Dr. W. Keith Thornton is a third generation dentist who now limits his practice to the treatment of sleep disordered breathing, airway management during anesthesia, and temporomandibular disorders. He has over 75 US and foreign patents for oral appliances, CPAP masks, and combination oral appliance mask interface systems for the treatment of sleep-disordered breathing.
Over the past thirty years, Dr. Thornton has served in many faculty and consultant positions. For 25 years Dr. Thornton has taught appliance therapy for temporomandibular disorders (TMD) at The Pankey Institute and Baylor College of Dentistry. He has also advised the Army, Navy, Air Force, and VA. In addition, he is a member and has held executive responsibilities in nine different dental or sleep societies including the Dallas County Dental Society, Academy of General Dentistry, and the American Academy of Dental Sleep Medicine. He is a Diplomat of the American Board of Dental Sleep Medicine.
In the first issue of Dental Sleep Practice, I thought our readers would appreciate an interview with one of the profession’s greatest leaders in both the development of adjustable mandibular positioning devices and the treatment of sleep apnea by dentists.
Steve Carstensen DDS
Editor in Chief, Dental Sleep Practice
What can you tell us about your background?
I studied science and engineering at Rice University and Southern Methodist University before earning my DDS from Baylor College of Dentistry in 1969. I was commissioned as a lieutenant in the US Navy that same year and spent a year in a general practice residency at the Oaknoll Naval Hospital in Oakland, California. I had a month’s anesthesia rotation during that training. Then, I was stationed in the Philippines for two years at Cubi Point Naval Air Station before returning home to become an associate in my father’s general practice. In 1972, we focused on the treatment of temporomandibular disorders and were among the first dentists to use bite splint therapy.
In 1993 my focus began to change away from TMD treatment and comprehensive restorative dentistry, and over the last 20 years I’ve transitioned to a sole focus on the treatment of sleep-disordered breathing.
What prompted this change?
In 1993, an ENT specialist in Dallas told me his concern about UPPP surgery, a “roto-rooter” extraction of excess tissues of the throat to clear the airway of any obstruction. It was a primary treatment at the time for patients with severe Obstructive Sleep Apnea (OSA) who did not respond well or comply with Continuous Airway Pressure (CPAP) treatment. The surgical removal can include the uvula, tonsils, adenoids, part of the soft palate and even a part of the inner tongue. With this invasive treatment comes the risk of many complications.
I began studying sleep-disordered breathing therapies and after a year of “inventing” came up with my first TAP® device. Like other oral mandibular repositioning appliances of the time, it alleviated snoring and sleep apnea by holding the mandible forward during sleep to prevent the soft tissues of the throat and the tongue from collapsing into the airway. Unlike other devices at that time, mine could be adjusted vertically, laterally, and protrusively—enabling titration in a sleep lab. I became intrigued with perfecting this device and with helping patients improve their longevity and quality of life.
Back in the 1990s only a few dentists were collaborating with sleep medicine specialists to fit their patients for oral devices. The potential for helping millions of OSA sufferers drove me to push forward. I was able to create a comfortable oral appliance that greatly increased patient compliance. That meant a lot to me personally, to my patients, and also my family who joined in the effort to start up the production, marketing, and education required to make my device widely available. This family effort has grown on a large scale, and the contributions of my wife and daughters to this business have enabled me to focus on what I love most: treating patients, teaching colleagues, and inventing.
How did you transition and build a practice focused on treating OSA patients?
Because I was very serious about studying the effects of my appliances, I was assertive in reaching out to sleep laboratories and collaborating with them and used home monitors to objectively measure the effect of patients self-titrating their appliances. I worked with everyone who would work with me. This included the patient’s primary physician or referring sleep physician, other dentists interested in airway management, cardiologists, internists, and even influential patients who found CPAP too uncomfortable to use. I developed a reputation nationally for being a serious inventor and passionate student of the subject who could demonstrate results.
What do you recommend to dentists who are interested in developing expertise in this area?
Today, there are several professional societies and many postgraduate learning organizations to turn to for training and advice. Dentists simply need to start thoughtfully and mindfully implementing their learning, continue learning from their experience, and stay up to date through their reading, CE, and conferences. All along, the patients I have treated have been thrilled with TAP® therapy. Most of my patients either have failed CPAP or want something that they can wear when they can’t wear CPAP or don’t want to take it on a trip. Once they get on the TAP®, they usually stop wearing the CPAP. If the TAP® doesn’t manage their sleep apnea, then we add the TAP® PAP mask combination, which they prefer greatly over the regular mask. In virtually all compliance and preference studies, oral appliances are significantly ahead of CPAP. This is particularly true since the TAP® can treat snoring without the intrusiveness of the sound of the CPAP. We offer a monitor for those who want to measure compliance.
I say all of this, because every general dentist practice has patients who suffer from OSA and want help. Dentists are on the frontline of providing this help. As a dentist specializing in sleep disordered therapy, I can collaborate with the patient’s physician closely in the diagnostic work up and follow up – not just the selection and fitting of the oral appliance. And, I am the one referring many patients to the MD/sleep lab instead of the other way around.
My advice is to make conversation about snoring a part of your general examination. Help the patient discover his or her circumstances and educate them about the health risks of not receiving treatment. You can send your patients to a sleep lab for diagnosis and oral appliance prescription that you fulfill and continue to evaluate. You can always reach out to lab manufacturers of oral appliances for precise information you need for selecting the most appropriate device.
Dentists and their patients are now benefiting from over 20 years of scientific studies involving oral appliance therapy (OAT). There was a long period when CPAP was the first recommendation for all severity of OSA. In 2006, when the American Academy of Sleep Medicine (AASM) updated their guidelines, OAT became the first recommendation for mild to moderate OSA. Today’s guidelines indicate follow-up sleep testing is not needed for patients with primary snoring, but it should be performed in patients with OSA after final adjustments of the oral appliance. The latter group should also have a dental follow-up every 6 months for the first year and at least annually thereafter. A repeat sleep study is indicated if signs or symptoms of OSA worsen or reoccur. With new oximetry devices and applications, digital oximetry recordings can be done overnight in the
patient’s own home and read remotely by the attending physician and dentist.
The guidelines also recommend that patients with OSA who are treated with OAs have regular follow-up with the dentist to monitor compliance, evaluate device deterioration or maladjustment, and determine oral health and integrity of the occlusion. Because there are so many US citizens affected by OSA who are yet undiagnosed and treated and because Medicare and insurance companies have opened the way for reimbursement, I personally hope all dentists are participating in OAT on some level, even if it is helping patients understand the benefits and referring their patients to those with OAT expertise. Millions of our patients nationwide can be helped.
What training do you recommend to interested dentists?
All dentists have the basic technical and educational background to be involved in treating sleep disordered breathing.
There is no need to become overwhelmed. I advise dentists to take one course at a time focused on sleep dental medicine, get their feet wet and keep learning in incremental ways. In 2014, I am presenting this type of required course at Texas A&M University Baylor College of Dentistry along with Steven D. Bender, DDS, and hoping to spur interest in seeking more knowledge and helping more patients nationwide.
Dentists should reach out for mentorship, advise each other and collaborate. The market demand for services is huge and will grow. It’s an enormous opportunity to provide a special service, reputation brand a practice, and do something very meaningful without worrying about the local competition.
Through postgraduate courses focused on dental sleep medicine, they will learn what they need to know about medical insurance and Medicare to ensure that everything required is carefully documented. I know you are passionate about your inventions and many dentists are interested in how you developed your business.
Can you tell us very briefly about this?
When I invented the Thornton Adjustable Positioner (TAP®) in 1994, I immediately founded my first oral appliance company, Oral Appliance Technologies to market and supply TAP® appliances. In 2000, Oral Appliance Technologies was succeeded by Airway Management Inc. (AMI), and recently AMI divided into two companies, Airway Management Inc. and Airway Management Laboratories (AML). As of today we’ve delivered more than 300,000 oral appliances to patients worldwide. The first generation oral appliances were large, minimally adjustable hinged bite plates similar to athletic mouth guards. The latest generation of OAs are smaller, more comfortable, less visible, and micro-incrementally adjustable.
The TAP® can be vertically adjusted and account for side-to-side movement for patients who grind or clench their teeth. I believe our newest device, the myTAP™ is truly revolutionary. It is an immediate fit, precision appliance that has most if not all of the desirable features of a mandibular advancement device, yet it is inexpensive and can be fit in less than 30 minutes. Ideally, it will be used as both a trial device and as a titration device at both home and in sleep labs.
I attribute a lot of our success to continuing customer education and personalized care, ongoing product research, and highest quality materials provided by partnering suppliers. I am particularly proud of the fact that the Tap was selected by many independent researchers for studies on sleep disordered breathing. There are now over 32 independent studies including one by the Army, which involved approximately 500 soldiers deployed to Iraq and Afghanistan. We have focused on compliance with regulatory requirements and quality standards set forth by the Food and Drug Administration (FDA), ISO Standards, and Texas Health Department.
To get to the level of distribution we see today, early on we partnered with other dental laboratories to construct the Tap appliance. Today we have over 200 laboratories involved.
Just this year (2014), we began working with Pillar Palatal, LLC, a medical device company who is now the exclusive United States distributor of the myTAP™ oral
appliance, for the Otolaryngology (ENT) physician market. OSA was discovered by researchers in an academic sleep lab, and the first CPAP treatment was developed by a physician. Sleep-disordered breathing became the purview of, first, psychiatrists and PhD researchers, then neurologists, and now the pulmonologist and dentists. If a dentist or anesthesiologist had been involved initially, I think oral appliances and, therefore, dentists would have played a much more prominent role years ago. Dentists were limited not only by their amount of involvement compared to other disciplines, but also by reimbursement. It took years for insurance companies and the medical profession to accept TAP® appliance therapy. The TAP® became the device of choice for studies and treatment because it was and is the only appliance that can be infinitely adjusted vertically and protrusively after construction; can be adjusted by the patient while in the mouth; has an attachment for CPAP; and can be titrated in the sleep lab. It is easily portable, providing easy airway management for travelers and deployed military personnel.
Technology is always advancing. I am continuing to develop appliances and looking into the future. One of my most recent developments is the TAP® PAP Nasal Pillow Mask that provides patients with all the benefits of other CPAP masks at the same price but with less air leakage and pressure drop, more comfort, and less noise.
Are there any final thoughts you would like to leave with us?
Yes. One thought I’d like to mention is that team-based care that brings the dentist and physician together can make a tremendous difference in the lives of patients. We need partnerships with MDs to treat this sleep disorder, and I am an advocate of developing science based guidance for dentists, practicing physicians who are sleep specialists, and also general physicians who are educated in this sleep disorder. A combined task force approach to develop clinical guidance for dentists, determine research gaps, and promote dentist-physician team-based learning is a goal we should be seeking with our State Dental Boards and other organizations. I am excited about the launch of the Dental Sleep Practice journal. We need more places where sleep practiitioners can find inspiration and guidance. I am honored that you chose to pose these questions. It’s especially nice to be able to communicate with so many colleagues in this conversational way. I look forward to another 20 years of making a difference.