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Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Comments (0) | Friday, September 4, 2015

Scott: 
I guess your goal is to pick fights with me. The American Thorasic Society journal is the American journal of respiratory and critical care medicine. In a review of the literature for 2014, the opening line was what I quoted. It is not a position paper by the academy but an analysis of the selected scientific literature. Just like the multiple reviews of the scientific literature that I have written for the American academy or restorative dentistry published in the journal of prosthetic dentistry every July. 

Sent on the new Sprint Network

----- Reply message -----
From: "Scott Neish" <f1ford50@gmail.com>
To: <core-dentistry-discussion@googlegroups.com>
Subject: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep
Date: Fri, Sep 4, 2015 10:19 PM

Jeff, 
I am perplexed a bit here. I would want to know about an organization and what they are about before I would use any statements to support my practice. The recent AASM/AADSM debacle should still be fresh in our minds. I truly want to connect with the best minds out there to offer my patients the very best I can. You have not offered much of an endorsement here after quoting their position. Are there any groups in medicine that you know of that are focused on corrective treatment modalities rather than management modalities?
Scott Neish


On Sep 4, 2015, at 8:11 PM, 'txacad@aol.com' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com> wrote:

I do not know. I am not involved.

Sent on the new Sprint Network

----- Reply message -----
From: "Scott Neish" <f1ford50@gmail.com>
To: "core-dentistry-discussion@googlegroups.com" <core-dentistry-discussion@googlegroups.com>
Subject: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep
Date: Fri, Sep 4, 2015 8:42 PM

Jeff, 
I am to understand the ATS represents the "tip of the spear" as far as sleep medicine/dentistry is concerned?
Scott Neish

Sent from my iPhone

On Sep 4, 2015, at 5:36 PM, 'txacad@aol.com' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com> wrote:

As support for the last statement...ATS update in sleep medicine 2014...first line...an anatomical predisposition is necessary for OSA. Interestingly, there was no mention of orthodontics or orthognathics in the article including the pediatric section. 

Sent on the new Sprint Network

----- Reply message -----
From: "'txacad@aol.com' via CORE Dentistry Discussion" <core-dentistry-discussion@googlegroups.com>
To: "core-dentistry-discussion" <core-dentistry-discussion@googlegroups.com>
Subject: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep
Date: Fri, Sep 4, 2015 7:00 PM

Three points:
1. Treatment of osa may be medical but is being directed by MD.
2. No one makes a MAA for the treatment of high blood pressure. We might obtain a reduction as a benefit. If we make the MAA to reduce hypertension, we are practicing medicine and will be well outside of the purview of the referral.
3. Treatment of OSA with a MAA is a dental issue. Patients must have a structural abnormality to have apnea. Those structures are dental in nature. Early treatment is dental. 

Sent on the new Sprint Network

----- Reply message -----
From: "Brian T Fick" <brian_fick@me.com>
To: "core-dentistry-discussion@googlegroups.com" <core-dentistry-discussion@googlegroups.com>
Subject: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep
Date: Fri, Sep 4, 2015 2:37 PM

Please understand… I think it's "all good" and I understand the rationale for all this. But whether you're treating hypertension or OSA I would call both of those endpoints.... (treating "medical" problems)

But…

Jeff,… Maybe you would say that OSA is a "dental problem"

Brian T Fick DDS
First Choice Dental Group
Partner / TMD Facial Pain 
621 South Park St.
Madison Wi. 
53715
608.251.3535 O
608.698.7594 C

On Sep 4, 2015, at 11:52 AM, 'txacad@aol.com' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com> wrote:

Brian: 
Do you fabricate a MAA to resolve OSA or to solve their hypertension. Their is very good science to suggest that I can improve  the OSA in most patients. That is an anatomic issue of the oral cavity. In fact, advancing the mandible has been a common protocol in dentistry for 45 years. Now medicine has co-opted our device. If I get their blood pressure to improve it is a medical bonus. 

Sent on the new Sprint Network

----- Reply message -----
From: "Brian T Fick" <brian_fick@me.com>
To: "core-dentistry-discussion@googlegroups.com" <core-dentistry-discussion@googlegroups.com>
Subject: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep
Date: Fri, Sep 4, 2015 9:47 AM

Jeff 

What you're saying makes a lot of sense to me merely from the standpoint that I prefer to take your conservative approach as to what I promise patients. One follow-up question that may seem simple tho...

You say you focus on dental problems and then tell the patients that their  medical challenges "may be improved but that that's not the goal" ....the goal is the dental treatment.

Correct?

If you use an MAA to attack airway collapse isn't that a medical problem? Aren't you attacking a medical problem directly?

Help me understand...

If you were to suggest a LeFort osteotomy to help with malocclusion or if you were to suggest orthodontic therapy to improve their interarch distance... those would be dental focused treatments but an MAA seems to be more of a medical focused treatment device?

No?

Brian T Fick DDS
First Choice Dental Group
Partner / TMD Facial Pain 
621 South Park St.
Madison Wi. 
53715
608.251.3535 O
608.698.7594 C

On Sep 3, 2015, at 12:12 PM, 'Jeff Rouse' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com> wrote:

I know about HRV and have used Cardiopulmonary coupling for 2+yrs now. I think that a focus on the autonomic nervous system is the key to a dentists role as a provider of preventative care. Nasal taping and oral appliances that do force the jaw protrusively will improve the respiratory/HRV coupling and reduce sympathetic activity during sleep. MT, ortho, ENT surgery can make that extend into the day. There is a very important semantic and implementation difference in our messages. I promote intervention based on dental issues while I discuss the possible improvement in their medical condition. The postings you have made are much more causal in nature than I feel comfortable with. I cannot say...fix your underdeveloped maxilla and your Crohn's will go away, or improve, or change in any way. You said earlier that there is a "stacking" effect. When is the stack to high to get any change at all. No one knows. I think it is wrong if you have a patient enter care with any belief that their medical issues will change. It needs to simply be a bonus. We also implement  very differently. If you only use one device to fix the problem, your intention-to-treat failures are too high. Every person that turns down the appliance is a failure of the device. I think we need to control airways and then provide a resolution strategy that provides multiple options of care to match the level of treatment the patient is willing to accept at this time.

yes I have evidence of a piece of plastic immediately correcting coherence in a patient with dysautonomia...in fact the piece of plastic does this more often than not.....interesting no?

Please show me. You have told me about the airway improvements you have been achieving. Thus far, the only case that was posted was a patient who looked better (a dental co-morbidity) but got very little change in his airway. He did better with his MAA. Being prettier with a more effective MAA is a far cry from solving epilepsy and Crohn's.

Additionally, this is getting a little silly. It is beginning to appear to people like the king has no clothes. If I began to promote the Jeffblock or RouseNA, told tales of how the blind can see and the lame can walk...we currently would have the same amount of proof. There is a HUGE change coming in airway education in 2016. More dentists and dental teams will be exposed to this topic early next year than in the entire history of sleep dentistry. The focus will be to integrate it into a restorative dental practice. This forum will have an unbelievable impact on the future of dentistry because the topics we are discussing here will form the foundation for the teaching lessons. We cannot promote and I cannot teach about something that is currently "magic". Get this group some proof. It doesn't need to start out as a huge research project but it cannot be "trust me".


Jeff Rouse


-----Original Message-----
From: 'Scott Sim' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com>
To: core-dentistry-discussion <core-dentistry-discussion@googlegroups.com>
Sent: Thu, Sep 3, 2015 5:58 am
Subject: Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Jeff, HRV (coherence) is a screening tool...It gives more information...it's is non invasive...it alerts a patient to a potential unknown problem that that may seek treatment for, (please don't assume MDs are not involved) and yes I have evidence of a piece of plastic immediately correcting coherence in a patient with dysautonomia...in fact the piece of plastic does this more often than not.....interesting no?  Remember, my piece of plastic does not FORCE THE JAW FORWARDS in non-physiological way.....
PS...are you aware of the connection between dysautonomia and IBD (Crohn's...)?   the more information a patient has, the more able they are to make a smart decision for their health care...
SSimonetti

Sent from my iPad

On Sep 2, 2015, at 10:17 PM, 'Jeff Rouse' via CORE Dentistry Discussion < core-dentistry-discussion@googlegroups.com> wrote:

Didn't say it was an opinion. I said it is a garbage term that can refer to everything from orthostatic hypertension all the way to multiple systems atrophy. When you say that you can fix dysautonomia with your appliance, you are saying you can keep people from falling down AND dying of MSA. Can you not see how out there you are with your rhetoric. You are obviously very smart but I think that we should hold it down on all the benefits of an appliance until say you have shown a single case where something actually happened that you promised would happen.

Currently, the National Institute of Neurologic Disorders and Stroke and the Cleveland Clinic, to name a few, believe that it is not curable. Yet, because you test people for HRV, I am to believe you have the answer.

The longer a person lives with it, the more the symptoms stack...might be true but the next line..."important to address this issue before it progresses" implies that your piece of plastic is a way to address it and that you can prevent progression. You proof of that comes in the next line where you say that you monitor HRV and it finds the problems that can be addressed. So you must have a significant number of people that you can show us presenting with "dysautonomia" and excessive LF HRV. You surely have treated them with your appliance and seen a measurable reduction in their symptoms and an alteration in their HRV to a HF pattern. I guess I will begin my wait for those cases as well. I honestly hope they are coming. I would be the first in line for your course


Jeff Rouse


-----Original Message-----
From: 'scott sim' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com>
To: core-dentistry-discussion <core-dentistry-discussion@googlegroups.com>
Sent: Wed, Sep 2, 2015 3:46 pm
Subject: Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Jeff, I disagree...dysautonomia is EXTREMELY important and it is involved with many pathologies....
Some cardiologists such as Dr. Thomas Cowan MD believe in HRV as an extremely important, underutilized diagnostic device...."The real revolution in the prevention and treatment of heart disease will come with increased understanding of the role played by the autonomic nervous system in the genesis of ischemia and its measurement through the tool of heart rate variability (HRV). " (2013, Dr.Cowan from Dr Mercola website)
If dentists have the ability to measure or test (non-invasively) something as important as HRV, don't you think it should be embraced?  
when I spoke with Dr Cowan, he believes that HRV and Coherence can be improved over time, and its not inevitable that they decline...however the longer a person lives with dysautonomia, the more the symptoms stack...its important to address this issue before it progresses and that is why I test HRV with most of my disordered breathing patients...non-invasive, no radiation, simple test that can identify problems that CAN BE ADDRESSED...
Dysautonomia is not an opinion, its a measurable pathology....
SSimonetti



On Wednesday, September 2, 2015 4:27 PM, Steven Bender <stevenbenderdds@gmail.com> wrote:


"The art of medicine consists in amusing the patient while nature cures the disease "
Voltaire

Steven D Bender DDS
Director: North Texas Center for
Head, Face & TMJ Pain
5068 W Plano Pkwy. Ste. 100
Plano, TX, 75093
off:214-2918063
fax: 214-291-8062


This e-mail, including any attachments, is meant only for the intended recipient and may be a confidential communication or a communication privileged by law. If you received this e-mail in error, any review, use, dissemination, distribution, or copying of this e-mail is strictly prohibited. Please notify the sender immediately of the error by return e-mail and please delete this message from your system. Thank you in advance for your cooperation.

On Sep 2, 2015, at 3:17 PM, 'Jeff Rouse' via CORE Dentistry Discussion < core-dentistry-discussion@googlegroups.com> wrote:

First, dysautonomia is a vague term that it is meaningless in a real world setting. It is like saying I can fix TMJ or even TMD. Tell me exactly which autonomic issue that you can fix
Second, I have heard that He Has Risen over and over again but I need to see the rock. Show me and the medical community cases you have done and provide me more than she feels better. Everyone feels better if you make them look better, if you empathize with their plight, and if they have invested a significant amount of time and money. That is how splint therapy works for most people.



Jeff Rouse


-----Original Message-----
From: 'Scott' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com>
To: core-dentistry-discussion <core-dentistry-discussion@googlegroups.com>
Sent: Wed, Sep 2, 2015 2:24 pm
Subject: Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Jeff, if a dentist had a treatment to improve dysautonomia, don't you think the medical community should be shown how since they can't do that!?!
SSimonetti

Sent from my iPhone

On Sep 2, 2015, at 3:04 PM, 'Scott' via CORE Dentistry Discussion < core-dentistry-discussion@googlegroups.com> wrote:

Jeff the point was, in treating a dental abnormality, if we see results beyond straightening teeth, the medical community needs to know about it... Let the doctors call it a " medical treatment " if they want (aka mandibular repositioning appliances) but that does not mean we should have our hands tied as dentists in reporting resolution of medical conditions....
After all, the number one concern for a doctor is Do NO HARM!  I feel very confident my intraoral treatments DO NO HARM  and that pushes me to find more patients who would benefit from a DO NO HARM treatment that may help systemic problems, WHILE STRAIGTENING THEIR TEETH!
SSimonetti

Sent from my iPhone

On Sep 2, 2015, at 2:41 PM, 'Jeff Rouse' via CORE Dentistry Discussion < core-dentistry-discussion@googlegroups.com> wrote:

Could not disagree more. The way that we progress is to work with our medical colleagues to corroborate the findings of improved systemic health. You are playing in an arena where peoples lives could be compromised over an unproven and possibly flawed/false assumption of resolution. Legally and ethically, I do not believe that we should treat anything outside of the dental co-morbidities of a compromised airway. If by focusing on the dental, we can improve the medical...win-win. You are not a doctor providing health care. You are a dentist providing dental care that may de facto improve health. We have fought this battle in Texas recently and we have a huge amount of freedom exactly because of the philosophy that I just laid out. If we try and blow smoke and pretend to know more about neurology and respiratory physiology than the specialists, we will get burned. Interdisciplinary care is paramount. I do not believe in going off on your own and selling our patient on curing their epilepsy by using a Homeoblock or DNA appliance (yes, I know they are different). 

By the way, still would love to see some cases....

Jeff Rouse


-----Original Message-----
From: 'Scott' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com>
To: core-dentistry-discussion <core-dentistry-discussion@googlegroups.com>
Sent: Wed, Sep 2, 2015 1:12 pm
Subject: Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Jeff, good post but I feel that philosophy could be a detriment to progress... If, in treating patients for an orthodontic problem, we notice improvements in organ systems that go beyond the teeth, aren't we obligated to dive deeper into our potential treatment outcomes? Or should be look the other way and say " that's for the medical profession to figure out" for fear that it may be beyond the scope of our licenses?  
Dentistry is in a position today, more so than ever before, to Improve the overall health of a patient....if anecdotally and radiographically, we are improving things that a "dentist" normally wouldn't have the ability to treat, I feel obligated to provide the "dental" treatment to improve "medical" conditions... After all , we are doctors that provide health care to patients... I for one will not limit myself to the teeth when I see the systemic improvements occurring in front of my face from intraoral appliance therapy...
SSimonetti

Sent from my iPhone

On Sep 2, 2015, at 12:42 PM, Tom Colquitt < tcasoulet@gmail.com> wrote:

Jeff -

Nice overview of how to read,how to think, and how to proceed with caution.
i'd be a lot more cautious in waiting for the evidence if I weren't so damned old  with so little time left to see how many ways we can help our patients with conservative approaches.. so many poor breathers... so little time!

I can't say I'll just stick to dental issues but will continue to underpromise, leavened with hope and encouragement.. and hope to overdeliver.

So far, clinically and anecdotally, it seems to be working to most everyone's benefit.

Thanks for helping keep us straight, Jeff.

 tom c

On Wed, Sep 2, 2015 at 10:44 AM, 'Jeff Rouse' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com> wrote:
Barry:
Real easy example from your note...Bicuspid extraction does not have to reduce the size of the airway if the molars are allowed to move anteriorly. The intramolar width would be reduced but the volume would remain unchanged.
Most of the people on the blog have not gone to a program where they learned to critically appraise the literature so let me add a couple of easy ideas. 1. I like NadEr's note that we typically read the literature that supports our position less critically. We need to read all of them with the same critical eye. 2. Read the Methods and Materials then the Results. That is really all you need to read. Most people read the introduction and discussion because it is easier BUT you are reading the authors bias when you do that. The articles on sleep bruxism force will tell you in the intro and discussion that the forces are tremendous and very damaging but the data in every article shows that it is not. Read the science not the opinion. 3. If there is an important statement made in the article based on another persons research, look up that study. Many times the author miss quotes the research. Never trust another person to do your work for you. 4. Research is a set of small steps to build knowledge. No single study can answer the entire problem. If it tries, the study has so many independent variables that it will be worthless. That means you have to read a lot in order to reach a conclusion.

One of the problems that I detect on this blog is that people (myself included at times) read a single article and then fill in the blanks with their beliefs. We keep bickering over "do we need research, how research has failed us in the past, science hasn't caught up with my observations, can't leave people sick just because the science doesn't support".  I think that we can treat and explore with limited support IF we are giving them an advantage independent of airway and we stay away from medical treatment. What do I mean by that....First, if I finish my ortho and my airway is still compromised, my teeth will occlude better and I will look better. No one guaranteed that my airway would be resolved. It was presented as a possible/probable side-benefit.  If you want to unravel the genetic potential for the patient, that is awesome BUT if we promise more than we can deliver based on the science...that in my opinion is wrong. Informed consent implies that you are presenting a realistic evaluation NOT your biased beliefs. Second, I think we have to tread VERY lightly when we jump into "treating" or "diagnosing" medical issues with airway protocols. I do not think, based on my reading of the literature, that we can offer myofunctional therapy, orthodontic therapy (epigenetic or not), or appliance therapy and promise any change to a medical condition. Literature does not support and your license doesn't either. Stick with resolving a dental issue with a possible medical benefit.

Couple of side notes...I followed up on some of the nasal literature that was distributed a few weeks ago. I appears that the nasal receptors that are sensitive to airflow cause a dilation of the orophaynx. The idea that the tongue leads appears to not be the case. The tongue answers to the nose. If we only focus on MT, the tone improves but the trigger for GG activation is missing. Got to breathe nasally to make the MT work ideally...at least that is how I read the literature!!!


Jeff Rouse


-----Original Message-----
From: 'M Nader Sharifi, DDS, MS' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com>
To: core-dentistry-discussion <core-dentistry-discussion@googlegroups.com>
Sent: Tue, Sep 1, 2015 10:20 pm
Subject: Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Barry, in this particular study I believe they claimed consecutive patients, but they then listed the criteria for selection. I'll have to pull this up because, to me, it became comical how many exclusions and how narrow their selection became. Yes, they may have used consecutive patients, but every one was the same 5'11'' and 173 pounds. Not really, but you get the picture.

Patient selection like this in a study contorts the results in a direction desired. Then...when the process is applied in the general population, the results worsen since we are using a less selective patient pool and the average results are decreased. That will wash out or dilute the results to be lower for us than for the study participants.

There are so many ways to shift the balance in a study to go one way or the other. There isn't a key per se, but I read studies two different ways. One is flawed and I try to overcome this, but its human nature. Maybe there are more ways to read than these two, anyone want to add?

The two ways I read are with a critical mind to find the bias or flaw in the study and challenge the author to convince me. This is probably the better way to read every article. The other way is when I come across something that I seemingly already believe in and it supports my predisposed opinion. Then I read, improperly, to reinforce my opinion and likely gloss over the same problems I might otherwise have reacted to if I had read with a critical eye.

Our personal experiences influence this greatly. Take post and cores. Years ago many of us we taught that posts reinforce a tooth. When I was in school a transition occurred and we were told that "we used to believe that posts reinforce a tooth, but now we know they don't." Oddly enough, my masters conclusions included that cast posts outperformed direct posts and that posts could indeed reinforce a tooth, but my director was adamant that we don't publish that because it would only invite criticism because it was "wrong."

Over the course of years studies showed that resin posts outperformed cast gold posts. Because my research didn't support that I read these with a critical eye. I found a common flaw. In all these studies - for years - every cast gold post was cemented with ZnPO4 while all the direct posts they were compared to were resin cemented. Apples and oranges. And very unfair.

Finally, researchers at the University of Washington resin cemented cast gold posts and they far, far exceeded the results from direct posts of all shapes, size and materials. They ended up doing a series of studies that really shifted the thinking that a resin cemented cast gold post and core with 1.5 mm facial and lingual ferrule could actually strengthen a tooth.

Today, I believe that the research from Washington shifted that thinking. Even Frank Spear referenced this research one of his articles and quoted, "maybe a shift has occurred and a post really does reinforce a tooth." Personally, I only use posts to retain a core, but I then only use cast gold and I resin cement them...until I learn otherwise!

Nader.

M Nader Sharifi, DDS, MS
mnsddsms@aol.com



-----Original Message-----
From: Barry Raphael < dralignmine@gmail.com>
To: core-dentistry-discussion < core-dentistry-discussion@googlegroups.com>
Sent: Tue, Sep 1, 2015 9:17 pm
Subject: Re: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Tangential to the discussion of the tongue-cum-vibrator (how do you like THAT double entendre?), Nadir mentions a phenomenon that I think may be common to many studies, but which I don't quite understand.  He said, "  I worry about the results washing out in a less selective patient pool."

I worry about this occurring, too, like in the studies that say that orthodontics does not effect the TMJ or that extracting premolars does not decrease the size of the airway.  

Nadir, and all, can you explain to me how studies can be designed to "wash out" certain phenomenon and how to keep our eyes open for such studies?  How does case selection create a potential bias for accepting a null hypothesis, for instance?  Can it be that under the pretense of selecting a "random" or "consecutive" cohort, that you wash out those that might be susceptible to a variable by including those that are not, and therefore claim no effect?

(Did I just answer my own question?)

Barry

Barry

On Tue, Sep 1, 2015 at 8:01 AM, 'M Nader Sharifi, DDS, MS' via CORE Dentistry Discussion <core-dentistry-discussion@googlegroups.com> wrote:
Dear Brian:

We recently had a meeting with one of the ENTs from Rush who was involved with this. I was very excited to learn about it on the way in, but very disappointed on the way out. I had expectations that this would be a 24/7/365 airway solution rather than a sleep solution.

Here are some concerns that were brought up by attendees after the presentation...

It is a surgical procedure.


Their study wasn't that great. It had a very selective patient pool that they treated - much more selective than we would see on a daily basis. And, with that, they didn't have stellar results. I worry about the results washing out in a less selective patient pool. I'm sure there will be a specific patient that this will end up being ideal for, it just wasn't the "airway" solution that it was initially presented as.

The stimulator needs to be turned on, it is not automatic so there will be a compliance issue and it will only be used at night, not during the day.

It needs to be turned on because the tongue exits the lips from this stimulation and that can't happen all day.

And, last, there isn't a high speed button for you wife to turn select on occasion.

Onward we march.

M Nader Sharifi, DDS, MS
mnsddsms@aol.com



-----Original Message-----
From: Brian T Fick <brian_fick@me.com>
To: core-dentistry-discussion <core-dentistry-discussion@googlegroups.com>
Sent: Tue, Sep 1, 2015 8:44 am
Subject: [CORE-Discussion] Sleep Apnea Implant, CPAP Alternative | Inspire Sleep

Implantable tongue stimulator...

What do we think of this?





Brian T Fick DDS
First Choice Dental Group
Partner / TMD Facial Pain 
621 South Park St.
Madison Wi. 
53715
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dr. barry raphael
the raphael center for integrative orthodontics
the raphael center for integrative education
1425 broad street, clifton, nj 07013
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