sleep disturbance. At this point, if a prior PSG (polysomnograph) administered by a certified sleep center and interpreted by a sleep physician has been completed, then Dr. Buck can commence fabrication of an oral sleep appliance.
Alternatively, if no PSG has been completed, Dr. Buck will require referral to a sleep center for completion of a PSG and physician interpretation before oral appliance therapy begins. It is critical to carefully and thoroughly manage this deadly disease with a team approach.
Treatment sequence Oral Sleep Appliance Therapy ( presumes prior diagnosis of OSA by Sleep MD):

1- The treatment process involves records, history and clinical exam along with dental impressions of the jaws. Dr. Buck will carefully take a calibrated bite to open the airway with instrumentation to start appliance therapy. If greater than 1 year since PSG, Dr. Buck will administer take home study for baseline prior to OAT (oral appliance therapy).
2- Delivery of appliance with any adjustments for comfort and fit. Instructions for completion of adjunctive sleep logs, and specific instructions on patient guided titration.
3- One month interval checks between months 2-5 for review of sleep logs, physical evaluation and check on appliance. Possible custom calibration of appliance for increased efficiency.
4- At completion of titration phase (4-6 mos.), administration of ambulatory/take home sleep study to objectively measure appliance therapy results
5- Possible referral back to sleep physician or other medical professional for further management, or possible of co therapy to increase effective treatment results

Treatment sequence: Oral Sleep Appliance Therapy without prior diagnosis OSA:
1- Consultation and intake screening exam. Possible administration of take home/ambulatory sleep study. Results to be sent to sleep physician for interpretation
2- Referral for PSG and formal diagnosis from certified sleep center and physician (Dr. Buck will consult with sleep physician on course of therapy or therapies to best manage patient)
3- If appropriate, records, impressions, and calibrated bite for fabrication of sleep appliance.
4- Delivery of appliance with instructions:
Possible course of actions after delivery of appliance;
A-Referral back to sleep center for adjustment of CPAP and initiation of co-therapy
B- If Truly CPAP intolerant (presumes moderate to severe OSA) than sleep physician supported Oral Appliance Therapy with supervision to maximal improvement (MMI) in place of CPAP
C- If other nasal airway problems, referral to ENT physician for nasal patency treatment either before or during OAT treatment.

OAT Treatment Considerations:

Oral appliance therapy (OSA) is very effective, safe and very well tolerated by patients. These appliances are medically tested and certified as effective in the management of mild to moderate OSA. It is critical to understand that "snoring" guards, or other over the counter devices, including snoring remedies are dangerous at best. The disease of OSA is not a social nuisance, but rather a deadly disease if not treated. By simply attempting to treat snoring, a patient may unintentionally worsen the condition, and hasten serious medical complications.

Dr. Buck also strongly believes that OAT is not intended to supersede or compete with proper management of OSA by CPAP. Some dental sleep treatments are marketed as replacing properly fitted and adjusted CPAP by qualified sleep physicians, this is not in the patient's best interest. Take home studies are a good baseline and tool for progress, should not be substituted for medically supervised PSG. Dr. Buck believes all suspect OSA should be diagnosed properly by physicians, and management should be a collaborative, team approach for the best results. Poorly-treated OSA, will still lead to very undesirable medical complications, or contribute to other deadly diseases such as diabetes, obesity, hypertension, stroke and cardiovascular disease.

OAT has few complications. These would include slight movement of teeth and opening of contacts (space between teeth); increase in untreated TMJ related pain such as headaches, jaw and tooth pain, joint pain; changes in bite making the bite not as uniform as before OAT. These are acceptable complications given the serious nature of untreated or poorly treated chronic OSA. Since Dr. Buck is a TMJ expert, he can assist in treating this condition, which commonly accompanies OSA. If TMJ problems were unrecognized before OSA treatment, OAT may unveil this and require subsequent management.

Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. In central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to breathe. Mixed apnea, as the name implies, is a combination of the two. With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality.