David Gergen Interviews Recent ASBA Hall of Fame Inductee, Neal Seltzer, DMD, FAGD, D'ASBA, D'ABDSM, D'ACSDD

David Gergen Interviews Recent ASBA Hall of Fame Inductee, Neal Seltzer, DMD, FAGD, D'ASBA, D'ABDSM, D'ACSDD

An Interview Long Overdue
I recently had the privilege to spend some time with Dr. Neal Seltzer, the 2024 recipient of the American Sleep and Breathing Academy Hall of Fame award. This award is given to long standing members of the ASBA who have demonstrated a history of career achievement, a sustained commitment to advancing the profession, and significant contributions to the field, all while conducting themselves with professionalism among their dental and medical peers. Dr Seltzer has been treating patients with oral appliances for over 33 years and estimates he has probably helped treat over 10,000 patients. He is a partner at Long Island Dental Sleep Medicine in New York, one of the longest established oral appliance dental practices in the country.  I wanted to pick his brain and gain insight to his formula for success.

David Gergen: How did you first become interested in oral appliance therapy for obstructive sleep apnea?
Neal Seltzer: Like many dentists who have incorporated oral appliances into their practices, I first became interested in this field because I was snoring and was searching for a solution for myself.  Back in 1991, I was introduced to the early Snore Guard developed by Dr Thomas Meade, a dentist from Nevada.  He had realized that by mimicking the mandibular advancement we do while performing CPR to open an airway when a person is unconscious, dentists could help maintain a patent airway while we are atonic in our sleep. This was no toy. Tom had collaborated with Dr Wolfgang Schmidt -Nowara, a well-respected physician also from Nevada who was studying the effects of mandibular advancement on the airway.

With the support of Dr. Schmidt-Nowara, Tom’s device gained legitimate respect amongst the medical community. I ordered one of Dr Meade’s appliances, and remarkably my snoring was eliminated. My wife was amazed at the result and I thought to myself, this has potential. What I didn’t know was that my relationship with Dr Meade was going to have a monumental effect on my career. Tom Meade was a brilliant businessman and without my knowledge he had been marketing his Snore Guard to sleep physicians around the country via marketing brochures that he would fax to sleep centers. This was way before the advent of emails or the internet as we know it today with google and other search engines. To my amazement, a local sleep physician had received one of Dr Meade’s brochures in which I was listed as “a qualified, experienced, expert” in the use of the Snore Guard and he contacted me to treat one of his patients who was intolerant of CPAP. Bless Tom’s bravado. My one experience (myself as a patient) had endorsed me as the local oral appliance guru.  The patient contacted me, the Snore Guard was ordered, an appointment was made to fit the appliance, and his snoring as well as his apnea was cured.  I was blown away by his gratitude as he claimed I had saved his life. I knew at that moment that I wanted to do this again. I immediately contacted my partner, Dr Jeffrey Rein, and said the practice is going to go in a new direction. We are going to start saving lives!

Davide Gergen:  Neal, that is quite a story. To make this story even more remarkable, you know that I am the orthodontic lab technician that Dr. Meade used to help develop the Snore Guard way back in those early days. I was working with many of the dental field’s early Icons like Harold Gelb and Robert M. Ricketts building various splints and functional appliances and Tom Meade reached out to me because of my lab’s reputation for innovation and quality. Hearing your story, it’s so incredible that our careers in sleep medicine were linked by the Snore Guard so long ago. 

(Left) Thomas Meade - One of the original ASBA Hall of Fame inductees

Those early days were exciting and filled with many progressive thinking people who felt what you felt and saw an opportunity to help people improve their quality of life.  Besides Dr. Meade, who else was influential in your career.

Neal Seltzer: You know Dave, 33 years is a long time and during that time I have been fortunate to have met so many passionate people in this field.  Some, I have been closer with than others, but all have played a part in the journey. I certainly will not be able to list all of them here, but a few were very significant in helping move the needle forward.  Dr. Wayne Halstrom, the inventor of the Silencer oral appliance, his son Don, along with Randy Clare had a huge part in helping build my practice in those early days. His appliance the Silencer was a brilliant concept. It not only had the ability to move a mandible anteriorly, but it also had a vertical component that is often neglected in many of today’s appliances. The research on vertical is still controversial to this day but clinically we found that in many situations it did make the difference in obtaining a successful outcome. Another unique concept that Wayne incorporated into the fabrication of the Silencer was the use of a proprietary gothic arch tracer that recorded the envelope of mandibular motion, translated it into the fabrication of the appliance, and insured that the appliance would not create excessive forces on the teeth or TMJ.  Dr Rein and I did countless Silencers.  It was our “go to” appliance for many years and we never saw tooth movement or TMJ issues.

As my practice grew and as the field grew, more and more appliance choices became available leading to a myriad of designs.  Be it known, I have probably used or at least tried every appliance ever conceived.  All these designs have incredible people behind them and all of them, including you and your labs Herbst appliance that was, and is, an industry workhorse, had some influence on me and the development of my practice and patient care.  Some have come and gone, and some are still in use as the major appliances we see today.  I’d like to give a shout out and a big thank you to every one of these individuals here but there really are too many to mention in this interview. However, to anyone reading this, if you and I have worked together in any capacity, and you know who you are, I am truly grateful for your help and friendship.

David Gergen: Can you share some advice for colleagues and especially young dentists who are hoping to build their sleep practices or get started in this field.

Neal Seltzer: Well, as I had mentioned, our dental practice was going to start treating snoring and sleep apnea. We knew what snoring was, but we knew nothing about sleep apnea. We also knew that if we were going to try and get physicians to refer to us, we better start learning about this asap. I cannot emphasize enough that this is the most important component about entering this field…. education about sleep and breathing!  If you are going to enter the medical world, you must be able to understand the medical condition you are treating and to converse with physicians you better know your stuff.

Physicians want to refer their patients to a dentist who they can rely on. In the early days it was hard to find places to learn. We went to medical meetings and joined dental study clubs that were being created by dentists who were dabbling in improving the airway. Now, there are great organizations and academies that provide incredible education opportunities for dentists to learn about the airway, sleep and oral appliance therapy.  You know Dave, this is another part of the story that deserves some recognition. It wasn’t always easy for dentists to get their foot in the door with physicians. The organizations that we all take for granted today, that legitimize what we do by offering credentialing and diplomatic status and have enabled us to hold our own with our medical colleagues, were hard fought to develop. I think this is a good place to recognize some individuals who we all owe a debt of gratitude to. The American Academy of Dental Sleep Medicine "AADSM" started out as the Sleep Disorder Dental Society and was conceived on a phone call in 1990 between Robert Rogers, Allan Bernstein, Arthur Strauss, Michael Alvarez, Peter George, Alan Lowe, Gary Johnson, Jeffrey Hall, and Don Rosenbloom. Dr. Rogers’ wife Mary Beth should also be noted here as she was the driving force, as executive director of the organization.  Of course I can’t neglect to include you, Dave, and your endless energy and vision for helping to create the American Sleep and Breathing Academy "ASBA" along with some of the leading Docs in the field both Dental and medical (Edward Spiegel, Steve Carstensen, Bradley Eli, , Todd Swick MD, (list some of our founding members). The AADSM and the ASBA have both helped educate dentists and have been powerful forces in helping our field grow to better help our patients. Since their inceptions, these organizations, have grown and there have been many more passionate individuals involved with their development who have contributed to our field. To all, a big “Thank You!”

David Gergen: How can a dentist who wants to treat obstructive sleep apnea find patients?

Nael Seltzer: As we just discussed, meeting with local physicians is one way. Introduce yourself as a dentist in the area who is offering this service.  Start slow. Have them send patients who have refused or failed CPAP. Ask for one or two. If you are successful, they will send more. Screen patients in your dental practice. Many dentists are not screening for OSA. The ADA now encourages dentists to do this as part of their medical history questionnaire. It’s amazing how many people undiagnosed with OSA are already in your practice.  Reach out to various social organizations such as senior clubs, veterans’ groups and houses of worship. There are many marketing tools available to reach the public. Print ads, radio, tv, and the internet can all help potential patients find you.

David Gergen: As you mentioned already, there are so many oral appliances to choose from. Can you share with us how you choose which appliances you use in your practice.

Neal Seltzer: Dave, you are correct. There are so many choices, and the list continues to grow continuously. This is a good thing.  The competition between manufacturers to claim superiority keeps the race to build the best mouse trap moving forward. Over the last 30 years the appliances have evolved from rudimentary boil and bite appliances to sophisticated devices made of superior materials that are smaller, more biocompatible, more durable, more comfortable and provide superior results. The advent of scanners and digital technology have made the fabrication of appliances more accurate. The development of compliance recorders and the future anticipation of other imbedded data recorders are going to rival the information provided by CPAP machines.

BraeBon's DentiTrac MicroRecorder. A small, powerful compliance tracking recorder that fits seamlessly into almost any oral appliance.

I believe that with the already great compliance of oral appliances and success stories we see as dentists, the addition of obtaining significant data about a patient’s sleep will truly put oral appliance therapy on par or ahead of CPAP on many levels.

In our practice we strive to deliver appliances that are precision made, have impeccable fit, are made of durable materials, maintain their integrity, stay clean, are comfortable, are backed by companies that stand by their products with good warranties and customer service, and yield excellent results. If the patient experience is excellent, the feed back to their physicians will be excellent and that is essential for continued referrals and practice growth.

David Gergen: Here’s a tough one. How about getting paid?  How do you deal with the business side of oral appliance therapy.

Neal Seltzer: This is a loaded one. So many aspects to this question. I think this comes down to personal choice. Do you want to charge a fee for your work and only accept your full fee? Do want to work with medical insurance?  Do you want to be in network or not?  My advice to anyone just entering into dental sleep medicine is to contact one of the many billing companies that can help you navigate the world of medical billing. There is a lot to learn and once you are educated you can decide how you will structure your practice.

David Gergen:  I know you have been involved in teaching your fellow dentists in various aspects of dentistry throughout your career. Early on, you were an assistant clinical professor at NYU college of Dentistry working with special needs patients.  Later, and for many years you were teaching in the private sector, as the Clinical Director of the Equipoise Dental Center, educating dentists about precision attachment removable prosthetics, and of course throughout your career you have written articles and spoken at various dental meetings and study clubs about oral appliance therapy.

You and I, along with a few other dentists from the ASBA, had the amazing opportunity to speak in front of a congressional caucus in Washington DC to help educate people in our government about the devastating health effects of OSA, its effects on the transportation industry and daily life, and the remarkable treatment option that dentists can provide with oral appliance therapy.

With all these experiences under your belt, what are some things you hope to see for oral appliance therapy and airway health in the future.

Neal Seltzer: I think intervening with people at the youngest ages is essential for minimizing the number of patients that will develop OSA. We already know that the health of the pregnant mother can affect the fetus and its developing oral morphology.  We have come to understand the effect of breast feeding on the development of the oral cavity, its effects on tongue position, swallowing and breathing.  Educating dentists and physicians in both dental and medial schools about OSA is very neglected to say the least. If you don’t understand as a clinician how far reaching and devastating the effects of proper breathing and our bodies need for oxygen are, you will miss out on how so many medical conditions are caused or effected by this.

Early intervention is key to prevention. So many pediatricians I speak with have very little understanding about this.  As dentists, the use orthodontics can be a life altering aide in the developing airway and, in my opinion, this should be the most important factor in considering and doing orthodontics.  The understanding of the upper airway, and specifically the mouth, needs more dental/medical collaboration. The mouth is one of the entrances to our airway and its effect on breathing cannot be minimized. Our bodies prioritize obtaining oxygen above all else. Before food, before water, air will determine how are developing bodies react to the lack of it. Because of this, all other systems that make up our bodies will adapt to make sure we get that air even at the cost of sacrificing or stressing these systems. I believe its these stresses that lead to or contribute to the breakdown of these systems, many diseases, and ultimately aging.

(Far Right) Dr. Neal Seltzer during an Official ASBA visit to the House of Representatives

David Gergen: Are there any things that you feel can be improved in our ability to deliver treatment or reach more patients?

Dr. Neal Seltzer:  One thing that has bothered me for a long time is the sleep world’s reliance on AHI as the standard of deciding if a patient needs care and if their care has been improved. Research is showing us that other markers and indicators maybe more helpful in reaching better outcomes. Oxidative stress, hypoxemia, and hypoxic burden for example are perhaps a better indicator as well as biomarkers such as c-reactive protein and erythropoietin.

Certainly, finding a way to improve insurance coverage for oral appliance therapy would be a giant help in our ability to care for more people. As in so many areas of medicine, the insurance companies fail to understand the power of prevention. Its in their best interest to learn themselves how preventing and treating OSA can improve the overall health of their patients and in the long run save billions of dollars in the cost of treating comorbid illnesses associated with untreated OSA.

Lastly, you and I know all too well from our experience in Washington DC, the far-reaching effects of untreated OSA on drowsiness in the transportation industries and day to day life for all of us. So many highway accidents as well as airline, railway, and shipping disasters have been associated with undiagnosed and untreated OSA. For everyday life, poor sleep and breathing effects millions of people at school, work, and in social situations. Public awareness of all this certainly needs to be improved.  Dave, programs like the Pro Player Health Alliance to screen retired NFL players for OSA, that you developed, and I have had the privilege to be involved in, are one example of increasing public awareness. We need more programs like this. William Dement, the father of modern sleep medicine, once noted that as devastating as OSA is, its preventable and treatable. We just need to get the knowledge and treatment to the patients.

David Gergen: Those are all important points. We certainly covered a lot of topics today. I’m sure we could go on for hours, but we are limited by time. I want to thank you for sharing your experiences and ideas with me. I appreciate our friendship and all you have done to improve the lives of your patients. Congratulations again on your well-deserved induction into the ASBA Hall of Fame. 

David Gergen (Left) Neal Seltzer (Right) Hall of Fame Inductee Award, April 2024 Las Vegas, NV