Elevating the Practice of Dental Sleep Medicine
Welcome to APP-NEA™
, the definitive educational and clinical resource center
dedicated to the treatment of sleep disordered breathing, including obstructive
sleep apnea (OSA) and snoring. Our flagship product, MAD-FIT™
the practice of oral appliance therapy for disordered sleep breathing, making
patients’ journeys to consistently sleep quality and full night sleeps smoother and
From patient education about OSA to connecting them with the appropriate
network of professionals, to development and management of professional
education and networks, to superior clinical and administrative systems and
support for the professionals, we’ve got it covered.
goal of APP-NEA™
, LLC is to make the practice of dental sleep
medicine predicable, ef ficient and effective for all dentists no matter where they
practice across the globe. Dental sleep medicine focuses on the treatment of
breathing using oral “appliance” (mouthpiece) therapy . Patients
and dentists alike have a common motivation to have their oral appliances fit
comfortably and perfectly from the start to get patients right away to the point
where they can rest comfortably and wake up refreshed on a consistent basis.
Treating Sleep Apnea: It’ s Complicated
The most common treatment for sleep apnea is Continuous Positive Airway
Pressure (CPAP) therapy. The CPAP machine keeps the airway open by forcing
air through flexible tubing to a face mask the patient wears to sleep. Although this
therapeutic option is ef fective for those who use it consistently and correctly
every night, many do not tolerate the CP AP. This presents a challenge for many
people to adhere to its prescribed usage.
Oral appliances (similar to mouth guards) are an alternative treatment option for
those who struggle with OSA or snoring. Many patients prefer oral appliances
because they are comfortable, quiet, portable and easy to wear . The American
Academy of Sleep Medicine (AASM) currently recommends the use of oral
appliances, known as, “ Mandibular Advancement Devices” when applied to the
treatment of sleep-disordered
breathing, as the preferred treatment for those
diagnosed with “mild” to “moderate” OSA. Even in the case of those with “severe”
sleep apnea, AASM recommends the use of an oral appliance if the patient
cannot tolerate (meaning that they are “non-compliant”
with) a CP AP.
Unfortunately, oral appliances are often very challenging and inconvenient to fit.
A patient is typically required to visit their dentist for “trialanderror”
multiple times before their oral appliance can fit comfortably .
MAD-FIT™ Makes Fitting Oral Appliances Faster and
Dr. Pankaj Singh, the founder of APP-NEA™
LLC, has been devoted to finding a
more scientific approach to fitting therapy in oral appliances for much of his
career. Hundreds of patients, a major clinical study and over a decade of
research later , Dr. Singh has developed a predictive algorithm that determines
the ideal and most comfortable jaw position for an oral appliance for ef fective
airway management of OSA in a single patient visit.
We named the algorithm "MAD-FIT™
" for the perfect fit and position it gives a
Mandibular Advancement Device (MAD) from the very first visit. The algorithm
allows dentists to bypass the current unscientific, subjective, and timeconsuming
trial and error method of serial titration of an oral appliance. A patient’ s breathing
is improved from the first time they wear a MAD-FIT™
titrated appliance. Our
method uses up to date analytics and clinically relevant data to engineer the
positioning of the jaw by an oral appliance.
MAD-FIT™ : How it Works in a Nutshell
Multidimensional analysis of hundreds of thousands datapoints
comprehensive clinical, radiologic and polysomnographic evaluation of the
patients resulted in the engineering of the MAD-FIT™
predictive algorithm. This
allows the dentist to determine the optimal titration point, bypassing the highly
subjective and unscientific trial and error titration method. This prevents the
tongue from falling back and blocking the throat and distracts it away from the
roof of the mouth to achieve maximum effective passive breathing, thereby
reducing the sleep apnea index.
Clinically Proven Results
390 OSA patients underwent treatment with a serially titrated MAD. Serial titration
continued until there was no change in subjective findings. This was followed by
an overnight polysomnograph study at 3 months post final titration, after which all
patients were also given a one piece nonadjustable
MAD set in the final titration
position. Each titration measurement, ESS assessment and compliance of all
patients was recorded at each titration visit and at their annual follow up visits.
Characteristics of the 330 patients who completed overnight polysomnography
did not significantly dif fer from those who did not. In the set of 390 patients with
treatment outcome data, 205 were males and 185 females. In the male subset,
166 completed the program by taking a post titration overnight sleep study; 39
not follow up with an overnight sleep study . Responders and nonresponders
not differ significantly in terms of age, or neck circumference. There were no
differences between responders and nonresponders
in baseline upper airway
structure , however dif ferences were observed in changes in velopharyngeal
measurements. Responders showed a greater increase in AP
diameter , minimum
CSA, mean CSA and volume.
Of the female patients, 145 followed through to the post titration overnight sleep
study and 40 did not. There were no significant dif ferences in age, BMI and neck
circumference. Baseline and changes in upper airway structure did not dif fer
between responders and nonresponders.
There was no linear relationship
between changes in AHI and airway volume. Cephalometric measurements and
soft tissue centroid movements did not dif fer between treatment responders and
However, it did appear that dif ferences in the degree of mouth
opening, as assessed by the cephalometric
induced by the
appliance had an impact on treatment outcome. These findings conclude that the
volumetric changes in the airway are multifactorial, and unlike previously thought,
the degree of opening of the mouth has a direct result on the changes
experienced in the oral airway and lateral positioning with the comfort and
compliance of the MAD.
In a crosstabulation
of these 390 patients, there was no correlation between total
airway and velopharyngeal volume changes between responders (those who
completed the entire program including posttitration
sleep study) and nonresponders.
However, changes in oropharyngeal volume appear to show some
consistency between the two.
MAD altered upper airway geometry , associated with
movement of the parapharyngeal fat pads away from the airway and increased
velopharyngeal lateral diameter to a greater extent and also increased anteroposterior
diameter with anterior displacement of the tongue and soft palate. The
MAD resulted in anterior displacement of the tongue base muscles, (AHI
reduction ≥ 50%) and increased velopharyngeal volume relative to the baseline.
The study concluded that a properly titrated MAD had a higher degree of
compliance than CPAP therapy and was as effective in managing mild to
moderate OSA and in candidates with nonCPAPcompliant
severe OSA. MAD
was instrumental in a significant volumetric increase in the airway and decreasing
the sleep apnea indices.
Using the data generated by this large clinical study and his hypotheses on what
determines effective final (optimal) titration of a MAD, Dr . Singh developed a
proprietary optimal titration (best fit) algorithm and fit it statistically .
multicenter effectiveness study to test the stability and accuracy of
algorithm included 125 patients with the same inclusion criteria as
the initial study. This followup
study concluded the MAD-FIT™
calculated the end titration jaw position faster and more precisely than serial
titration (trial and error) allowing the patients to experience better sleep from the
first night of treatment with an oral appliance.
Of the 125 patients treated with the MAD-FIT™
algorithm, 115 patients were
compliant with the MAD for 4 nights or more per week, 103 patients reported
successful treatment from the first night of wearing a MAD, and only 21 patients
required further titration ranging from 1.8
mm to +2.4 mm with a subset mean of
The APP-NEA™ Approach to a Better Night’s Sleep,
we believe the key to the successful management of patients with
obstructive sleep apnea is a seamless partnership between their dentist and
physician. In order to provide patients with the best possible care and control
over their condition, our approach to successful OSA treatment is multifaceted.
This includes scientific and clinically proven educational resources, clinical and
administrative systems, and ongoing support to our physician & dental partners,
among other services and resources.
Often, the clinical aspect of sleep apnea and snoring treatment is the least
difficult to implement. Because these services crossover into the medical realm, it
requires a shift in the way dentists think as care providers. Without proper
training in sleep apnea intervention, many dental practices face challenges when
attempting to integrate nonclinical
aspects to the full picture of OSA treatment.
Considerations such as compliance, billing medical insurance and ef fectively
communicating with their medical counterparts are examples of such factors that
can be overlooked. At APP-NEA™
, we work with dental teams to help them
provide effective management of these issues as they work towards a seamless
integration of professional services on behalf of the patient.
1) Singh PP. Large Scale, Longitudinal Ef ficacy Study of Management of
Obstructive Sleep Apnea (OSA) with a Mandibular Advancement Oral Appliance
(MAD). Sleep. Manuscript Number: SP0 0397 16
2) Pankaj P. Singh, DDS, DICOI, DSBOI/ID, FAAID, “Followup
Clinical Study Testing
Application and Effectiveness of the MADFIT
Algorithm“, Working paper, to be
submitted to Sleep