Dentistry plays a vital role in modern healthcare today, focusing on both oral health and its connection to the overall well-being of the individual. In this regard, dental professionals are increasingly recognized for their ability to identify and address systemic health issues. Personalized oral and dental healthcare interventions, which emphasize disease prevention through individualized rather than population-based surveillance, can improve diagnosis through more accurate data collection and evaluation, promote earlier detection of abnormalities to help avoid the need for more invasive and expensive treatment, and reduce the occurrence of side effects related to mistreatment and delayed treatment.
In many contemporary cultures, diet, exercise, sleep, and breathing are recognized as the essential pillars of overall health and well-being. They are interconnected and influence each other, impacting both physical and mental health. Because the craniofacial respiratory complex encompasses the structures of the head, face, and oral cavity, and alterations in these structures can directly impact breathing, dentistry finds itself in a unique position to work with the medical community in a transdisciplinary fashion to prevent and treat sleep-related breathing disorders, which affect the overall health of so many people worldwide today.
Prevalence of OSA
Sleep-related breathing disorders comprise a continuum of conditions ranging from snoring and upper airway resistance syndrome (UARS) to severe obstructive sleep apnea (OSA). In addition, they include central sleep apnea and sleep-related hypoventilation disorders.1
OSA is a sleep disorder characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep despite ongoing respiratory efforts. This results in fragmented sleep and intermittent hypoxia.2 Although this disorder has been estimated to affect 17% of middle-aged women and 34% of middle-aged men,3 it may be more prevalent. In a more recent assessment, a PubMed and Embase search was used to identify published studies reporting the prevalence of OSA. This was the first study to report on the global prevalence of OSA. With 1 billion people affected and with prevalence exceeding 50% in some countries, it is clear that more effective diagnostic and treatment strategies are needed to minimize the negative health impacts of OSA.4
Approach to Treatment
For patients with sleep-related breathing disorders, including OSA, the primary goals of treatment include the reduction of the health risks associated with breathing disorders, improvement of sleep quality, a decrease in daytime sleepiness, and the reduction or elimination of snoring. Because OSA is a sleep-related breathing disorder with a high prevalence of comorbidities, as well as diverse clinical manifestations and phenotypes, conventional approaches to its diagnosis and treatment may no longer be the most effective. The debate about whether continuous positive airway pressure (CPAP) therapy or oral appliance therapy (OAT) is the best primary treatment was argued at the 2025 American Academy of Dental Sleep Medicine (AADSM) annual meeting. The results of the first line obstructive sleep apnea treatment (FLOSAT) study were shared prior to publication,5 and novel approaches to measuring the hypoxic burden were presented, including sleep apnea specific hypoxic burden (SASHB). The problem with all of this is that it fails to incorporate a diagnosis of the cause or causes of the disease. The most appropriate path to optimizing the treatment of OSA should begin with a diagnosis of the specific cause for each individual, which represents a philosophical shift toward a more personalized approach.
This article outlines a workflow that begins with a more proactive screening protocol to address the fact that approximately 80% to 90% of OSA cases remain undiagnosed6 and incorporates a novel next-gen data collection protocol,7 which leads to a diagnosis of the cause or causes and recommendations for treatment. This workflow, which is referred to as the Lamberg protocol, is a treatment algorithm based on addressing the compensations and cause or causes of the disease as a prerequisite to treatment. It is only when the cause of a sleep-related breathing disorder is revealed that an individualized treatment can be selected for the patient.
This approach is consistent with what Peter Attia, MD, refers to as the transition from Medicine 2.0 (ie, the treatment of acute conditions) to Medicine 3.0. This transition reflects a move from evidence-based guidelines toward evidence-informed guidelines, the adoption of early preventive measures for potentially chronic conditions, and the application of a highly personalized approach to the overall health of individual patients.8 Similarly, Dentistry 2.0 is transitioning to Dentistry 3.0. The concept of Orthodontics 3.0 was recently presented by Mike DeLuke, DDS, MDS, at the 2025 annual meeting of the Pediatric & Adult Airway Network of New York (PAANNY).9 Orthodontics 3.0 involves examining each patient as an individual rather than an average patient and looking beyond the teeth to include examination of the face, tongue, airway, behavior, and sleep quality. It also acknowledges the risk of doing nothing (ie, “watchful waiting”).
The Lamberg Protocol
The Lamberg protocol is based on addressing specific structural, functional, and behavioral compensations and the cause or causes of the airway problem rather than a severity index of the frequency of respiratory events or the hypoxic burden during sleep (Figure 1). The workflow begins with either an adult or pediatric screening questionnaire. When sufficient risk is revealed by the score, the patient is referred for a polysomnogram (PSG) or home sleep apnea test (HSAT).
Sleep Study Diagnosis
The results of the PSG or HSAT may indicate OSA. However, if they are negative for OSA, the patient is evaluated for UARS, which is frequently overlooked because respiratory effort-related arousals are underestimated in PSG studies and esophageal pressure sensors are infrequently used in clinical laboratory settings.10
UARS cannot be overlooked because it may be responsible for health consequences equivalent to or worse than those of OSA. Untreated UARS can lead to several negative health outcomes, including reduced quality of life, increased risk of cardiovascular diseases, hypertension, type 2 diabetes, and various mental health issues. It can also cause persistent insomnia, daytime fatigue, cognitive impairment, and chronic somatic disorders, such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. Generally, UARS is defined as airflow limitation due to increased respiratory effort that leads to arousals from sleep without significant desaturation that are associated with daytime symptoms.11 More specifically, UARS has been defined by the following parameters: an apnea-hypopnea index (AHI) score of < 5 events/hour, oxygen saturation ≥ 92%, and a respiratory effort–related arousal index of ≥ 5/hour.12 Another study used a slightly different definition that included an AHI score of < 5 events/hour, a minimum SpO ≥ 92%, the presence of airflow limitation during sleep for ≥ 5% of total sleep time, and daytime sleepiness and/or fatigue.13 Nonetheless, the fact that multiple definitions are used for UARS should not be an obstacle to identifying it.
At this stage of the protocol, patients who tested positive for OSA, along with those who tested positive for UARS, are then referred for next-gen data collection. Due to the frequency with which insomnia coexists with sleep-related breathing disorders and the potential negative health consequences, all patients who undergo sleep testing should also be screened for insomnia using the insomnia severity index (ISI). Insomnia and OSA are the most common co-occurring sleep disorders. Comorbid insomnia and sleep apnea (COMISA) has a global prevalence of approximately 18% to 42%, and among patients presenting for treatment, it has a prevalence of approximately 29% to 67%. COMISA is associated with increased medical morbidity (eg, cardiometabolic conditions) and psychiatric morbidity (eg, mood disorders, post-traumatic stress disorder) as well as worse daytime function relative to each condition alone. As a result, clinical management of COMISA is often very challenging.14 Furthermore, a longer duration of insomnia has been associated with a higher risk of incident diabetes.15 A new term, COMIUARS, has been suggested for patients who are diagnosed with UARS and comorbid insomnia.
Next-gen Data Collection
The next-gen data collection phase of the protocol is broken down into three main categories—structure, function, and behavior—which are complemented by an evaluation of potential genetic contributions and an evaluation for comorbid insomnia. This separation of data collection helps the clinician focus more on diagnosing the cause of the problem or problems and ultimately reveals seven general treatment target areas:
1. Nasal resistance/obstruction
2. Soft tissue restrictions, infringements, BMI
3. Skeletal and dental compensations
4. Physiologic dysfunction
5. Behavioral compensations (muscles and habits)
6. Genetic contributions
7. COMISA/COMIUARS
There are so many types of treatment available, including mandibular advancement devices (MADs), positional therapy, upper airway surgery, and maxillomandibular osteotomy.16,17,18 The primacy of connecting the treatment options to the diagnosed cause or causes cannot be overstated. Clinicians need to focus less on comparing the technologies that are available and more on identifying the best ways to specifically address the biologic compensations that are present.19
To help in this regard, the protocol takes each of the seven treatment target areas and further breaks them down into subcategories, each of which has been shown to be responsive to specific treatments. Treatments and their specific targets are then graphically associated to help in treatment planning patients. To improve the protocol, additional research is needed to aid in the diagnosis of specific compensations and associate them with the most effective treatments. In order to reach the entire population and combat the high levels of undiagnosed disease, the data collection process must be simple and cost-effective. Beyond the targeted treatments, the protocol includes lifestyle modifications, which are noninvasive and benefit everyone.
Conclusion
Integrating screening for sleep disordered breathing into dental practice represents a pivotal step toward bridging oral healthcare with overall healthcare. Dentists and orthodontists are uniquely positioned to identify anatomical and behavioral risk factors for sleep disordered breathing, enabling early intervention that can prevent long-term systemic health complications.20 Because dental professionals see their patients twice per year with a focus on the craniofacial respiratory structures, the field of dentistry is organically becoming the primary care platform for airway. From orthodontists and maxillofacial surgeons to otolaryngologists, sleep medicine physicians, and myofunctional therapists, a transdisciplinary approach should be the foundational element of the treatment algorithm used to treat these patients.21
By collecting data (ie, structural, functional, behavioral, etc) that relate to risk factors which contribute to the collapse of the airway, the Lamberg protocol provides a rational approach to treatment choices. As dentists’ understanding of the complexities of the airway grows, it will become increasingly important to work with specialists from a variety of related disciplines to more predictably target and treat the cause or causes of sleep-related breathing disorders and move forward from merely treating the severity of these conditions. This sleep medicine strategy represents a transformative shift in healthcare, emphasizing an individualized approach to treatment that considers the bidirectional relationship between sleep and health.22
Editor’s Note
For more information about the Lamberg protocol, including the figures that detail each of the seven targeted treatment categories, the related forms, and resources and educational opportunities, visit: https://drlamberg.com/.
About the Author
Steven Lamberg, DDS
Diplomate
American Board of Dental Sleep Medicine
Private Practice
Northport, New York
References
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Figures and Images
Fig. 1
Steven Lamberg, DDS
