Dental Sleep Practice - Fall 2014 Issue

9 Rules

by Glennine Varga

Know Your Patient

The Lamberg Questionnaire

by Steven Lamberg, DDS

Fall 2014

We Can See It Now,

But Wait!

There’s Moore!

CBCT in Dental Sleep Medicine

Oral Appliance Therapy

for the Edentulous PAP Intolerant Patient

by John H. Tucker, DMD

Jeffory J. Wyscarver, RPSGT Interviewed by Michael C. DiTolla, DDS, FAGD

Supporting Dentists Through PRACTICAL Sleep Apnea Education

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INTRODUCTION

There Are Many Parts to This Puzzle

A

s we put the second issue of Dental Sleep Practice together, it’s exciting to see growth even from the first one. The outpouring of support from all the sleep community fuels our passion for gathering scientific articles, expert advice, and clinically important treatment stories for all to learn from!

Dr. Berley’s legal column is sure to make you think – as the treatment of sleepy patients becomes more and more widespread, every professional seeks the best way to provide care. The ‘rules’ seem to change all too frequently; Ken gives us some ways to think about how those boundaries are set.

Following that, Dr. Rob Rogers, founder of the Sleep Disorders Dental Society, which became the American Academy Dental Sleep Medicine, offers his perspective on the various roles we all play.

Some patients seem to be beyond the reach of dental sleep medicine; wait until you read how Dr. John Tucker opens the door to edentulous sleep apnea sufferers.

Every dental sleep practice is full of people with significant medical comorbidities – how do teams sort them out? Dr. Steve Lamberg has worked very hard to create a screening system, published here for the first time, to help dental teams. Consider yourself challenged.

Are you, the dentist, excited about this new service but wonder how your team can learn their part? We welcome Glennine Varga to the pages. She’s lead trainer for OSA University with years of educating dental teams. She introduces a helpful framework for organizing your team’s new skillset.

Marketing a new service leads to the rewards necessary to support the investment required. Getting the word out to your community is Sasha Thompson’s special talent. This is her first writing for a magazine. Once she realized how important it is for dental teams

to make sure they’re easy to find, she committed to putting her thoughts in writing. Brave move!

Continuing the series of profiling the most impactful dentists in sleep, you’ll meet Dr. Todd Morgan, an extraordinary dentist from Southern California. Just interviewing him about his incredible accomplishments (so far) is at once intimidating (I could never do what he is doing) and motivating (if he Steve Carstensen, DDS can do it, I can at least do better!)

Do you ever find yourself at odds Diplomate, American Board of with your patients about bruxism? Dental Sleep Medicine Glidewell Labs interviewed sleep professional Jeffory Wyscarver, RPSGT, about his commitment to dental sleep and bruxism.

Dr. Michael DiTolla offers up insightful questions to help dentists find common ground with their patients.

Imaging is on every dentist’s mind – what ... Every should I do? Does cone beam technology professional seeks add vital diagnostic data? Dr. Kent Moore, one of the country’s premier oral surgeons, the best way to has something to say about that. Dr. JC Quinprovide care. tero completes his case study where imaging guided the orthodontic planning to get a great result.

Welcome to Dental Sleep Practice! Our website, www.DentalSleepPractice.com, will provide even more content and a simple way to subscribe so you will never miss an issue.

Read us, share the magazine with your team and colleagues, and most importantly, learn how to make a bigger impact on your community health!

Your thoughts, requests, questions, and insights are enthusiastically invited: SteveC@MedMarkAZ.com

DentalSleepPractice.com

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CONTENTS

6

Corporate Profile

We Can See It Now, But Wait! There’s Moore!

An interview with Kent Moore, DDS, MD, Oral & Maxillofacial Surgeon Cone Beam Technology is here to stay. How do we use it? What’s next?

22 17

Clinical Focus

Oral Appliance Therapy for the Edentulous PAP Intolerant Patient

Medical Insight

A New Screening Tool Connects Comorbidities to Sleep Disordered Breathing

by Steven Lamberg, DDS, DABDSM Our patients present with complex medical histories. Use the Lamberg Questionnaire to sort them out.

by John H. Tucker, DMD Ever wonder if you can help edentulous patients breathe better? Here’s how

Legal Ledger

40 2 DSP | Fall 2014

Scope of Practice: The Most Misunderstood Concept in Dentistry

by Ken Berley, DDS, JD, DASBA It’s up to you to define how you practice – you and the laws of your state

CONTENTS

34 Practice Management The Public is Looking for You! Be Easy to Find!

by Sasha Thompson, M.Ed. Getting found on the web is part of helping as many people as possible

36 Focus on Practice

12

Perspective Clinical Spotlight

Airway Development and Prevention of Obstructive Sleep Apnea in Children: A Case Report, part 2

by Juan-Carlos Quintero, DMD, MS Part two of a case report of a young patient set on the right airway path by thorough diagnosis and creative therapy

14

Clinician Spotlight

Dr. Todd Morgan — Curious About Better Patient Care This dentist blends research, innovation, and a commitment to saving lives in one dental sleep practice

28 Sleep Bruxism

Jeffory J. Wyscarver, RPSGT Interviewed by Michael C. DiTolla, DDS, FAGD Respiratory Technologist with years of patient care partners with dentists to measure sleep bruxism

32 Practice Management

9 Rules to Practice in a Dental Sleep Medicine Office

by Glennine Varga Team learning is the key for practice success. Here are 9 ways to make it happen

4 DSP | Fall 2014

by Robert R. Rogers, DMD, DABDSM No one has a longer perspective on patient/dentist/physician/insurance interactions than Dr. Rob Rogers

46 Legislative Matters

Making a Difference in Washington

by Congressman Marty Russo Dentists influence Congress to consider Oral Appliance Therapy

48 Product Review

Fall 2014 Publisher | Lisa Moler Email: lmoler@medmarkaz.com

Editor in Chief | Steve Carstensen, DDS Email: steve@medmarkaz.com Managing Editor | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com Editorial Advisors Rob Rogers, DMD Ken Berley, DDS JD Amy Morgan John Remmers, MD Dale Miles DDS Steve Bender DDS Bruce Templeton, DDS, MS Ofer Jacobowitz MD Christina LaJoie Brian Allman DDS Sarah Shoaf DDS MSD

Ez SLEEP PILLOW TALK™ Here’s a quick survey of important points about treating sleepy patients

52 Implementation Insight Dental Sleep Medicine Implementation: Puzzle or Mosaic?

by Dr. Gy Yatros It takes systems to make sure critical details are documented for medical services.

54 Product Profile MicrO2™ Insert

You’ve never seen a product like this one!

56 Sleep Humor

Chief Operating Officer | Andrea Hood Email: andreah@medmarkaz.com National Account Manager | Michelle Manning Email: michelle@medmarkaz.com National Account Manager | Adrienne Good Email: agood@medmarkaz.com Creative Director/Production Manager Amanda Culver Email: amanda@medmarkaz.com Brand Coordinator Jacqueline Baker Email: jbaker@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) 3 years (12 issues)

$79 $189

©MedMark, LLC 2014. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

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CORPORATEprofile

We Can See It Now, But Wait!

An interview with Kent Moore, DDS, MD, Oral & Maxillofacial Surgeon, Charlotte, NC

W

ill this work for me, Doc? If only dental teams offering help for sleep-disordered breathing could answer this question with confidence! Will the airway respond to mandibular advancement? How far does it need to move?

Where does the airway close? Can we know where the narrowest spot is, and does that information tell us anything? Does the 3D image from a cone beam give us any answers?

Dr. Kent Moore is an oral surgeon in Charlotte, North Carolina with a keen interest in answering these and other questions about imaging the airway with cone beam computed tomography (CBCT). Dental Sleep Practice sat down with Dr. Moore for a take on some of the excitement around this technology.

6 DSP | Fall 2014

DSP: Kent, dentists are either using CBCT or thinking about it: give us an idea about what it is used for in the dental office today.

KM: I use mine quite a bit for assessing neurovascular risk prior to implant placement and wisdom teeth extractions; prior to and after any sort of reconstructive facial skeletal surgery, I’ll obtain one. What concerns me is that a lot of dentists are buying these scoped-down versions with limited

CORPORATEprofile

There’s Moore! fields of view, probably for either financial or risk-management reasons. But I don’t want to focus on what might be sales issues – I’d like to talk about what might be coming down the road – then you’ll see why a limited area image may not be helpful. If we think only about what it can tell us about skeletal morphology, they might be missing the point – there can be some real pertinent information in terms of airway size and shape that will hold some utility for us in the future.

Today dentists are using scanners for digital impressions for making oral appliances; I think someday the CBCT may have sufficient data and resolution to make the oral appliances directly from this type of scan, but I certainly don’t see the need for digital scanners going away anytime soon.

CBCT in Dental Sleep Medicine

DSP: Is it the data from the scan that is going to make that available, or is it the software that is improving?

KM: I think it’s both – but I see more software-driven abilities to utilize the data we are getting. There are several good vendors out there offering very good utilities for upper airway assessment.

I’m excited, but we do need to take a step back and understand the limitations of cone beam: these scans are being done during wakefulness, while the patient is upright, and they are an average scan over 10, 15 or more seconds with normal tidal breathing going on. You’re going to get an average of the upright wakefulness airway size over the time of the scan, unless the patient is holding their DentalSleepPractice.com

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CORPORATEprofile breath. It’s far less radiation than a medical grade scan; getting these average values is one of the trade-offs for that.

DSP: What does that mean for our ability to diagnose apnea using a cone beam?

KM: When you think about it, Obstructive Sleep Apnea is a diagnosis based on a physiologic-based sleep study exam: a sleep study performed in a sleep lab or with a portable monitor while the patient is in a recumbent body position (supine/lateral/prone) during natural sleep. We know that the airway collapses in size from upright wakefulness to supine REM sleep. The cone beam CT Scan, however, produces an image which the doctor examines to study anatomic details typically during upright wakefulness. I don’t think we’re ever going to diagnose apnea purely from an image...particularly one taken during upright wakefulness.

DSP: It seems that most professionals agree that cone beam does a great job of identifying the airway shape, with the limitations you mention, which might indicate risk factors for SDB.

KM: Exactly – with Obstructive Sleep Apnea (OSA) the anatomy predisposes a person to the physiologic problems – small airway size helps us to consider who may suffer from this disease. This will be very powerful as we put airway size and shape together with other measureable factors such as BMI, age, gender, neck circumference, and ethnicity and probably some others which will play into this down the road. What we know now through our current knowledgebase is just not sufficient to predict who will have it and what oral appliances can do to help.

As long as we acknowledge these limitations, I think there are some very exciting things being done with cone beam. The thing that jumps out at me the most right now is incorporating the technology that Dr. John Remmers is introducing. His MATRx device for the first time allows us to titrate the mandibular advancement during sleep to the point that apnea is resolved, at least in a cohort of patients.

If we take that MATRx device, titrate a given patient, and study that patient in both sleep and wakefulness both during the su-

8 DSP | Fall 2014

pine and upright positions, we can study how much expansion of the airway has occurred through the use of that device. Specifically, what is the effect on the minimum cross-sectional airway size? We know there is a difference between different-shaped airways, and there have been some published classification systems, by Fujita and one I published in 2002 – which have used endoscopy both while awake and with propofol anesthesia.

I’d like to study patients who have had the MATRx test, not only while they are asleep, but also while they are awake. If we take a baseline scan on a patient and again with the patient in the titrated position, we can go back and compare the airway size at the same point of the anatomy. The working hypothesis is that patients with milder forms of OSA will require less expansion of their minimal airway size (in order to resolve their OSA) as opposed to patients with more severe OSA (who will require greater expansion of their minimal airway size to resolve their OSA).

If we can gather enough data across a variety of age, gender, ethnicity, BMI and neck size and shape, I really believe we can start to be able to evaluate from a prospective manner who will be a responder to oral appliance therapy.

DSP: So will the data that dentists are gathering now be useful to make this prediction?

KM: If we take patients who have had a MATRx test, so we know the position of the mandible in a properly titrated study, that’s very powerful; we can image the mandible at rest and at that titrated point. This could also be done in a MRI during natural sleep – it’s been done at Stanford in a modified MRI. More and more as this type of work progresses, our ability to predict airway response to therapy will improve.

As we can make this data more accessible, even during general upper airway surgery, the surgeon (be it an OMS or ENT) could obtain real-time guidance as to how much to advance the mandible or manipulate the airway during anesthesia to avoid apnea. Taking the next step beyond that, once we know the effective amount of airway expansion needed for a specific demographic of patient, we can use that data to prospectively inform surgeons contemplating corrective jaw surgery or any type of surgical manipulation of the

CORPORATEprofile airway — across medical and dental specialities — for that same patient demographic.

Currently maxillofacial surgery for airway improvement is planned using cephalometric data; imagine if the effect on the airway could be known so that the movement could be dictated based upon needed minimal airway size? We’ll need some other data, of course, but I know Sirona has produced a software program named “Function”, which allows a user to see changes in mandibular position during protrusive and vertical mandibular movements. If we can incorporate the airway size data into this program, this would allow us to measure soft tissue response to incremental movement of the bony structures. This could be a very important tool as it becomes possible to link the airway shape to movement. We’re not there yet, but with several software companies working on projects like this, it’s all very exciting.

DSP: I’ve seen some presentations lately using cone beam data to guide Maxillomandibular advancement surgery planning for airway impact. Instead of guessing, your data might allow the surgeon to be more precise?

KM: That’s exactly what I’m saying. Expanding beyond advancement to any kind of surgery aimed at improving the airway; currently, no one has any way to tell how much airway expansion is required to resolve OSA with any given patient. With the studies I’m proposing, I hope we can crack that nut and be more predictable. The downside is that it’s going to require a lot of studies, carefully done in a statistically valid manner. In this case, by using clinically observable data, we can produce a guideline — using quantitative airway analysis — that everyday doctors can use. Dr. Peter Cistulli, from Sydney, Australia, is probably the world’s foremost researcher in this field; he recently published an elegant article where he constructed an airway model using computational fluid dynamics. This is an incredible feat, but we will still need to perform observational studies looking at varied patient phenotypes.

DSP: So should a dentist contemplating a new imaging device be thinking cone beam rather than another type of digital system? Also, if they are sitting with a patient who seems to be

at risk for SDB, should they take a cone beam to assess that risk?

KM: That’s a tough call — right now, for a given set of parameters like the ones I’ve mentioned, we really don’t know what constitutes a ‘small airway’ for any one of these people. Until we have that knowledge base, it’s hard for me to say that screening someone for SDB using a cone beam is legitimate.

Although when you consider all the other uses of the image dataset, the ability to see the size of the airway may be important.

Dentists buying scanners with a limited field of view may be missing the boat. A limited scanner that doesn’t allow them to image the airway won’t give them any basis for making the call if they can’t compare their patient against norms I hope we will uncover.

I would say if a dentist is interested in sleep medicine and managing patients with oral appliances, there’s no question that’s the investment they need to think about for their practice; I would certainly encourage them to do that. But we still need that sophisticated software, coupled with statistically valid quantitative data — subdivided by patient phenotype — to be able to make the comparisons.

This will help the connection with sleep docs as they see dentists acting more like medical doctors.

DSP: So the dentist considering making this investment needs to know what capabilities the software may have or be developing to put all these other measurements to use?

KM: That’s exactly right. Having the technology in hand will allow data collection that will build this capability. The way I envision this down the road may be like this: Let’s study a group of Asian males, 30-32 years old, neck circumference of 16.5 inches, and with BMI’s of 28-30, with similar airway shapes who have had a properly titrated MATRx study done.

If we can study 100 of these people, we will then have data we can begin prospective studies against. Recruitment will certainly be a challenge, but what I see happening is collecting reference data and using this in a prospective fashion down the road.

DentalSleepPractice.com

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CORPORATEprofile DSP: Could a dentist, trained in what data needs to be collected, participate in a study like this?

KM: They could, in fact. I’m in the middle of submitting an application with NIH Small Business Innovation Research for MRI imaging during supine natural sleep, but we’ll need upright, wakeful cone beam data in the study population as well. If we can collect the pertinent demographics and physical metrics into the scanner for each patient and collect the data in a valid manner in a centralized site, we’ll be able to compare.

The ethnic component is going to be an important part of this — we see differences between phenotypes but there’s little data.

The problems with collecting ethnicity can be solved by using genetic testing with a blood test or even a swab of the cheek. There are companies that can do this testing.

DSP: One question that often comes up is “Should the dentist have the cone beam data read by a radiologist?”

KM: I always have anything suspicious read by a certified orofacial radiologist, but I find that most of them have not done much in the field of airway size assessment. I think if a dentist is looking at a limited use for, say, an implant, there may not be a need for this extra expense — but it is true that if dentists or nonradiologist dental specialists decide to examine their own volumes, however,

then they are held to the same standard of care as an oral maxillofacial radiologist and required to find and report any unusual conditions that may reside in that volume. This is a significant responsibility, one that might require additional training for some dentists.

DSP: If we are working with physicians on our sleep patients, though, having a scan read by a specialist is more what they would expect, don’t you think? Does it reduce dentists’ liability for what’s on the scan? Is it worth an extra small cost, which can be billed to medical insurance?

KM: I don’t disagree at all. Any scan interpreted by a certified orofacial radiologist, especially one clued in to airway issues, will help the dentist learn more about the medical aspects of what is being done. This will also help the connection with the sleep docs as they see dentists acting more like medical doctors.

It’s going to be a state-by-state issue for dentists’ liability, Steve. You have Dr. Berley writing a legal column for your magazine – that might be a question for him.

DSP: As I mentioned earlier, some companies are overlaying intraoral scanner files with cone beam data and producing virtually articulated images, with the ability to move the mandible according to the anatomy.

KM: I envision a day when that construction, together with a protocol driven by real data about that patient’s airway size, demographic and presenting physical data, can be directed to create an oral appliance to put the patient in just the right position to open the airway. Dr. Remmer’s MATRx device will be a huge step for taking more of the guesswork out of patient care.

The thing that really excites me is we have a chance to collect all this data in a HIPAA secure fashion in a central database that will enable us to make a real difference in helping patients. Getting NIH involved, handling my practice, corrective jaw and orthognathic surgery, oral appliances, emergencies in the ER, thinking about what’s next and what’s possible – these are interesting times!

Segmented airway volumetric view with bones and soft tissue

10 DSP | Fall 2014

Interview by Steve Carstensen DDS, Editor in Chief

DSPbuzz

Receives National P

ress...

We’re thrilled to have both our Editor in Chief Steve Carstensen, DDS, and our Publisher Lisa Moler featured in these two prestigious magazines.

AGD Impact June 2014 Vol. 42, No. 6 pages 16-20 Circ. 50,000

First For Women July 14, 2014 pages 40-41 Circ. 5,000,000

...impressive coverage after only one issue. Stay tuned for more...

CLINICALspotlight

Airway Development and Prevention of Obstructive Sleep Apnea in Children: A Case Report, part 2 by Juan-Carlos Quintero, DMD, MS

P

reviously we discussed the correlation between dento-facial patterns and pharyngeal airway measurements as a risk factor for obstructive sleep apnea (OSA). All dentists should understand these relationships and be in tune with the role 3D imaging plays in the screening for patients at risk for OSA. Dentists are often in a unique position, compared to our medical peers, to screen for and triage patients, particularly children suffering from OSA because of our understanding of the mouth and jaws. Breathing is a function of craniofacial anatomy, so ensuring proper facial growth & development and the paralleled development of patent airways is an absolute mandate for any dentist who sees children. Recent imaging technology advances in the form of ultralow dose cone beam computerized tomography (CBCT), such as the new i-CAT FLX (Imaging Sciences International), have made everyday imaging of airways possible with dose exposure less than a panorex and as low as 8 µSv. The application and implication of this technology in the screening and prevention of OSA in the pediatric population are enormous. It is now possible to readily and safely screen for children with small airways who either have OSA, are at risk for OSA, or are at risk for developing OSA later in life and intervene. The following is a case study demonstrating the importance of early detection and treatment.

Figure 5

12 DSP | Fall 2014

Figure 6

Case Report

An 8-year-old female patient presented for an orthodontic evaluation with a chief concern of “wanting a prettier smile.” During the initial interview, it was revealed that the patient was a chronic mouth breather, and a regular snorer. The parents also reported a lethargic disposition during the day with inattentiveness at school and disinterest in sports. At the time of the exam, the patient appeared to be breathing only through her mouth and had signs of venous pooling (“droopy eyes”). A narrow smile and a constricted maxilla was noted. A 3D diagnostic session was completed consisting of photographs (Figure 5) and a low-dose CBCT taken on an i-CAT machine using 16x13 cm field of view and a 4.9-second exposure time.

The evaluation revealed crowding with impacted maxillary canines in the mixed dentition, with a constricted arch form (Figure 6). The CBCT radiographic study showed an extremely narrow pharyngeal airway with a minimum cross-sectional airway (MCA) of 47 mm2 (Figure 7). The patient also presented

CLINICALspotlight

Figure 7

with adenoid hyperplasia encroaching upon the pharyngeal airspace (Figure 8).

The treatment plan consisted first of ENT management in the form of adenoidectomy with coblation of turbinates followed by 10 months of orthodontic Phase I dual arch expansion treatment. Specifically, the patient received a Rapid Maxillary Expander off of a 2x 6 bracket system in the upper arch and a lower removable Schwartz expander followed by a 2X6 bracket system. Final Phase I records were taken consisting of photographs and a low dose CBCT. Figure 9 shows the facial changes before and after treatment, 12 months apart. Figures 10 and 11 show the changes in the pharyngeal airway volume and cross- sectional areas following adenoidectomy, coblation of turbinates, and Phase I orthodontic expansion. Figure 12 shows the resolution of the ectopically positioned permanent maxillary canines. Note the more upright and vertical positions of the canines.

Post treatment, the mother reported a dramatic improvement in the patient’s overall health, level of alertness, a reduction in daytime sleepiness, an improvement in academic performance, and increased athletic activity — all signs of better sleep and oxygenation.

Conclusions

In children, airway issues must be identified and treated as early as possible. Delays in treatment can only delay the suffering of the family and the child. Proper screening using ultra-low-dose CBCT imaging and early management through inter-professional collaboration with ENTs, pediatricians, and allergists during the growing years of the face may prevent OSA in future generations by promoting healthy growth of the craniofacial complex, and thus pharyngeal airway development, during childhood.

A special thank you to the participating ENT on the case, Albert Fernandez, M.D. (Coral Gables, Florida).

Figure 8

Figure 9: Left, before treatment; right, after treatment

Figure 10: Left, before treatment, MCA=47 mm2; right, after treatment MCA=210 mm2

Figure 11: Left, before treatment with adenoids; right, after treatment without adenoids

Figure 12: Left, before treatment; right, after treatment

Juan-Carlos Quintero, DMD, MS, received his dental degree from the University of Pittsburgh in Pennsylvania and his degree in Orthodontics from the University of California at San Francisco (UCSF).

He also holds a Master of Science degree in Oral Biology. He has served as national president of the American Association for Dental Research-SRG, is a faculty member at the L.D. Pankey Institute, and an attending professor at Miami Children’s Hospital, Department of Pediatric Dentistry, as well as immediate past president of the South Florida Academy of Orthodontists (SFAO). He currently practices in South Miami, Florida. His academic interests include applications of 3D craniofacial imaging and airways in orthodontics. Follow Dr. Quintero’s blog on airway development on www.airwaydevelopment.com.

DentalSleepPractice.com

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CLINICIANspotlight

Dr. Todd Morgan — Curious About Better Patient Care Intro: You may think your impact is limited to your patients, or to the doctors you work with. Think bigger, like Dr. Todd Morgan; one of the true pioneers of our field, and you might be part of shaping entire fields of medicine. His story begins with his early research and what he called the “Jaw Advancement Device.” As a busy clinician and patient advocate, he has continued to develop new design features and innovate calibration techniques for oral appliances. He publishes regularly in peer reviewed journals, has authored book chapters and even entire illustrated books. His newest book, for children and parents, is Why the Long Face? A Book about Thumb Sucking1.

Todd believes that much of the basis for understanding airway collapse hinges on early craniofacial growth and development. “It’s easy to understand why obesity can cause OSA, but what about other folks?” Todd went on to say: “The human pharynx is unique among mammals, and we’re lucky it’s floppy enough for speaking. But when muscles largely turn off in sleep we are also uniquely defenseless to collapse. This becomes especially true for those patients with the classic narrow arch form and high palate- a sign of a narrowed airway as well.” “They get quicker to collapse, or, they could have an inadequate neuromuscular response to that challenge.”

“We are just beginning to understand really how oral appliances positively influence pharyngeal dynamics, and in whom. It’s not simple.” Todd invited me and our readers to read a chapter on phylogeny of the pharynx that he wrote with Dr. John Remmers if these concepts stir interest: Phylogeny and Animal Models: An Uninhibited Survey2.

His current research investigations are looking into the role of oropharyngeal exercise for OSA, and as a rehabilitation strategy for stroke sufferers with swallowing difficulties. Todd believes that myofunctional strengthening can play an important adjunc-

14 DSP | Fall 2014

We are just beginning to understand really how oral appliances positively influence pharyngeal dynamics, and in whom.

tive role in improving outcomes for patients, and that patients are looking for self-help strategies.

Outside his busy general dental and sleep practice, he has served in leadership roles for the AADSM for more than ten years, and is the current Chief of Oral Medicine at Scripps Memorial Hospital in Encinitas. He is the Dental Sleep Medicine consultant to Scripps Clinic Division of Chest Medicine in La Jolla, California, and currently serves on the Board of Directors of the California Sleep Society.

Dr. Morgan also holds three patents on oral appliance design.

Todd’s Story: After graduating dental school in 1986 I returned to San Diego, renting some space that was previously a dental office. While waiting for patients to stroll in I had time on my hands and read everything. One day I happened upon an anecdotal report on the “Snore Guard” invented by Tom Meade DDS,

CLINICIANspotlight at the time being promoted by Tom and his colleague Wolfgang Schmidt-Nowara, MD. Out of curiosity I scheduled a time to meet with them. Well, once I understood a bit more, there was no stopping from then on. I was hooked!

For lots of years after that I was creating my own version of the Snore Guard by gluing two night guards together – and having lots of success treating snoring and having a big impact on many of my patient’s lives. I was treating OSA but didn’t know it, and I wanted to learn more! So I took a chance and went to Scripps Clinic’s Sleep Medicine Department in 1990 with my acrylic creations.

There I met Dr. Stuart Menn who engaged me and together we published (after 3 years of revisions and three sleep fellows) a sentinel article in the Journal SLEEP called: The Mandibular Repositioning Device: Role in the Treatment of Obstructive Sleep Apnea3. I feel very fortunate that I had a chance to collaborate and develop friendships with many of the leading experts in sleep medicine of our time, like Drs. Milton Erman, Merrill Mitler, Dan Kripke, Phillip Westbrook, Arthur Dawson, Steven Poceta and Dan Loube to name only a few. My tail has been on fire ever since then, yet I am excited to know that my adventure in learning, teaching and publishing in this field has yet only just begun.

What Contributions Do You Feel You Have Made to DSM:

I feel like my largest contribution lies in my devotion to patient care. Saving lives is very cool. Secondary to that is research and teaching, which I’ve integrated into my patient care. It’s such a passion of mine that

I feel like my largest contribution lies in my devotion to patient care. Saving lives is very cool.

Secondary to that is research and teaching, which I’ve integrated into my patient care.

it’s hard to treat anyone without wondering “What I will discover with this case?” There is still a ton to uncover, all the way from patient selection to improved appliance design. I believe the key to success and best outcomes is finding the correct bite for the case right from the start. This is why we have worked hard to develop the Apnea Guard system, once we understood the importance of adding vertical height to the protrusive position.

We actually stumbled onto discovering the impact of vertical while conducting our NIH funded oral appliance outcome studies in the late 2000’s. Back then, we studied 130 patients using the TAP II and TAP III appliances and saw different outcomes when we dived patients by gender and which appliance was fabricated. The TAP II had significantly more vertical opening than the TAP III. When we retested a subset of our cohort and crossed over appliances we discovered that the male subjects did much better with more vertical opening. Once I understood when to use vertical my clinical result greatly improved in my practice. A bit later we decided to develop the Apnea Guard trial appliance that guides the user thru a simple algorithm for proper vertical selection in each case and the Apnea Guard is now growing in popularity for this reason, and because you can offer immediate treatment while the patient waits for their custom appliance. Based on our FDA trial that compared Apnea Guard to custom appliance outcomes4, we know that the Apnea Guard correctly predicts the correct protrusive and vertical jaw position and that that position can be transferred to the final customized device. I am very excited about the future of this technology.

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CLINICIANspotlight I am currently focusing on the role of oropharyngeal exercise in treating OSA. Over the past five years some wonderful evidence has been published that shows this type of exercise can be very helpful. Everyone thinks about the Didgeridoo study published by Punan5 quite a while back when exercise for OSA comes up. That study was small and interesting, but it is largely impractical to buy and start playing one of these massive instruments. It is also interesting to ponder how circular breathing technique helps to strengthen the right muscles to defend against airway collapse.

Then in 2009, a Brazilian investigator named Katia C. Guimaraes6 published a remarkable paper showing dramatic improvements in OSA in a group of 40 men with moderate OSA using speech therapy exercises and neuromuscular stimulation. I was so impressed I decided to study and better understand the actions of all of the pharyngeal muscles as well as the reflexes associated with tongue positioning. Through this effort I was able to design a novel device called the Pharyngeal Training Appliance (PTA), nicknamed the “Lifeguard.” Right now we are in the investigational stages of adding the PTA to our clinical protocol when oral appliance outcomes fall short of expectations. Early results are looking good. We also have the PTA started in a clinical trial for rehabilitation of stroke patients with swallow dysfunction7.

So, the future is wide open in my opinion.

There is plenty to discover and develop in the field of Dental Sleep Medicine, including on the treatment arm and the business model/ patient management side of things. I love the collaboration with my physician colleagues, which is largely missing from the other disciplines within dentistry.

In summary, none of my studies, collaboration, or research would matter if it didn’t help patients. My advice is to find mentors, as I have, and trust the instincts we all have for good patient care. My role these days is to carry on what my mentors offered me and give the practicing dentist tools to help them be the best at improving the health of their community. Dental Sleep Practice Magazine will be a way for you to read about, and hopefully publish the great ideas you come up with.

Figures 1 and 2: The laboratory prescription, casts, and PVS Apnea Guard inserts are set to go forward with fabrication of the custom device of choice. The dentist may then refill the trays at the determined protrusion and vertical for immediate use and relief of symptoms while waiting for delivery of the custom appliance.

Figures 3 and 4: Laboratory procedure for articulation of casts using the Apnea Guard bite registration protocol. In this case the laboratory jigs show use of upper and lower vertical size high, providing 8.5mm of incisal opening.

The “PTA” appliance features an exercise flap and elastic resistance to strengthen the tongue protruding muscles. The appliance facilitates three exercises that improve neuromuscular response of the pharynx.

1.

2.

3.

4.

5.

6.

7.

16 DSP | Fall 2014

www.thumbsuckingbook.com “Phylogeny and Animal Models, an Uninhibited Survey” Chapter 5, Obstructive Sleep Apnea: Pathophysiology, Comorbidities and Consequences, Volume 3. 2008 The Mandibular Repositioning Device: Role In The Treatment Of Obstructive Sleep Apnea. Stuart J. Menn, *Daniel I. Loube, Todd D. Morgan, Merrill M. Mitler, Joel S. Berger and Milton K. Erman. Division of Sleep Disorders, Scripps Clinic and Research Foundation, La Jolla, California, U.S.A.; and *Pulmonary Service, Walter Reed Army Medical Center, Washington, D.C., U.S.A. Initial Evaluation of a Titration Appliance for Temporary Treatment of Obstructive Sleep Apnea. Levendowski, DJ, Morgan T, Westbrook, P, J Sleep Disordered Therapy, 2011, 1:1 DOI10.4172 Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial.

Puhan MA1, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O BMJ. 2006 Feb 4;332(7536):266-70.

Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009 May 15;179(10):962-6. Guimarães KC1, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G www.ptappliance.com

CLINICALfocus

Oral Appliance Therapy for the Edentulous PAP Intolerant Patient

Introduction Obstructive sleep apnea (OSA) is a disorder characterized by repetitive collapse of the upper airway during sleep, with consequences of nocturnal hypoxemia and recurrent arousals from sleep.1 The prevalence of OSA is significant and increasing with greater obesity and aging of populations.2 In addition to decreased neurocognitive performance from recurrent nocturnal arousals, there exists an increased risk of fatal and nonfatal cardiovascular events as well as all-cause mortality in patients with severe OSA.3,4 Recent evidence has demonstrated that the risk of cancer mortality and ischemic stroke carry a doseresponse association with the severity of sleep-disordered breathing (SDB).5 The United States population of adults 65 years of age and older is to increase from 13.5 million in 1991 to 21.8 million by 2020 yielding a relative increase of 61%. Depending on the definition used for AHI 62% to 81% of this population will suffer from OSA.7 Endeshaw et al reported that the risk of OSA might increase as a result of edentulism.8 Full mouth extraction manifests a worsening of the cardiorespiratory symptoms, approximately doubling the number of episodes of apnea-hypopnea per hour in a patient with OSA.9 Edentulism leads to a decrease in the size and tone of the pharyngeal musculature, which is a crucial risk factor for OSA.10 A loss in vertical dimension of occlusion leads to a reduction of the lower face height, counterclockwise rotation of the mandible and may lead to OSA.10

Almeida et. al. commented, “There is no consensus in the literature about the impact of complete denture wear on OSA.”11 “Contrary to previous studies, we found that OSA patients may experience more apneic events if they sleep with their dentures in place.

Specifically, in mild OSAS patients, the use of dentures substantially increases the AHI especially when in the supine position.”11 Bone resorption in edentulous alveolar processes has been studied extensively. It is a chronic, progressive and irreversible process that occurs in all patients.12 In complete denture wearers there is a greater degree of mandibular resorption than maxillary resorption. Atwood and Tallgren documented that mandibular bone loss is four times greater than maxillary bone loss. Irreversible loss of supporting bone structure results in the most DentalSleepPractice.com

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CLINICALfocus common patient complaint, difficulties with retention and stability of mandibular dentures.13,14 After twenty years the complete denture patient experiences loss of the vertical dimension of occlusion as viewed from the right profile. The mandible rotates in a counterclockwise fashion leading to a increase in relative prognathism. Maxillary alveolus remained stable while the mandibular alveolus resorbed. Dentures rotated counterclockwise and shifted slightly forward. These observed changes were not significantly affected by the sex of the patient or by the denture technique employed.15 Dental implants date back in history to 3000 B.C.16 Dental implants are now regarded as the “Standard of Care” for the edentulous mandible. “The panelists reached consen-

Figure 1

Figures 2A & 2B Figures 3A & 3B

Figure 4

Figure 5

sus that they would recommend an IRMOD (Implant Retained Mandibular Over Denture) instead of a CD (Complete Denture) as the first-choice standard of care for patients who are healthy or have mild systemic disease, but not for patients with severe systemic disease.”

(See Fig. 1)

Procedure

Treatment of the edentulous population suffering from OSA with PAP therapy can be challenging. The following is a technique developed by the author for treatment of the PAP intolerant edentulous patient with oral appliance therapy engaging two mandibular implants.

The complete dentures must be well fitting and in good repair. If the prosthesis is ill fitting or shows signs of excessive wear fabrication of a new prosthesis is indicated.

The first step is to duplicate the tissuebearing surface of the existing prosthesis (maxillary and mandibular) with a silicone based putty such as Ivoclar Vivadent’s SilTech® Condensation Silicone (Figs. 2A and 2B). This is preferred over taking new impressions that may lead to over extension of the oral appliance as well as saving time.

The addition of paper clips to the underside of the silicone duplicate will provide a retentive mechanism for the addition of stone bases (Figs. 3A and 3B).

Stone bases can now be added to the duplicate silicone models to provide stability for mounting to an articulation device (Fig. 4).

The duplicate silicone models are sent to the dental laboratory for fabrication of bite rims (Fig. 5).

Record the existing vertical dimension with the patients existing prosthesis in place.

An eyebrow pencil can be used to mark a position on the nose and chin then record-

John H. Tucker, D.M.D. has maintained a private practice in Erie, Pennsylvania since 1982. He is a graduate of the University of Pittsburgh School of Dental Medicine. He has completed the Boston Seminars in Implant Dentistry with Dr. Paul Schnitman, the University of Buffalo Esthetic Dentistry Program, and all levels of the Dawson Center for Advanced Dental Study, and the University of Buffalo Patient Mastery Program. In 2005, he was awarded a Certificate of Proficiency in Esthetic Dentistry from the University of Buffalo. He is a Member of the American College of Oral Implantology, the American Dental Association and the Academy of General Dentistry. He is also a Diplomate for both the International Congress of Oral Implantologists and the American Society of Osseointegration. Dr. Tucker has Mastership status in the American Academy of Implant Prosthodontics as well as Fellowship in the International Academy for Dental-Facial Esthetics. He is a member of the American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine.

18 DSP | Fall 2014

CLINICALfocus

Figure 6

Figure 7

Figure 8

Figure 13

Figures 10A & 10B

Figures 11A & 11B

ed on a tongue depressor for future reference (Fig. 6).

Seat maxillary bite rim and determine Fox Plane that mimics the patients existing complete maxillary denture (Fig. 7).

Seat mandibular bite rim and adjust accordingly to develop vertical dimension that replicates the patient’s vertical dimension with their complete dentures in place. The marked tongue depressor is used to verify the correct vertical relationship (Fig. 8).

The bite rims should mimic the existing prosthesis in all dimensions (Fig. 9).

A George Gauge 5.0mm bite fork was modified to accommodate the maxillary bite rim and secured with a VPS bite registration material (Figs. 10A and 10B).

The mandibular bite rim is modified to accept the incisal edge clamp of the George Gauge (Figs. 11A and 11B).

Determine maximum protrusive available and set George Gauge to correspond amount of protrusive desired. In this case 70% of maximum protrusive was used as the initial treatment position for the oral appliance (Figs. 12A and 12B).

Verify the protrusive bite position on the models prior to sending to the dental laboratory for fabrication of the oral appliance (Fig. 13).

The oral appliance is returned from the dental laboratory. The patient was treated using a SomnoDent appliance. The patient had

Figures 12A & 12B

Figure 9

Figure 14

Figures 15A & 15B

two dental implants with Locator® attachments that provide retention of his complete mandibular denture. The Locator® attachments will also provide retention of his oral appliance (Fig. 14).

The appliance is seated to verify that it fits passively over the Locator® attachments. The appliance is adjusted as indicated. (Figs. 15A and 15B) The Locator® attachment housing can be transferred to the oral appliance directly in the mouth using cold cure acrylic or a BISGMA resin such as EZ PickUp™ available from Sterngold™ (Figs. 16A and 16B).

The Locator® attachment housings having been transferred to the oral appliance (Figs.

17A and 17B).

The completed oral appliance (Fig. 18).

Figures 16A & 16B

Figures 17A & 17B

Figure 18

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CLINICALfocus Treatment Results and Comments

I believe it is important for the treating practitioner to investigate the reason(s) why the presenting patient is intolerant of PAP therapy to have an understanding of the patient’s attitude regarding treatment of their disease.

20 DSP | Fall 2014

Being an AADSM Accredited facility, I aspire to the AADSM Treatment Protocol. This involves a complete clinical examination, determination of current health of oral tissues and radiographic survey.

This patient was refereed for treatment of his OSA with Oral Appliance Therapy as a result of being intolerant to PAP therapy. His sleep physician provided a prescription for treatment. The diagnostic PSG revealed an AHI of 22.9/hour and Nadir SpO2 of 85%.

The patient was questioned during the initial consultation and examination as to why he was intolerant to PAP therapy. I believe it is important for the treating practitioner to investigate the reason(s) why the presenting patient is intolerant of PAP therapy to have an understanding of the patient’s attitude regarding treatment of their disease. I am of the mindset that we should reinforce the possibility of revisiting PAP therapy with the patient in the event the patient had a misunderstanding of their disease and treatment. A discussion as to Oral Appliance design, rational for Oral Appliance Therapy and treatment efficacy was completed with the patient. The informed consent was offered to the patient as well as the ability to ask any questions he may have regarding his treatment. Related treatment fees were also reviewed with the patient prior to treatment.

The patient reported that he had tried several nasal pillows and full-face masks. His primary complaint was instability of the nasal pillows and discomfort of the pre-maxilla.

He also reported that full-face masks led to a feeling of claustrophobia. The patient was questioned as to his complete denture wearing status while attempting the various PAP therapies. He commented that he had tried all PAP therapies with and without complete dentures in place. “I feel more comfortable with my dentures in place but no matter what I tired I had pain under my nose or felt claustrophobic”, was his comment.

I reviewed with the patient the possibility of fabricating an Oral Appliance that would mimic his complete dentures with the mandibular component engaging the implants.

The patient was also informed that I had patent pending status regarding Oral Appliance Therapy on implants to avoid any conflict of interest (COI). He stated that he understood the treatment process and COI. His com-

ments were. “This is exciting to me.” “When can we get started?” The patient completed the informed consent. Treatment was initiated as per the protocol described in this article. The proposed treatment plan was documented appropriately and communicated to the patients sleep physician and primary care physician.

After approximately three weeks the appliance was inserted using Pressure Indicating Paste ensuring a comfortable fit of the appliance. The patient was instructed to wear the appliance during sleep as well as hygiene of the appliance. All patient questions and concerns were answered to his satisfaction.

“I like this appliance idea and think it is going to work for me” was his comment upon departing the office.

The patient was contacted via phone 48 hours following delivery of his Oral Appliance to verify that he did not have a problem or questions regarding use of the appliance.

The patient indicted that he did not have a problem wearing the appliance and did not have any questions. His comment was, “I love this thing and I think its working!”

The patient was seen two weeks post appliance insertion. The patient was asked subjective questions regarding his therapy. The questions with his responses are noted: 1. Do your wear your appliance when you sleep? Yes All the time? Yes 2. Does your appliance fall out? No 3. Has your snoring been reduced? Yes. “She says I don’t snore anymore.”

4. Are you less tired during wake time?

Yes 5. Are you dreaming more? Yes 6. Do you have any jaw pain? No 7. Do you have any tooth pain? “I don’t have teeth.”

Based on the patients positive subjective answers I elected not to calibrate the appliance at this time. It is interesting to note that there was no report of tissue irritation or lack of retention by the patient. He was re-appointed for a six-week follow-up appointment and informed to contact the office should he have any discomfort or questions.

Appropriate documentation was noted in the patients EMR (electronic medical record) and communicated to his appropriate health care providers.

Six-weeks following, the patient was once again asked the subjective questions

CLINICALfocus regarding his therapy as previously noted.

The only change noted was his comment that he seems to be “snoring a little” as per his wife. The appliance was calibrated by 1.0 mm forward advancement. Once again it is noted that there is no patient complaint of appliance discomfort. He was re-appointed for a six-week follow-up appointment and informed to contact the office should he have any discomfort or questions. Appropriate documentation was noted in the patients EMR and communicated to his appropriate health care providers.

After approximately four months of Oral Appliance Therapy and appropriate calibration based on his subjective comments he was re-evaluated with a PSG to document efficacy of treatment. The PSG with oral appliance therapy revealed an AHI of 4.6/hour and Nadir SpO2 of 90%.

It is my opinion that follow-up testing should be delayed for approximately four to six months post Oral Appliance delivery to allow the body to heal. It is interesting to note in a recent study by Hoyos et al “CPAP treatment increased IGF-1 levels after 12 weeks but not 6 weeks, with a further increase at 24 weeks. These findings indicate that CPAP improves specific components of the GH/ IGF-1 axis by improvement in hypoxemia in middle-aged men with OSA in a time-de-

pendent manner. Future research should incorporate these findings when investigating any time-dependent improvements into longer-term measures of cardiometabolic health, in the ever-increasing population of those with OSA.”18 The technique and protocol described can be utilized with any type of Oral Appliance and any number of dental implants. The author has had experience in utilization of various appliance designs (Figs. 19A and 19B).

My personal experience had led me to select appliance designs that do not rigidly connect the mandible to the maxilla. Appliances that rigidly connect the mandible to the maxilla have a tendency to un-seat the mandibular component from the attachments or dislodge the maxillary component. Careful selection of appliance design is indicated based on the above recommendation.

As was previously noted, treatment of the edentulous population with Oral Appliance Therapy can be challenging due to instability of the prosthesis as a result of bone loss.

The addition of two mandibular implants is now considered to be the Standard of Care providing excellent retention of the complete mandibular denture during wakefulness.

These implants can also provide retention of an Oral Appliance for the PAP intolerant edentulous population during sleep.

Figures 19A & 19B

References: 1.

Malhotra A, White DP. Obstructive sleep apnea. Lancet 2002; 360:237–245.

2.

Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20:705–706.

3.

Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: An observational study. Lancet 2005;365:1046 1053

4.

Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and Mortality: A prospective cohort study. PLoS Med 2009; 6:e1000132.

5.

Nieto FJ, Peppard PE, Young T, Finn L, Hla KM, Farre R. Sleep-disordered breathing And cancer mortality: Results from the Wisconsin sleep cohort study. Am J Respir Crit Care Med 2012;186:190–194.

6.

Douglass CW, Shih A, Ostry L (2002) Will there be a need for complete dentures in the united states in 2020? J Prosthet Dent 87:5–8

7.

Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O (1991) Sleep-disordered breathing in community dwelling elderly. Sleep 14:486–495

8.

Endeshaw YW, Katz S, Ouslander JG, Bliwise DL (2004) Association of denture use with sleep-disordered breathing among older adults. J Public Health Dent 64:181–183

9.

C. Bucca, A. Cicolin, L. Brussino et al., “Tooth loss and obstructive sleep apnoea,” Respiratory Research, vol. 7, article 8,2006.

10.

C. Bucca, S. Carossa, S. Pivetti, V. Gai, G. Rolla, and G. Preti, “Edentulism and worsening of obstructive sleep apnoea,” The Lancet, vol. 353, no. 9147, pp. 121–122, 1999.

11.

Almeida FR, Furuyama RJ, Chaccur DC, Lowe AA, Chen H, Bittencourt LR, Frigeiro ML, Tsuda H.Complete denture wear during sleep in elderly sleep apnea patients-a preliminary study.

Sleep and Breathing September 2012, Volume 16, Issue 3, pp 855-863.

12.

Carlsson GE. Clinical morbidity and sequelae of treatment with complete dentures. J Prosthet Dent. 1998;79:17-23

13.

Atwood DA, Coy WA. Clinical, cephalometric, and densitometric study of reduction of residual ridges. J Prosthet Dent 1971;26:280-95

14.

Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-longitudinal study covering 25 years. J Prosthet Dent. 1972;27:120-32

15.

Douglass JB, Meader L, Kaplan A, Ellinger CW Cephalometric evaluation of the changes in patients wearing complete dentures: a 20-­year study. J Prosthet Dent. 1993 Mar;;69(3):270-­5.

16.

Ring M E. Pause for a moment in dental history: A thousand years of dental implants: A definitive history -Part 1. Compendium 1995;16:1060-1069.

17.

Kavitha P. Das, BDS, MPH, MS; Leila Jahangiri, BDS, DMD, MMSc; Ralph V. Katz, DMD, MPH, PhD. The first-choice standard of care for an edentulous mandible. JADA 2012;143(8):881889.

18.

Hoyos CM; Killick R; Keenan DM; Baxter RC; Veldhuis JD; Liu PY. Continuous positive airway pressure increases pulsatile growth hormone secretion and circulating insulin-like growth factor-1 in a time-dependent manner in men with obstructive sleep apnea: a randomized sham-controlled study. SLEEP 2014;37(4):733-741.

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MEDICALinsight

22 DSP | Fall 2014

MEDICALinsight

by Steven Lamberg DDS, DABDSM

I

lluminating medical conditions that often accompany sleep disordered breathing can help patients understand the necessity of treating the disease causing their conditions. The prevalence of comorbidities can help assess the risk of having sleep disordered breathing. Since many medical providers must collaborate to ensure complete patient care, increasing interdisciplinary communication will enhance the integration of patient care between providers. The term Integral Sleep Medicine is proffered.

The many faces of SDB are revealed by examining frequently associated conditions such as: High blood pressure (hypertension), heart failure, heart rhythm disturbances, atherosclerotic heart disease, pulmonary hypertension, and insulin resistance. Additionally, cognitive impairment (memory problems), depression, anxiety, and gastroesophageal reflux disease (GERD) are among possible complications of untreated sleep apnea. People are often motivated to seek information by a family pattern of early death. Discussing medical history with patients, dentists have excellent opportunities to screen community populations for SDB. Since treatment options include oral appliances, starting the conversation in the dental office provides patients important information as they pursue resolution of SDB. To help the dental team understand some of these SDB-Comorbidity connections, the following is a list of commonly quoted statistics: • 1/3 of population suffers from some sleep disorders: 20M SDB, 10M Periodic Limb Movements, 20M Insomnia, snoring and other disorders.

• Snoring Prevalence 67% general population. “National Sleep Foundation” 2005 • 94% of OSA population snores, 6% are silent apneics.

• Studies show anywhere from 9% to 24% of the population have OSA (Wisconsin Study 1988, SHHS, Young) The mechanism of harm seems to be Intermittent Hypoxia.

• Metabolic Syndrome effects 24% of general population.

• Weight loss of 10% can decrease AHI 30%-50%.

• If 90% of affected people have not yet been diagnosed, approximately 20% of your patient population may be at risk of SDB. A risk assessment questionnaire can identify who should have diagnostic sleep testing (PSG).

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MEDICALinsight Categories have been broken out to facilitate inter-disciplinary dialogue.

Category 1: (some of the standard screening questions)

“STOPBANG” questionnaire: Snoring, Tired, Observed apneas, Pressure (BP), BMI, Age, Neck circumference, Gender) 1. Physical: BMI, Sex, Age >50, Neck Size, Tonsil Grade, Oral Pharyngeal Crowding, Tongue level, Hyoid position, Craniofacial characteristics Orthodontic type, Palatal vaulting, Family History of SDB 2. Have you had unexpected weight changes recently?

3. Have you ever had a PSG? Titration study? Home sleep test?

4. Do you snore loudly enough at night to cause conflict with others?

5. Have you been told you have stopped breathing at night?

6. Did you ever wake up choking?

7. Do you awaken unrefreshed?

8. Do you have morning headaches?

9. Do you feel sleepy during the day? (Rely on Caffeine or Prescription Stimulants) 10. Do you feel fatigued during the day?

11. Do you have difficulty breathing through your nose?

(Post nasal drip, or dry mouth in morning?)

Category 2: Cardiovascular:

• SDB predicts an increased prevalence of CAD, Stroke, Arrhythmias, Hypertension. Endothelial Dysfunction.

• SDB in CAD patients is twice that of non-CAD patients • Increase in free radicals (oxidative stress), homocysteine and decrease in nitrous oxide leads to damaged endothelium and loss of vessel elasticity, resulting in hypertension.

• Stroke OR is 3x if AHI>30 • Within OSA population, 50% are hypertensive

• Within Hypertensive population, 30% have OSA • Drug Resistant Hypertension, prevalence of OSA: 96% men, 65% women • For Hypertensives whose BP doesn’t “dip” at night, 90% have OSA • 38,000 CV deaths/year linked to OSA • Heart Failure patients: 26%-37% have OSA and or CSA • Severe OSA patients OR=5.2 for CV mortality • Within Angina Population 54% had OSA • Nocturia (2 or more events) or Enuresis, May result from diuretic hormone in response to respiratory event.

• Endothelial Dysfunction leads to Erectile Dysfunction.

• Within Erectile Dysfunction population, 44% have OSA • Nocturnal Arrhythmias occur in 50% of OSA patients • 68% of patients with atrioventricular block have OSA • Ventricular Arrhythmias in 66% of OSA patients (PVCs) • In Severe OSA cohort, risk of AFib is increased 4x • In AFib cohort studies: 42% to 45% to 81% have OSA • Patients with AFib may benefit from screening for OSA because OSA is a treatable risk factor for the initiation and recurrence of AFib after ablation.

• In Pacemaker patients, 59% have OSA.

Category 3: Pulmonary:

• In OSA population, 10%-20% have COPD • COPD with OSA = “Overlap Syndrome” increased mortality • OSA increases BP of Pulmonary Artery leads to Pulmonary Hypertension and possibly COPD • COPD causes Nocturnal Oxygen Desats, impairs sleep, decreases SWS and REM • 11% to 20% of those with controlled asthma reported sleep disturbances • OSA patients have OR of 2.87 for asthma • Asthma cohort has 72% inc. risk for developing OSA • Each disorder makes the other worse • In Asthma cohort, 70% have Rhinitis

Dr. Steven Lamberg has been practicing dentistry for over 30 years with an emphasis on cosmetic, reconstructive and implant dentistry, and has developed a passion for Dental Sleep Medicine over the last 10 years. After attending Washington University in St. Louis, he earned his DDS at NYU College of Dentistry. His pursuit of education lead him to the Dawson Center and later to study in Seattle at the Kois Center. Dr. Lamberg went on to become the founder of the Long Island Center for Dental Esthetics and Occlusion, developing and presenting hands on clinical dentistry programs on the latest and most effective methods of cosmetic, reconstructive and implant dentistry. He served as Chief of Staff at the Jewish Home and Hospital in NYC, President of the New York Chapter of the American Academy of Cosmetic Dentistry, Associate Clinical Professor at SUNY Stony Brook Dental School, and presented lectures and clinical courses on occlusion and esthetic dentistry at NYU College of Dentistry and for PAC live. Dr. Lamberg also created Lamberg Seminars, offering clinical courses in Dental Sleep Medicine for the entire team. He is the inventor of the Lamberg SleepWell Appliance “LSW” which is a patented, FDA cleared intraoral device for the treatment of snoring and OSA. Dr. Lamberg is a Diplomate of the American Board of Dental Sleep Medicine and the Academy of Clinical Sleep Disorders Disciplines. He lives and practices in Northport, New York.

For speaking engagements, he can be contacted at 631-261-6014, or SteveLambergDDS@gmail.com.

24 DSP | Fall 2014

MEDICALinsight Category 4: Gastroenterology:

• In Western countries, GERD symptoms such as heartburn and acid regurgitation occur in about 20% of adults.

• While the airway obstruction is superior to the junction of the larynx and the esophagus, each “event” will cause increased negative pressure in the esophagus which may create aspirations of stomach contents.

• In Nocturnal GERD pop, OR of having OSA is 2.97.

• In OSA pop, 24% have GERD. • Morbid Consequences of GERD include: changes of cells lining the lower esophagus. About 10% of people with chronic symptoms of GERD develop Barrett’s esophagus which is a precursor to esophageal adenocarcinoma, a serious and potentially fatal cancer.

• In GERD cohort, TMJ disorders are twice as prevalent • Patients with GERD have a significantly higher risk of concurrent asthma compared with patients without GERD.

Category 5: Neurology:

• Neurological disorders with primary neurological symptoms are improved by treatment of comorbid OSA include: dementia, stroke, epilepsy and headache.

• Intermittent hypoxia in OSA is an independent risk factor for axonal damage of peripheral nerves.

• Strong association between OSA and peripheral neuropathy and retinopathy. (60% of patients with diabetes and OSA also have a peripheral neuropathy) • SDB common in patients with many neuromuscular disorders.

• 30%-70% Alzheimer’s patients have SDB • 20% Parkinson’s patients have OSA • Within OSA patients, OR of developing Glaucoma within 5 years is 1.67 • OSA treatment shown to reduce frequency of cluster headache.

• RLS=8% in general population, 90% of these have PLMD • RLS symptoms in 40% of subjects with iron and B12 deficiency • Hyperhidrosis (night sweating), may be related to excessive body movement.

Category 6: Endocrinology:

• Diabetes prevalence in America is 8.3%. Prediabetes (>20 yr olds) 35%.

• Within Type 2 Diabetes population, 36%-50% have OSA. • Menopause: Decrease in Estrogen and Progesterone leads to increase in SDB due to weight gain and decrease muscle tone. HRT may help.

• 24% of the general population has Metabolic Syndrome, a cluster of conditions ( increased blood pressure, a high blood sugar level, excess body fat around the waist, and abnormal cholesterol levels) that, when occurring in combination, increase your risk of heart disease, stroke and diabetes.

• In Metabolic Syndrome cohort, OR for MI is 2.63 compared with normals

• • • •

Metabolic Syndrome + OSA= Syndrome Z 70% of OSA patients are obese, so 30% aren’t obese.

Within obese patient population, 30% have OSA. In Metabolic Syndrome Cohort, prevalence of modsevere OSA is 60% • In patients with OSA, prevalence of metabolic syndrome is 40% greater • Narcolepsy is result of reduction of Hypocretin (orexin) and can be accompanied by: Cataplexy, Hypnogognic Hallucinations, Sleep Paralysis (SP), and Sudden Onset REM Sleep (SOREMS).

Category 7: Otolaryngology:

• Nasal congestion patients are 2x as likely to have OSA • A variety of sinus problems are: Post nasal drip, sinusitis, nasal resistance, rhinitis, deviated septum, dry mouth upon awakening.

• Nasal congestion is independently associated with snoring frequency. (Wisconsin study 5000 patients) • Allergic rhinitis increases risk of asthma 3x.

• Otological Symptoms 85% in TMD population (tinnitus 42%, ear pain 42%, dizziness 23% and diminished hearing 18%)

Category 8: Urology:

• In OSA population, between 40% and 60% have Erectile Dysfunction “ED”. Within ED population, 40% have OSA • With increased severity of OSA, there is also increased occurrence of: overactive bladder, urgency incontinence.

• Sleep Fragmentation from SDB may decrease circulating antidiuretic hormone, which normally prevents us from urinating at night.

• OSA should be considered whenever a patient reports frequent awakenings from sleep to urinate, even when the symptom was previously attributed to the presence of BPH. DentalSleepPractice.com

25

MEDICALinsight Category 9: Bruxism and TMD:

• Sleep Bruxism “SB” reported in 8% of general population, 87% in TMD population, 25% in OSA population.

• WIthin SB population, 30% have SDB • Within SB population, 65% suffers from headaches (OR for headaches in SB is 4.3) • Within OSA population, the OR to have SB is more than doubled • Within OSA population, 25% have SB. • In general population,12% have TMD. • In OSA population, 25% have TMD. • Within TMD population, 75% have chronic pain.

• Within TMD population, 30% have OSA. • Within TMD population, 85% have Otological Symptoms: tinnitus 42%, ear pain 42%, dizziness 23% and diminished hearing 18%. (in general population between 10%-31% have Otological Symptoms)

Category 10: Psychology and Psychiatry:

• Insomnia: between 10%-15% general population have chronic insomnia.

• In Insomnia cohort, 27%-67% have OSA. • In OSA cohort, 50% have some type of insomnia.

• OSA concurrent with Insomnia is called “SDB+” • Sleep Fragmentation and Deprivation leads to: activation of Hypothalamic-Pituitary-Adrenal axis and Sympathetic NS stimulation, and increased cortisol release.

• Within the psychiatric outpatient population the prevalence of OSA is increased.

• Within OSA population, the prevalence of Psychiatric comorbid conditions are increased.

• In OSA cohort, 21.8% have Depression, as compared to 9% in the general population.

• In OSA cohort, 11.9% have experienced PTSD, as compared to 3.9% in general population.

• In OSA cohort, 5.1% experience Psychosis at some point in life, double that seen in general population.

• In Depressive Cohort: @20% have OSA, OR for OSA is 4 • SDB causes increases in: Cognitive Impairment, Mood Swings, ADHD, Difficulty Concentrating, and Circadian Rhythm Disorder.

• Many anxiolytic medications affect sleep architecture.

Benzodiazepines reduce muscle tone, compromise airway patency, and reduce REM sleep.

Category 11: Chronic Pain Patients:

• Chronic Pain: 15% in general population, 50% in elderly population.

• Chronic Pain causes a decrease in Slow Wave Sleep.

• Within chronic headache population, 80% have OSA (6:1 male over female) • Pain reported in 66%-84% of patients with SB • SB patients have 3x headaches compared with control • Within Fibromyalgia cohort, 74% have chronic headache, IBS

26 DSP | Fall 2014

• Many autoimmune disorders cause muscle and joint pain which can interfere with sleep.

• Bidirectionality Theory: Pain causes poor sleep and poor sleep lowers pain threshold.

• Morning headaches: (must differentiate to: sinus, muscle pain, or vascular)

Category 12: Pediatrics:

• SDB inhibits growth in 1-10% of children by decreasing Insulin Growth Factor.

• Childhood onset asthma predicted development of OSA with OR of 2.1 • 10%-30% of children with SDB are misdiagnosed with asthma • OR for neurobehavioral problems is 2.98 • When AHI>10 there’s 6x increase in LV hypertrophy • Within “children with OSA” Population: • Enuresis 7%-30% • Persistent snoring 100% • Mouth breathing 84% • Mouth breathing has been associated with altered craniofacial growth, including narrow maxillary arch, posterior crossbite, long anterior face height with clockwise mandibular growth rotation, anterior open bite and mandibular retrognathia. SDB in children has been associated with numerous systemic health consequences including reduced systemic growth, systemic hypertension, and pulmonary hypertension causing right and left ventricular hypertrophy, respectively, as well as behavioral problems such as hyperactivity and attention deficit, aggression, and lower grades in school. Additionally, if left untreated, the altered growth pattern increases the risk of adult OSA. All children should be carefully observed while sleeping and any breathing sounds made, or apparent struggles with breathing, must result in additional diagnostic steps. The Brouilette questionnaire is an excellent screening tool as well.

Using the statistics cited above, it is evident there are many clues to the presence of SDB. Being curious about these subjects will enhance your medical history-taking.

Truly understanding them will greatly improve your ability to help your patient’s overall health.

The following questionnaire has been designed to aid in identifying patients at risk and form a medically appropriate basis for dialog with your patient and their other medical providers. Accurate diagnosis will lead to the most complete care for your patient. As future research provides more evidence correlating SDB and comorbidities, this document will be updated.

Scientific Support Data has been compiled from over 400 articles, including peer reviewed international journals and the ABDSM reading list.

Principles and Practice of Sleep Medicine, Kryger, Roth, and Dement, 4th and 5th Editions, Elsevier, were major resources.

Reprints of this article, a list of the references, and the Lamberg Questionnaire are available at no cost at www.LambergSeminars.com.

MEDICALinsight The Lamberg Questionnaire “LQ 1.0�

1: Standard Questions ___ Do you awaken unrefreshed or feel sleepy during the day? ___ Is your snoring loud enough to disturb others? ___ How long have you been aware of your snoring? ___ Have you been told your breathing stops while asleep? ___ Do you ever wake yourself from sleep feeling that you are choking? ___ Have you ever had a sleep lab study? If you tried CPAP was pressure > 10.5 cm. ___ Is your BMI>27? Or is your neck size > 17 men, or > 15.5 women?

2: Cardiovascular ___ Do you have high blood pressure, take medicine for hypertension, or have a pacemaker? ___ Ever diagnosed with: CAD, Stroke, Congestive Heart Failure, A Fib, or other cardiomyopathy?

3: Pulmonary ___ Have you experienced difficulty breathing during the day? ___ Do you have shortness of breath, even with mild exertion? ___ Ever been diagnosed with COPD or Asthma? ___ Do you have a chronic cough, either dry or productive?

4: Gastorenterology ___ Do you experience heartburn or acid reflux at night or in the morning? ___ Have you or your dentist noticed erosion on molars? ___ Do you take heartburn medications, either prescription or over the counter?

5: Neurology ___ Do you experience numbness, tingling or pain in your feet or hands? ___ Do you ever experience muscle weakness or difficulty with coordination?

6: Endocrinology ___ Have you been diagnosed with diabetes? ___ Have you unexpectedly gained or lost weight lately?

The Epworth Sleepiness Scale (ESS) How likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation: 0 would never doze 1 slight chance of dozing 2 moderate chance of dozing 3 high chance of dozing

___ Have you gone through menopause? Are you on HRT? ___ Notice repetitive limb movements or jerks in sleep, urges to move legs, or night sweats?

7: Otolaryngology ___ Do you experience a dry mouth upon awakening? ___ Do you have difficulty breathing through your nose? ___ Do you have allergies that make nasal breathing difficult?

8: Urology ___ Do you have difficulty getting an erection? ___ Do you ever leak urine involuntarily? ___ Do you have to urinate several times at night? Have you been diagnosed with BPH? ___ Experience decreased interest in sex or taken medications to enhance sexual performance?

9: Bruxism and TMD ___ Do you grind your teeth while sleeping? Do your front teeth have a worn look? ___ Have you had jaw muscles or joint pain, ringing in your ears, vertigo, or dizziness?

10: Psychology and Psychiatry ___ Are you irritable upon waking in the morning? ___ Do you experience insomnia (either falling asleep or maintaining sleep) ___ Do you experience: depression, PTSD, memory or concentration problems? ___ Do you take medications for any of these conditions?

11: Chronic Pain ___ Do you often wake up with a headache? ___ Do you experience any chronic pain anywhere in your body? ___ Do you take medications for pain on a daily basis?

12: Pediatrics ___ Do you know any children who are mouth breathers, or who make any sleep breathing sounds? ___ Do you know any children with bedwetting problems?

Sitting and reading ___ Watching TV ___ Sitting, inactive in a public place (theater or meeting) ___ As a passenger in a car for an hour without a break ___ ___ Sitting and talking to someone Sitting quietly after lunch without alcohol ___ In a car, while stopped for a few minutes in the traffic ___

Total ___

DentalSleepPractice.com

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SLEEPbruxism

JEFFORY J. WYSCARVER, RPSGT Interviewed by Michael C. DiTolla, DDS, FAGD

Dr. Michael DiTolla: Many of our readers see the term “sleep bruxism” and wonder what this is?

Jeff Wyscarver: The beginning for me with regards to tackling sleep bruxism came when I started talking to a number of dentists and notable pain clinic specialists who had a desire to be able to measure jaw activity while a patient slept. We introduced a device to dentistry that allowed us to measure the airway and the jaw activity while a patient slept, and this struck a chord with many clinicians.

MD: I’m familiar with the types of devices that can be worn for a sleep study, whether it’s performed overnight in a sleep lab or by the patient at home. How does this device differ from a typical sleep study?

JW: The fundamental difference is that our approach is from the dentist’s perspective and not from the sleep lab’s perspective. For example, I’ll describe a sleep study. Many people are surprised to learn that every full polysomnogram (PSG) done in a sleep lab collects jaw electromyography (EMG) data. Because the medical community doesn’t typically tackle bruxism directly, that data is essentially ignored and used for another reason. We learned that the jaw EMG was clearly in dentist’s wheelhouse. Our device detects obstructive sleep apnea, too, but it also tells the dentist what the

28 DSP | Fall 2014

jaw is doing in relation to the airway. This data is not necessarily collected for the purpose of diagnosing the patient with obstructive sleep apnea (in fact, DDME provides Board-Certified Sleep Physicians for that purpose), but it’s good for a dentist to understand what the airway is doing along with the jaw. I think the primary distinction is that jaw activity is measured on the same time axis as the airway, a bit of useful information for the dentist.

MD: If they’ve always measured EMG data in sleep laboratories, I guess that means they run some of the electrical leads to, say, the face outside of the masseter muscle, for example?

JW: Sleep studies actually measure the chin most often because of that has a unique measurable function during REM sleep. Jaw activity goes down to its lowest level, and the tonic baseline goes back up during non-REM sleep and waking.

MD: Interesting! So they’re actually using the data to determine REM sleep by measuring on the chin, not the masseter. Looking at the incidence of bruxism and obstructive sleep apnea occurring simultaneously, do you see a definite relationship between the two?

JW: In many cases, much more than I imagined, there is a correlation between para-

SLEEPbruxism functional or unusual jaw EMG activity and the presence of obstructive sleep apnea. I’ve been collecting data in conjunction with the dentists that I work with, and it’s unusual not to see some amount of chin EMG activity in the presence of apnea. Getting back to the uniqueness of the jaw musculature, I have learned that the jaw has a direct connection to the arousal response from other muscles in the body. Bruxism in the presence of disordered respirations is closely tied to what we call the “autonomic response,” which is when the body senses something and changes the physiological levels in response. The heart rate goes up, EEG levels change and the jaw participates in the arousal response. There are a variety of theories circling that response, and I think more data needs to be collected.

MD: You mentioned the Bruxism Monitor, which is the name of the device your company distributes. Can you tell me a little bit about how it compares to some of the other devices out there, maybe in terms of size, comfort and what it measures?

functionality of the Bruxism Monitor is that it records the audio of the sleep study. That’s valuable and effective information for two reasons: First, you can play back somebody’s snoring if you have to address patient denial.

The second reason is that when you’re measuring for bruxing, you have to comply with fairly stringent diagnostic criteria set by research done using full PSGs. The Bruxism monitor combines the audio signal, actually catchings the sound of the teeth clenching, which can be correlated with the EMG burst. To my knowledge, we have the only device on the market that can detect these two at the same time.

MD: What does that sound like?

JW: Well, it’s a low, grinding noise, and it’s actually painful to listen to; If you and I were to sit here and grind our teeth, it would be a fairly silent occurrence. But when you listen to nighttime grinding and you hear the teeth crunching, just imagine how much force it takes to produce that noise.

JW: When we decided to go into dentistry, we started out by asking, “What is “...the data collected can be used to the best sleep device out there?” We went through and evaluated a number of devices. improve the decision the dentist makes.”

With the selection criteria that we had, we put a premium on ease of use. The reason for that was we knew we were going to go into a non-sleep-trained environment, and we needed to be able to MD: I guess that could be interpreted to mean that collect good data on someone who has never done a sleep when you’re asleep some of those protective reflexstudy before. es are down, and you’re able to squeeze together Another category that we had was cost per test. There harder than you ever would while you’re awake. were a few devices that passed the ease-of-use category, but JW: Absolutely. We’re collecting a lot of data in the home, were actually quite expensive to use per test. The Bruxism and we’re uncovering some interesting information. If we ask Monitor cost per test was about half that of the remaining a patient wearing a Bruxism Monitor to grind their teeth as devices on our list. hard as they can, we’ll gain a calibrated measurement in miThe last selection category we evaluated was clinical yield, crovolts that records that strongest teeth clench while awake. which is a term we use to describe how much cost and effort it Then when that patient goes to sleep, it’s not unusual to see a takes to get effective, usable data. The Bruxism Monitor scores dramatic increase in that patient’s bite force during the night. very high marks, with a number of internal design features In fact, I would say that in most people that we’ve measured, which give the device a very high clinical yield. That is to say, their bite force is anywhere from 50 percent to 200 percent the data collected can be used to improve the decision the higher while they’re asleep than their maximum force when dentist makes. When we passed the devices through the three- they’re awake. I don’t necessarily have an explanation for this. phase selection criteria, the Bruxism Monitor won out.

MD: Well it sounds like you did a lot of research, and I certainly agree with the qualities you looked for in a unit. Dentists want operational affordability, and the patient doesn’t want to pay a lot to do the test either. So it sounds like your device measures muscle activity to come up with an idea about the bruxism, and it also measures hypopneas and apneas. Is it also able to record snoring or measure the volume of snoring?

JW: Sure it does. One of the features that improves the

MD: So we can measure how loud the snoring is, the apnea-hypopnea index (AHI) and the bruxism. How do you work all three of those factors together? And how do you figure out what type of category the patients belong in?

JW: I’m going to step back just a second and explain my perspective. Coming from a sleep lab in the medical community, we approach medical conditions in a certain way. Now that I work with dentists, I can’t help but impose my medical diagnostic training on this particular problem. We came up with a disposition matrix to manage observed data. The DentalSleepPractice.com

29

SLEEPbruxism Bruxism Monitor reports snoring in decibels. If the snoring is above a certain amount of decibels for a certain amount of time, you say “yes” to snoring. If the patient has an AHI above normal, you say “yes” to apnea-hypopnea index. If the patient has bruxism, and it crosses the mild-to-moderate level, you say “yes” to that. The disposition matrix gives the dentist a map he or she can use to guide the patient’s therapy.

I’ll give you a couple of examples of how the disposition matrix works. Let’s say that a dentist often treats patients with snoring. The monitor gives data about the possibility that the patient also has obstructive sleep apnea. So if the dentist just wants to treat the patient for snoring but the device indicates obstructive sleep apnea along with snoring, using the matrix means they have to put a check there. Now that dentist has to make a decision. Do they just put in a snore guard, or should they have the patient sent for medical diagnosis? I think most would agree the prudent decision would be to manage the apnea, and in the course of managing the patient’s apnea, the snoring will be managed. It’s not necessarily bad news for the dentist, but it’s an example of using efficient and effective information to make a good, sound clinical decision.

MD: Let’s say that the patient also coincidentally has bruxism, but maybe whatever testing device the dentist used gives no indication of whether the patient is bruxing during these obstructive sleep apnea events. When the doctor simply puts in the sleep apnea device, doesn’t it treat the bruxism in a sense because now there’s something in between the teeth?

JW: That is a perfect example of how our diagnostic system works. After therapy is started with an oral appliance, you titrate the airway by taking two or three measurements during the titration process. You’re going to know whether the patient is breathing well and the status of their bruxism.

I can say from personal experience that about half the time, the bruxism does not completely resolve.

MD: Interesting. Everybody seems to agree that continuous positive air pressure therapy (CPAP) is still the gold standard for treating moderate to severe obstructive sleep apnea (OSA). If a physician’s patient goes in for an overnight sleep study do you feel like that treatment completely ignores the bruxism aspect of it?

JW: CPAP is a treatment for a medical condition, and the medical community by and large has handed off any type of issue related to bruxism over to dentistry.

MD: You probably think it’s criminal that we’re not taught about any of this in dental school. Dentists graduate from school and are kind of left to decide if they want to get involved in a field like this. From your perspective, what’s the best way 30 DSP | Fall 2014

for a dentist to gain some knowledge in this area to get started treating these patients?

JW: I would say the vast majority of dentists who educate themselves in managing patients with apnea get their training after they graduate.

I’ll step back and tell a personal story of how I made the decision to go from medical to dental. When I was running sleep labs, we would have case conferences. I would say that 90 percent of patients that we saw had sleep apnea, and as part of diagnosing sleep apnea, we would have a pulmonologist, a psychologist, a psychiatrist, a neurologist, somebody like myself and the director of the sleep lab all sitting around deciding what to do with a patient that had an AHI of 30. It’s a fairly simple decision, so I was frustrated in medicine as to how difficult we made diagnosing people with obstructive sleep apnea. When I made the move to dentistry, I decided to make this as simple and direct as possible. When you have a relatively healthy patient, and they have complaints of snoring or pauses in breathing, I think that a dentist can be the quarterback at managing that patient.

Now, it’s important to understand that I didn’t say diagnose the patient. I said managing the patient’s process of getting treatment. What I say to dentists is: “Keep it as simple as possible. Make sure you don’t do studies on patients you shouldn’t. Make sure the patients that you identify are good candidates for the therapy that you can offer, and if they’re not, you need to find a place for them.” There is some training involved, there’s picking the right oral appliance, there’s getting good information on the patient that you’re treating; and then from that, you’re able to make some very good decisions and manage the patient’s airway.

I’ll make one other comment about dentists managing healthy patients that have obstructive sleep apnea. In the medical community, we’re very much event-driven. By that I mean that we wait for the patient to have an event to respond to it. We treat the symptoms, and we help them through the event. Dentistry’s model is different. Dentists want to see the patient over and over and over again. One of the things that you learn early when you’re treating patients with OSA is that it’s a chronic condition and requires a lot of follow-up. Follow-up is built into the dental business model. I think that’s one of the reasons that dentists are very well positioned to manage people who are healthy and have apnea complaints.

MD: I like what you said about dentists being able to be the quarterbacks of this process and coordinating the treatment, but leaving the diagnosis to the physicians. If dentists reading this want to get more information on the Bruxism Monitor or the services your company provides, where is the best place for them to go?

JW: We have a website at www.ddmeonline.com, where they can find information on our products and services. They can also e-mail us at ddmeonline@gmail.com or contact me on my cell at 951-496-6126.

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PRACTICEmanagement

Rules to Practice in a Dental Sleep Medicine Office

By Glennine Varga

A

s a dental team member, have you ever been given a new task that you don’t know much about? Has your doctor come home from a continuing education course and announced that the office will now be offering X, Y, and Z?! Then it becomes your job to explain the service offering to patients, promote it and become an expert! What?!

Let’s face it, anytime we are given something new, it can seem overwhelming and our natural tendency is to shy away from it. Dental sleep medicine can have this effect on many team members. With this in mind, remember that any new task takes practice and time. Learning about sleep health is an ongoing experience and an educational journey.

Here are nine simple rules to help guide you through your dental sleep medicine journey:

Rule #1: Know your topic.

Sleep disordered breathing is a relatively new field of study. Humans have struggled to breathe during sleep for thousands of years. However, science is just beginning to research it. Learn all you can about sleep staging, sleep breathing and terminology. It is a fascinating topic! The more you know, the better a resource you become to patients.

Rule #2: Engage with patients.

Once you understand how obstructed sleep breathing can impact a person’s overall health and wellness, it will become easier to talk with patients. Cardiovascular disease, diabetes and mood disorders are just a few conditions that are highly correlated with snoring and Obstructive Sleep Apnea (OSA).

Learn the signs and symptoms so that you can start conversations with a simple question, such as, “Have you ever had your sleep evaluated?”

32 DSP | Fall 2014

Rule #3: Master phone and objection skills.

Most patients will be scheduled for sleep consultations over the phone or during an office visit. When scheduling is involved, there will always be questions. Some of the more commons questions and objections are, “How much does it cost?” or “Does my insurance cover it?” Be prepared to answer popular questions and remember that all fees and insurance depend on the patient’s diagnosis and treatment.

Rule #4: Adopt a scheduling model.

There are two types of patients: non-diagnosed and pre-diagnosed patients. It is important for scheduling and maximizing time efficiency to have a protocol for each type of patient. The goal of the non-diagnosed patient is to get him or her diagnosed. The goal of the pre-diagnosed patient is to evaluate if he or she is a good candidate for an oral device.

5 67 8 9

PRACTICEmanagement Rule #5: Be prepared for financial arrangements.

Patients want to know treatment cost(s).

Determine the office fee and keep in mind that when a patient is a candidate for an oral device, financial arrangements will fall under one of four options. They are: fee-for-service, courtesy billing, network billing or Medicare arrangements. Have financial contracts prepared for each option.

Rule #6: Understand medical billing.

This is a big topic. For starters, realize that there is no benefit with DENTAL insurance. However, most MEDICAL insurance policies, including Medicare, allow benefit for oral devices used to reduce upper airway collapsibility. Documentation needed for reimbursement will depend on details found in the patient’s medical insurance policy. The practice’s relationship with Medicare is another big decision point for the doctor.

Rule #7: Teach patients about their condition.

The typical medical model is to diagnose and offer treatment. Teaching patients about their condition and how it may impact their lives is often an opportunity for the dental team to significantly help their patients. Describing what normal results look like and how diagnosed OSA may impact other medical conditions can be a much appreciated service.

Rule #8: Know your therapy.

There are well over a hundred different oral device designs, each with specific protocols for adjusting and long term care. Patients tend to turn to the team with questions on de-

vice specifics. Communicate with your dental labs and learn all that you can about the design your dentist chooses for each patient.

Rule #9: Debrief every case.

When adding a new service to the practice, it is important that everyone understands the steps along the way. Plan a quick huddle to review each dental sleep medicine patient and provide an update of the patient’s progress with therapy along with the administrative part of his or her care. This will give the entire team an opportunity to review office protocols, ask questions and celebrate both patient and team success.

Hopefully, the overview of nine critical rules to follow in dental sleep medicine has been helpful! This sleep team column will be dedicated to the team and provide practical tips and resourceful information in the upcoming issues. Let us know your specific issues by email to Editor@MedmarkAZ.com; while we can’t respond to every individual, your feedback will help us create the most useful Sleep Team Column we can!

Always remember that whether your team consists of two members or twenty-two, you are a TEAM. A team has each other’s back! A solid team spirit will drive volumes of success in dental sleep medicine.

Excellent documentation, clear protocol and patient success should be the culture of the practice. As a team member you have the ability to drive the success of dental sleep medicine in your practice. Enjoy your dental sleep medicine journey and, most of all, take pride in your ability to help people in your community live more full and rewarding lives!

Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain. She has been employed in dental education for over 18 years. Glennine is certified in radiology, electrodiagnostics, expanded duties dental assistant in the treatment of temporomandibular disorders. She has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and has trained the use of electrodiagnostic equipment for five years. Glennine is currently employed, full time, by IDEA Communications including OSA University. Glennine has trained and assisted hundreds of dental offices on practice management, TMD/Sleep Apnea concepts, medical billing and team training.

DentalSleepPractice.com

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PRACTICEmanagement

The Public is Looking For You!

Be Easy to Find!

by Sasha Thompson, M.Ed.

M

ary is fed up with trying to sleep with her husband’s snoring, and he won’t use his CPAP. Searching online, what turns up? Obstructive Sleep Apnea, CPAP alternatives and snoring treatment awareness are on the rise. Searches online are exploding but search engine results are falling flat. While Google Trends show a consistent increase of headline news related to sleep apnea and snoring symptoms as a top related search, store-bought devices currently dominate the Search Engine Result Pages, or SERPs, like Google, Yahoo and Bing. Headline news is pitching home runs with reports of tragedy and illness linked to sleep apnea and sleeping partners are seeking help for peaceful rest online. Dental sleep medicine practices have the opportunity to answer these restless information seekers by fortifying online messaging.After reading this article, you will be able to identify areas of opportunity for improvement in your sleep dentistry practice marketing. This article is a roadmap for creating a website that will convert patients, respond to search engines, and provide a basic understanding of search engine optimization.

34 DSP | Fall 2014

PRACTICEmanagement You have the ability to take control of how many new inbound patient phone calls for patients seeking dental sleep medicine treatment. Your website and SEO are step one. A well-implemented website will give you the ability to turn up the volume of new patient calls like the turn of a dial.

Let’s start with the hub of your marketing; your website. Whether you run radio or print ads, or get a referral, people will typically refer to your website to see if they feel confident in you and learn about the services you and your team can offer them. They scan the photos in search for a warm and competent practitioner accompanied by a patient-centric biography. If your dental practice website has stock photos, replace them with original photography. Hire a reputable photographer who understands dentistry and will work with your marketing consultant. For sleep dentistry, actual patient photos or video testimonials make a powerful connection with the prospective patient seeking help. This also sends a warmer message and outperforms stock photos for search engine optimization. Of course, written permission from the patient is always required for any use of photos or testimonials – an obstetrician has recently been chastised for having a wall of baby photos sent by proud and grateful parents, so be careful.

Your practice website has 8 to 10 seconds to attract your prospective patients, according to Nielsen/Norman Group. If your website visitor stays past 10 seconds, according to the study, they will stay 59 more seconds.

Having video testimonials will be helpful but you also need a well-organized and easy-to-navigate design. For the dental practice, have the core areas of the practice services in separate tabs within the navigation.

For instance, have drop-down menus for general dentistry, sleep dental medicine, and cosmetic dentistry. If the patient can immediately identify a sleep dental medicine practice because there is adequate content, they spend more time on your practice website.

Adequate content for sleep dentistry also establishes your practice as a credible resource for sleep dental treatment they are seeking.

Once you have attracted the prospective patient’s attention, it’s time to ask for the business. Have “call to action” buttons ready to work for you. “Call to action” buttons are prominent graphics that invite an immediate

response. For sleep dental medicine, some relevant Calls to Action might be “Refer a Patient”,” Schedule an Appointment”, or “Help my Husband Stop Snoring!” The number of new patients that schedule from your website’s “call to action” button’ should be reported with tracking tools.

The most common tracking tool is “call tracking.” This is attached to the practice website. As your SEO provider increases your visibility online, the number of calls and online requests from your “calls to action” should be reported monthly. New patient appointment requests should be reported in conjunction with website performance. If you are unfamiliar with SEO and would like to learn the basics, try SEO: The Free Beginner’s Guide from Moz. For dentistry-related services, it is important to note that dentistry is a local healthcare service, so you want to be sure that your vendor provides local search engine optimization so people looking nearby for you will find you. If your SEO provider is also managing your practice social media, stay authentic and avoid canned content.

Limit posts to local community events that relate to your patients.

As Larry Page, one of the founders of Google, explains in his Ted Talk Interview, his company engineers their service to render natural results. The reputable dental SEO provider’s job is to create natural search engine results with technical skill. Your sleep dentistry practice website should be user-friendly, have an easy-to-navigate design, and ask for your new patient’s business with effective “call to action” buttons. You have the ability to take control of your practice and fill in the gap for treatment options for sleep-troubled patients. My hope is when I repeat the same search for sleep apnea snoring symptoms; I’ll find more sleep dental medicine practices on the first pages of the Google, Bing and Yahoo.

Yours should be the first in your area!

Publishing her debut article in Dental Sleep Practice magazine, Sasha Thompson is a consultant and speaker for WEO Media, a Portland, Oregon, dental marketing agency. Her experience in educational psychology and learning theory bring quality educational events as well as insight to patient behaviors and perspectives online relative to the dental practice. Questions can be sent to sashthom@icloud.com

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FOCUSonPRACTICE

Perspective

by Robert R Rogers, DMD, DABDSM

T

his is a particularly exciting time to be involved in dental sleep medicine. We have as they say, reached critical mass. To a meaningful extent we have shown that the concept of oral appliance therapy is legitimate and effective. Most physicians understand this. Most insurance companies recognize this. Many dentists are competent and treating patients effectively.

36 DSP | Fall 2014

FOCUSonPRACTICE

Obstructive sleep apnea is a medical problem and so physicians are therefore the major player in the scheme of things.

Having been involved in this nascent field from the beginning, I can tell you this was not always so. Twenty-five years ago the original pioneers attempted to render therapy with oral appliances having no real support in the published literature. Because of this and the lack of established medical protocol our medical colleagues could not comfortably accept us as team members. And looking back, we had neither the competency nor the effective appliance technology to assume we should be.

Nonetheless, we slowly and surely fought on. We organized an academy and began to work closely with physicians to gradually move forward to where we are today. Without this partnership, it is doubtful that we would enjoy the credible recognition we do today However, the game is not over. In fact, it is really just beginning. As dental sleep medicine evolves still further, challenges remain.

The vast majority of the patients who could truly benefit from oral appliance therapy are not being referred to us. Why is that? What should we do about it? Will insurance carriers consider oral appliance therapy as a firstline treatment and reimburse us reasonably?

Will they impose restrictive regulation? What determines the insurance carrier’s attitude in this regard? Can we do anything about it?

Traditional consensus holds that dentists can treat but not diagnose obstructive sleep apnea. This notion is being intensely scrutinized these days – as well it should be. The American Dental Association and state dental laws define the practice of dentistry in very

broad terms. Might this open the door for us to diagnose and have unfettered access to more patients? After all, we are “doctors” and many of us feel we have a good background in sleep medicine and can render oral appliance therapy with little or no guidance from our medical colleagues. Is this the answer to our dilemma? In reality, this is not the right question to ask. More importantly, we should discern what the consequences would be if we adopted this approach. How would this affect the landscape in which we work? How would physicians react? Does it matter?

Obstructive sleep apnea is a medical problem and so physicians are therefore the major player in the scheme of things. (Yes, the mandible is an important ingredient in the recipe of creating and maintaining a patent airway during sleep, but fundamentally OSA is a medical issue, not a dental one.)

By upsetting our partnership with physicians and beginning to diagnose OSA from purely a dental perspective, we will be seen as dissolving the ties that have served us well in the past. Why should physicians be upset by this? I am reminded of the situation years ago when dental hygienists were keen on setting up independent hygiene practices without any oversight from licensed dentists. It made abundant sense to the hygienists since they are duly licensed to practice hygiene and have been doing so successfully for many years. We as dentists, however felt differently and fought tooth and nail against it. Is it so hard to imagine why physicians might feel uncomfortable if we begin treating obstruc-

Dr. Robert R. Rogers has had a special interest in the treatment of sleep disordered breathing since 1990 and treats patients in conjunction with many regional sleep centers. Presently, he is President and Director of Clinical Services for Pittsburgh Dental Sleep Medicine, PC and limits his practice to dental sleep medicine.

Dr. Rogers is the founding president of the American Academy of Dental Sleep Medicine (AADSM) and served again as president in 1995 and 1999. In addition to being a long-term member of the Board of Directors, he has participated in committee work on a consistent basis. Dr. Rogers is a Diplomate of the American Board of Dental Sleep Medicine and is the recipient of the AADSM Distinguished Service Award.

Dr. Rogers was the author/editor of the original AADSM educational slide series and is a contributing author to the graduate dental text, Clark’s Clinical Dentistry. He is currently the dental consultant to Philips-Respironics, Inc. Dr. Rogers was a member of the task force for the revision of the American Academy of Sleep Medicine Position Paper and Practice Parameters on Oral Appliance Therapy. He also co-authored the American Academy of Sleep Medicine Guidelines for the Evaluation, Management and Long-term Care of Adult Obstructive Sleep Apnea. In addition, he is a consultant for the National Institutes of Health regarding oral appliances as related to the treatment of sleep-disordered breathing.

Dr. Rogers is a frequent speaker at the AADSM Annual Meetings and has presented lectures on oral appliance therapy to physicians, dentists and patient groups throughout the United States and Europe.

38 DSP | Fall 2014

FOCUSonPRACTICE tive sleep apnea with little or no guidance from them? Are we really being treated as second-class practitioners or do we labor under an inflated opinion of ourselves? So the question really becomes not whether we can diagnose OSA but rather, should we? What will we get and what will it cost us?

From a legal perspective, it may be within our scope of practice to diagnose OSA. Recently, some competent dental/legal minds have put forth strong arguments that this is so. Even if it is, a prudent practitioner should wonder if it is defensible in court. Can a dentist satisfy the standard of care as it presently appears in the published literature? The most notable organizations that have addressed standard of care issues indicate that diagnosis of OSA should be made by a physician.

Whether or not this is right or wrong is immaterial. Perhaps subject to change in the future, it is in fact reality at this point in time.

Sleep-disorders dentists are incredibly important players in the treatment mix of obstructive sleep apnea. It is ludicrous to imagine that a medical team could function effectively without a dentist on board.

As such, we should evolve into a position of shouldering more responsibility and having more autonomy for the treatment of our patients. And we should be afforded smoother access to the many people who need our services. However, as dental sleep medicine experiences these natural growing pains, it will serve us best to consider all our options and the consequences of our actions. Simply succumbing to the loudest voices on social media threads may be less than productive in the long run.

The other major player in the treatment of obstructive sleep apnea is the insurance industry. They, after all, control the flow of money. (Yes, certain practices presently exist with a purely fee-for-service scenario but these are few and far between and will shrink into near nothing in the coming years.) As dentists, we are passionate about “running the show” and take great exception when anyone attempts to impinge on our autonomy. Like it or not, the practice of dental sleep medicine is heavily dependent on insurance participation. This is medicine with a dental spin not dentistry with a medical spin.

Our reaction to contemporary issues will not only influence how our medical colleagues relate to us but will also reverberate

throughout the insurance industry. Third-party insurers are intimately concerned with a number of issues that our behavior impacts.

They need to know that their patients are well cared for and that their money is well spent.

We have seen over the years that when competent dentists render proper care following established medical protocol, most insurance companies will indeed pay us somewhat reasonably. Recently however, the insurance carriers are becoming a little skittish due to the nature and increasing number of claims submitted by dentists. The sheer magnitude of claims being submitted is increasing exponentially. On the surface, there is nothing wrong with this. Unfortunately, in conversation with Medicare and other insurers, some claims appear to employ fraudulent coding and are requesting inappropriately high fees.

In addition, healthcare attorneys inform me that companies are springing up that appear to focus on gaming the system through creative, quasi-legal manipulation. The insurance industry is very savvy and they are critically aware of this. It has happened in the past many times in medicine and they know how to deal with it. They reduce fees and institute more and more regulation. It can be argued that much of that is our own fault.

After 25 years, dental sleep medicine is just now entering its adolescence and feels a little off balance as it grows up. Let’s make sure we keep our eyes on the road and our feet on the ground so we can claim our rightful place on the medical team.

Dentists are important players in the treatment mix of obstructive sleep apnea. It is ludicrous to imagine that a medical team could function effectively without a dentist on board.

DentalSleepPractice.com

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LEGALledger

Scope of Practice: The Most Misunderstood Concept in Dentistry

40 DSP | Fall 2014

LEGALledger A dentist’s scope of practice is divided into three separate and identifiable parts: 1. Dental Practice Act/Board of Dental Examiners a. “The Black Letter Law” b. Any rulings of the Board of Dental Examiners 2. Education and training 3. Employer/Insurance a. Limitations placed by the Dentist’s place of employment or insurance coverage.

Dental Practice Act/ Board of Dental Examiners:

Within the definition of the “practice of dentistry” in your state’s dental practice act is the description of your scope of practice. This is the terminology used by your State Board of Dental Examiners to define the procedures, actions, and processes that are permitted by licensed dentists in your state. Most states have adopted the ADA model definition or some variation thereof.

It reads as follows:

by Ken Berley DDS, JD, DASBA

I

t is unusual for a week to go by where I do not read an article or position paper from some organization or association that purports to outline the “Scope of Practice” for some discipline or field of dentistry. As I review these position papers, it is not difficult to identify the agenda of the organization that is proffering the alleged scope of practice proclamation.

We ALL have certain agendas! I am not saying that it is illegal or even wrong to have an agenda. I do however, feel that it is wrong for any organization to imply that it is illegal for a dentist to provide treatment contrary to their self-serving “Scope of Practice – Position Paper”.

ADA’s Definition of Dentistry: The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

Adopted: ADA Resolution 1997 Obviously, this definition is only a model to be referenced by state boards. The ADA’s definition has received favorable review and acceptance by many of them. As you can see, the definition is very broad in scope. Each state’s dental practice act and the included definition of the practice of dentistry, is much like our U.S. Constitution in that it is an evolving document which changes and grows as the practice of dentistry progresses. The definition is written so that it purposefully overlaps other professions. For example, dentists and otolaryngologists have a great amount in common.

All dental practice acts are searchable online making access easy for all practitioners.

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LEGALledger

Each dentist can choose to change his or her scope of practice by becoming competent in a new area of study.

I personally practice in Northwest Arkansas and the Arkansas Legislature has adopted the ADA Model with some modifications.

This is my Scope of Practice: 17-82-102. DEFINITIONS. (1)(A) “Practicing dentistry” means: (i) The evaluation, diagnosis, prevention and treatment by nonsurgical, surgical or related procedures of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body, but not for the purpose of treating diseases, disorders and conditions unrelated to the oral cavity, maxillofacial area and the adjacent and associated structures……..

Notice that my scope of practice is for any type of treatment, of any type of condition, of the “oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body…”

So, any condition that has any oral-facial component is well within the definition of the practice of Dentistry for the State of Arkansas. The State Board of Dental Examiners can then limit these broad privileges if the occasion arises. For example, in my 30 plus years of practicing dentistry, the Arkansas regulations and requirements for providing sedation have changed several times. While sedation broadly falls within the scope of practice for a dentist in Arkansas, the Arkansas Board of Dental Examiners have promulgated regulations defining the educational requirements and office/emergency equipment necessary to provide this service.

Education and Training

As a general statement, one’s education and training is far more important in determining a dentist’s Scope of Practice than your state’s dental practice act, because of the general nature of the definition. In most states, oral surgeons and general dentists both operate under the same definition of the practice of dentistry even though the scope of their practices are vastly different.

So what is the difference? Levels of education! One’s training is the primary determinate in establishing one’s Scope of Practice. Using that premise, it is easy to see that two general dentists practicing next door to each other can have different scopes.

Personally, I love implant dentistry. In our

42 DSP | Fall 2014

office we routinely perform sinus lifts, ridge augmentations, PRP for grafting and wound healing, and placement of implants. I placed my first blade implant in 1984. So the question remains, what is my scope of practice compared to the dentist next door? The difference is the 5000 hours of continuing education which qualifies me to practice at the level that I have chosen.

Therefore, general dentists in the same state can have different Scopes of Practice. Additionally, each dentist can choose to change his or her scope of practice by becoming competent in a new area of study. From a medical/legal stand-point the issue is whether adequate levels of training have been achieved to ensure competence. Each practitioner should be prepared to document his training and experience to the Board of Dental Examiners or a jury if the need arises. In each new area of study, practitioners should document courses taken and the conventions attended keeping a list of the dates of each course and the names of lecturers. Additionally, one should become a member of the prominent professional associations in that area and routinely read the appropriate journals.

Employer/Insurance

As we all know, not all dentists work for themselves. Many of us are employed in various capacities where our employer determines the services and procedures that we perform. In that situation, our employer may limit our scope of practice and establish guidelines for that organization. For example, it is likely within the scope of practice for all dentists to remove impacted wisdom teeth. However, not every office is prepared to offer this service. Limitations placed by the dentist’s place of employment or available insurance coverage, are a real restriction to one’s scope. I would not recommend that any dentist add a new procedure to his practice without consulting his liability/malpractice carrier to ensure coverage.

How do you determine whether a new procedure or service is within your scope of practice?

1. Review your state’s definition of dentistry. a. Within that definition is your “Scope of Practice” b. Review any rulings from your Board of Dental Examiners for restrictions

LEGALledger relative to the therapy/procedure in question. i. If any adverse rulings have been handed down, was the limitation based on education levels or was there a prohibition of that procedure? ii. If the procedure falls broadly within the definition of dentistry and no determination or ruling has been made to the contrary by your Board of Examiners, there is a legal presumption that the technique/treatment/procedure is within your scope of practice.

2. Education: a. Join the major professional organizations in your new area of study. “Look Like You Are One of the Group” b. Read the professional journals regularly and keep notes and abstracts which you can reference for review. c. Attend as many continuing education courses from diverse sources as possi-

ble. Keep copies of the informational flyer for the course for documentation.

3. Employer/Insurance a. Are there any restrictions that have been placed on you by your employer that will limit your ability to provide this treatment? b. Will your insurance company provide adequate coverage for this procedure?

If the answer is no, can you pay an additional premium to get the coverage?

Do State Medical Practice Acts limit my “Scope of Practice”?

This is a common misconception among dentists. Some dentists think they are prohibited from treating any condition that is treated by an MD. This could not be farther from the truth. However, the practice of dentistry and the practice of medicine are governed by separate boards and are regulated separately. It is the intention of state legislatures that the disciplines work together to provide care for our patients. Each state specifically

A Premier Bite Registration System for Treating Obstructive Sleep Apnea: Identify a target treatment position – Measure a Comfortable mandibular starting position in Both Anterior/Vertical alignment and obtain the pre-measured Bite registration.

Every dentist is ultimately in control of his or her Scope of Practice.

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43

LEGALledger exempts the practice of dentistry from any prohibitions expounded within the Medical Practice Acts. After defining the Practice of Medicine, the Arkansas Medical Practice Act provides the following exemptions: 17-95-203. Exemptions.

Nothing herein shall be construed to prohibit or to require a license with respect to any of the following acts: — (3) The practice of the following professions as defined by the laws of this state, which Sub-Chapters 2-4 of this chapter are not intended to limit, restrict, enlarge, or alter the privileges and practice of, as provided by the laws of this state: (A) Dentistry; (B) Podiatry; (C) Optometry; (D) Chiropractic; (E) Cosmetology.

Don’t get me wrong, each dentist must know his limitations. Every day we assess our patient’s needs and make a decision as to whether we are the appropriate practitioner to provide a particular service or treatment.

We are all aware how important it is to know when to refer for traditional dental therapy; sleep medicine is no different. Do what you are qualified and comfortable doing.

Personally, I refer all my patients to a sleep physician if I suspect OSA. Sadly, not all patients accept the referral. Frequently, patients that I have screened for TMD/OSA refuse the referral stating “I am not going to spend the night with all those wires hooked to my brain.” I may have a home sleep test that indicates that the patient has OSA, the patient may have had a full physical by his primary

Dr. Ken Berley is a practicing general dentist with over 30 years of private practice experience focusing on complex reconstruction and 20 years of experience as an attorney licensed to practice law in Arkansas and Texas. He has extensive experience as a litigator and was a full partner in Travis, Borland and Berley, Attorneys’ at Law before moving to Northwest Arkansas. Dr. Berley lectures in the area of sleep medicine risk management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years.

Disclaimer: This article reflects Dr. Berley’s opinion. It is not legal advice. The reader should contact an attorney in their state with experience practicing before their state dental board for legal advice.

44 DSP | Fall 2014

care physician within the last year showing no co-morbid diseases, yet a thorough reading of all documents, position papers and practice parameters of the AADSM/AASM seems to indicate that I cannot treat this patient with MILD OSA and be compliant with AADSM Practice Parameters. So, what do we do with these patients? Do we send a letter to their PCP and try to get a prescription? If so, what do we do about the requirement for a face to face evaluation by a physician? It doesn’t matter that the patient wants me to treat him. AADSM practice parameters state that a patient with OSA must be evaluated and monitored by a physician who is very knowledgeable in sleep. I am well aware that many dentists try to get around the face-toface physician exam and diagnosis by using an outside HST diagnosis service, however, in my opinion, they could be in breach of the standard of care as they have failed to comply with the AADSM/AASM requirement of physician evaluation, monitoring, and final PSG. These practitioners could be vulnerable to lawsuits. Without a doubt, the treatment of OSA is within my scope of practice and legally I do not need the permission of a Sleep Physician to practice dentistry as defined by the Arkansas Dental Practice Act. However, until our standard of care is better defined we are required to work around the various position papers that have been published.

The AADSM Practice Parameters would likely be introduced into evidence as your standard of care. Be aware, this opinion has not been tested in court and therefore is subject to rejection. However, in the next edition of Dental Sleep Practice, I will explore a method that I feel is legally defensible for the utilization of non-sleep physicians for patient intake and monitoring.

In Conclusion: Every dentist is ultimately in control of his or her Scope of Practice.

Very few limitations have been placed in our way. In my opinion this has been purposefully done to encourage each practitioner to expand his or her knowledge and abilities to the fullest. We should not become stagnant!

It’s up to you, and your state’s Board of Dental Examiners, to dictate your “Scope of Practice”. In my career, I have repeatedly been told that I cannot perform certain procedures because I am “Just a Dentist”. These encounters have provided an incentive to expand my level of knowledge.

LEGISLATIVEmatters

Making A Difference In Washington

by Congressman Marty Russo

I

’ve spent my career in politics and government with eighteen years in the U.S. House of Representatives and twenty-two years as a top lobbyist. My message to you is that what happens in Washington matters. The best way to impact federal policy making is to get involved. You can make a difference.

There is a lot of activity in Washington these days around legislating and regulating sleep apnea and transportation safety.

I can tell you that there are large gaps in understanding among federal policy makers regarding the latest advances in dental sleep medicine. There is no consensus among all the federal players as to how to best approach the issue of sleep apnea.

The good news is that this lack of consensus gives you an opportunity to have your voice heard. Here’s an inspiring story about how one organization made a difference in federal policy.

I first met the leaders of the American Academy of Craniofacial Pain (AACP) when receiving treatment for sleep apnea from Dr. Elliott Alpher of The Alpher Center in Washington, D.C. Dr. Alpher told me that the U.S. Department of Transportation (DOT) was actively preparing to issue policies covering commercial truck drivers and sleep apnea. The DOT was concerned about truckers falling asleep at the wheel and causing accidents.

Here’s the problem. The proposed policy was based on old medical data from 2008. There was no input from any experts on oral appliance therapy. The DOT believed that oral appliance therapy has “no method to monitor compliance.”

We know that there have been huge leaps in technology since 2008. Oral appliances are in fact a highly effective treatment for sleep apnea. Studies show oral appliances have a high compliance rate, compliance can be tracked and sleep stud-

46 DSP | Fall 2014

ies can now be held in the home. In short, had the DOT been able to implement that original policy, the government would be doing a disservice to truckers by excluding oral appliances as an acceptable treatment.

The leaders at the AACP got into action to tell the DOT the other side of the story.

A meeting took place on July 11, 2013 with over a dozen people present. The message was simple. Oral appliances have an important role to play in treating sleep apnea in truckers. Any policy that excludes oral appliances is a bad policy.

As a result of that meeting, the DOT is now a believer. They have the latest science on oral appliances and how they can be used in the treatment of sleep apnea. The AACP made a difference and played an important role in preventing bad policy from going forward.

In fact, so many groups spoke up about the proposed DOT policies that Congress got involved. Legislation was enacted that requires the DOT to go through the rulemaking process before issuing any policies on sleep apnea in truckers.

A rulemaking process means that the DOT has to do the following: • Hold an open, public process that ensures all viewpoints are heard • Explore all alternatives including less intrusive methods of treatment • Conduct a cost-benefit analysis This is going to take at least three years.

It gives the AACP and others in the dental sleep field time to offer additional expertise and commentary so that any regulatory

LEGISLATIVEmatters outcome includes a level playing field for oral appliance therapy.

Do you want to have your voice heard in Washington on sleep disorders?

Start by researching what the federal government is doing about sleep disorders.

Then, take the time to get involved.

I urge you to develop a relationship with your own Member of Congress and his or her staff. That Member is your single best source of help. If you haven’t met him or her, you should. If you belong to an association or academy, contact them to find out how they are being active in federal government issues. Offer your help.

When you speak with people, educate them on your issue. Public officials don’t know all that you know. Find out their questions and concerns. Understand all sides of the issues and not just your own point of view. Be respectful and helpful.

I always tell my lobbying clients that it’s important to become part of the solution

and not part of the problem. You do this by offering to provide relevant scientific information so that good decisions can be made, not by criticizing and complaining.

At this point in my career, I spend a lot of my time giving back by speaking to groups about how to make a difference in Washington. The crowd favorite is a fun presentation titled, “If You’re Not At The Table, You’re On The Menu.” My parting advice to you is that when it comes to treating sleep disorders, you want to be at the table with federal bureaucrats – not on their menu!

Congressman Marty Russo (retired) is a frequent speaker and lecturer about how to get things done in Washington. He draws on his years in Congress and as a top lobbyist to give insider tips for being an influential federal advocate.

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DentalSleepPractice.com

47

SLEEPq&a

Ez SLEEP PILLOW TALK™ iDentifySleep™ Training Series: Sleep Disordered Breathing (SDB) Basics An interview with Drs. Justin A Fu, MD, FAASM and Payam Ataii, DMD Q. Why is snoring of interest to me and my patients?

Snoring may be disruptive to the quality of your patients’ sleep. Snoring may also be a sign of a serious medical problem.

Q. What is snoring?

Snoring sounds are caused by airway tissues vibrating in response to narrowing of the airway during sleep breathing. These sounds are rarely troublesome to the snorer but may be to the bed partner.

Q. Why is snoring considered a sign of a serious medical problem?

Snoring may be a sign of sleep apnea, which results in poor sleep quality and can lead to excessive daytime sleepiness.

Being fatigued is a major cause of work-related accidents, car crashes, and loss of production.

Q. What is sleep apnea?

Sleep apnea is a potentially life-threatening condition that requires immediate medical attention. In fact, patients diagnosed with Obstructive Sleep Apnea (OSA) can’t breathe despite effort several times an hour for 10 seconds or more – sometimes, hundreds of times per night – preventing the brain and the rest of the body from getting sufficient oxygen.

when the soft tissue and/or tongue collapse during sleep.

2. Central Sleep Apnea: As a result of instability in the respiratory control center, the brain does not signal the muscles to breathe, despite an open airway.

Q. Who is at risk for Obstructive Sleep Apnea?

Q. How is sleep apnea categorized?

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48 DSP | Fall 2014

Sleep apnea is categorized in one of the following forms: 1. Obstructive Sleep Apnea (OSA): Is the more common of the two forms of sleep apnea. Generally, OSA is caused by a blockage of the airway,

Anyone at any age can have obstructive sleep apnea. Common risk factors for sleep apnea include: • Large neck size • Large tonsils, a large tongue or a small jaw bone • High-vaulted upper arches • A family history of sleep apnea • Gastroesophageal reflux (GERD) • People whose bed partner has observed choking, gasping or loud snoring • Nasal obstruction (deviated septum, allergies or sinus problems) • Overweight or obese • History of Hypertension, Chronic Heart Failure or Chronic Obstructive Pulmonary Disease (COPD)

SLEEPq&a

EzSleep ARES Sleep Study Report Patient Name Date of Night 1 Date of Night 2 Overall AHI 6

Study Ordered by Date of Birth Identification Number

Arzilli, Jacqueline 08/23/2012 08/24/2012 Overall RDI 14

% time < 90% SpO2 0.6 %

VEGA, FREDRICK 9/27/1953

Mean SpO2 95.8 %

% time snoring > 30 dB 29.5 %

PHYSICIAN INTERPRETATION AND COMMENTS: Findings are consistent with mild, non-positional obstructive sleep apnea (OSA).

CLINICAL HISTORY: 58 year old female presented with: 14.3 inch neck, BMI of 38, an Epworth sleepiness score of 17, Q. the Sleep Apnea history What of hypertensionis and symptoms of nocturnal snoring, waking upprevalence? choking and witnessed apneas. Based on the clinical history, the patient has a high pre-test probability of having moderate OSA.

Sleep Apnea & Bruxism Photo courtesy of Dr. Ataii case #114, #96

Q. What are the common signs and symptoms of Sleep Apnea?

• Loud snoring • Choking or gasping during sleep • Fighting sleepiness during the day (even at work or while driving) • Morning headaches • Memory or learning problems • Feeling irritable • Inability to concentrate • Mood swings, personality changes, feelings of depression • Dry throat when waking up • Frequent night-time urination

Cardiac Problems

Snoring

Memory Problems and Inability to think correctly

Stroke

Depression

Obstructive Sleep Apnea

High Blood Pressure

Increased Insulin Resistance

• Over 18 million Americans suffer from sleep apnea • An estimated 12 million Americans remain undiagnosed • Over 50% of all apnea cases are diagnosed in people aged 40 and over

SLEEP STUDY FINDINGS: Patient underwent a two night Home Sleep Test and by behavioral criteria, slept for approximately 9.7 hours, with a sleep latency of 3 minutes and a sleep efficiency of 91.3%. Mild sleep disordered breathing (AHI=6) is noted based on a 4% hypopnea desaturation criteria. The patient slept supine 21.9% of the night based on valid sleep time of 9.7 hours and is 1.1 times as likely to have apneas/hypopneas when supine. When considering more subtle measures of sleep disordered breathing, the overall respiratory disturbance index is also mild (RDI=14) based on a 1% hypopnea desaturation criteria with confirmation by surrogate arousal indicators. The apneas/hypopneas are accompanied by minimal oxygen desaturation (percent time below 90% SpO2: 0.6%, Min SpO2: 87.0%). The average desaturation across all sleep disordered breathing events is 2.6%. Snoring occurs for 29.5% (30 dB) of the study, 8.5% is very loud. The mean pulse rate is 61 BPM. TREATMENT CONSIDERATIONS: Consider nasal continuous positive airway pressure (CPAP/AutoPAP) as the first treatment option based on the AHI severity, daytime somnolence and co-morbidities. A mandibular advancement splint

(MAS) or referral to an ENT surgeon for modification to the airway should be considered to reduce daytime somnolence and Q. How is Sleep Apnea the potential contribution of OSA on existing diseases ifdiagnosed? the patient prefers an alternative therapy or the CPAP trial is unsuccessful.

Sleep apnea is diagnosed by a properly trained sleep phyDISEASE MANAGEMENT CONSIDERATIONS: None. sician through the use of testing equipment designed to measure sleep breathing patterns. Testing may be performed at a Signature: Date: 08-30-2012 13:37:40 PST sleep laboratory via a Polysomnogram or at the patient’s home Study Review: The raw data of this ARES study has been reviewed, with the report confirmed and electronically signed by Justin Fu. Caution:The FDA-cleared diagnosis of the Obstructive Sleep Apnea Syndrome mustsleep be based on all available clinical data, of which this study is only a using ambulatory testing equipment. part. Thus final diagnosis and treatment recommendations should include information from an examination of the patient by a knowledgeable physician.

ARES Traceability: 20120830202044_88e685f5-15f2-e111-afd0-005056b845be_N1.ASI; 20120830202044_88e685f5-15f2-e111-afd0-005056b845be_N2.ASI;

Q. What is in Home Sleep EzSleep Testing (HST)?

Sleep Study Report A home sleep test isARES a simple-to-perform diagnostic proJohn, Sample Smith cedure that58 patients can take in the comfort of their own Age Gender Female Height (in) 60 BMI 38 home.

While sleeping, the 14.3 home sleep test device monitors Weight (lbs) 192 Neck Size (in) OSA Risk High Risk Pred.

Severity Moderate the patient’s sleep patterns to include any pauses in their HBP Yes Heart Disease No breathing.

These FDA-cleared devices are designed to proDiabetes No Depression No Stroke No Epworth 17 vide data for physicians toFrequently diagnose sleep breathing patterns.

Snoring Frequency Patient Name

Gasping or Choking

Frequently

Observed to stop breathing during sleep

Sometimes

Study Date: 08/23/2012 Sleep Disordered Breathing events

Death Oxygen Saturation

Hormone Disruption

Increased traffic and workplace accidents

0 0 7 17

Mean

95.4

Min % <90% % <85% Mean dip

87.0 0.9 0.0 2.7

Supine Time(hr) % time Sup-NS Ratio

2.1 33.4 1

Head Position

Awake / Sleep by actigraphy

Time(hr)

Q. What causes Sleep Apnea?

Under healthy airway conditions during sleep, muscles keep the throat open and tongue clear of the airway so that oxygen flows into the lungs. In Obstructive Sleep Apnea, however, the throat briefly collapses or the tongue blocks the airway causing a complete blockage of airflow. Along with those pauses in breathing, the oxygen level in blood may drop significantly.

Cnt.Index ApI AHI RDI

Record Sleep % Eff. % REM

7 6.3 90.5 15.5

% >30dB

33.8

% >40dB

12.5

% >50dB

1.9

Mean Min Max Arousal/hr

59 45 77 17

Snoring with arousal indications

Pulse Rate with arousal indicators

Excluded from analysis (Valid Time = Sleep Time minus Excluded "All") Home Sleep TestSleep Report

% excluded Airflow

0%

SpO2

15.8%

All

Patient Name

Study Date: 08/24/2012 Sleep Disordered Breathing events

John, Sample Smith

Age

0%

DentalSleepPractice.com 58

Gender

49

Female

SLEEPq&a Q. What are the benefits of a Home Sleep Test (HST)?

1. The patient self-administers the home sleep test, and is able to spend the night in his/her own bed in familiar surroundings.

2. Home sleep testing can be especially advantageous to the homebound elderly who require specialized care such as a nurse or family member spending the night, expensive transportation costs, etc.

3. HST is also beneficial for those with trouble arranging time out of their schedules to spend the night in a lab.

4. The typical cost of a home sleep test is only a fraction of the cost of an in-lab sleep study, and yields effective results in the diagnosis of Obstructive Sleep Apnea.

when the patient cannot tolerate the use of a CPAP machine.

Oral appliance therapy involves the selection, fitting and use of a specially designed oral appliance that maintains an open, unobstructed airway in the throat when worn during sleep.

Q. What is the Dentist’s role in identifying patients with Sleep Apnea?

Dentists may detect the less evident symptoms of sleep apnea through a candid conversation with their patients during an exam that addresses the patient’s concerns and dental health details. A dentist may suspect a patient suffers from sleep apnea if the patient complains about lethargy, morning headaches, or dry mouth (typically caused by open mouth breathing during sleep or heavy snoring).

Q. Why do over 10 million Americans with Sleep Apnea remain undiagnosed?

Many sleep apnea patients remain undiagnosed because most often doctors are not properly trained on identifying patients with sleep apnea during a routine office visit.

Sleep Health Questionnaire M Name

F

Gender

DOB

Address, City, State, Zip

Weight

Cell Phone

Alt. Phone

Height

Email

PPO Medical Insurance Company (PPO Only)

ID#

Group#

Section 1 - Patient Sleepiness Scale: Step 1: Answer “Yes” or “No” for the following questions (circle Y or N). If you answer “yes” also circle the corresponding points in the column to the right.

Step 2: Total the points that you circled in the right column and record score in the space below.

Have you ever been told you stop breathing while asleep?

Y or N

8

Have you ever fallen asleep or nodded off while driving?

Y or N

6

Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing?

Y or N

6

Do you feel excessively sleepy during the day?

Y or N

4

Do you snore or have you ever been told that you snore?

Y or N

4

Have you had weight gain and found it difficult to lose?

Y or N

2

Have you taken medication for, or been diagnosed with high blood pressure?

Y or N

2

Do you kick or jerk your legs while sleeping?

Y or N

3

Do you feel burning, tingling or crawling sensations in your legs when you wake up?

Y or N

3

Do you wake up with headaches during the night or in the morning?

Y or N

3

Do you have trouble falling asleep?

Y or N

4

Do you have trouble staying asleep once you fall asleep?

Y or N

4

Risk Level - Score Low - 0-7 Moderate - 8-11

High - 12-15

Score

Severe - 16+

Section 2 - STOP-BANG Scale: Step 1: Answer “Yes” or “No” for the following questions (circle Y or N). YES to 3 or more questions means you are at high risk.

Do you SNORE loudly (ie, louder than talking or loud enough to be heard through closed doors)?

Y or N

Do you often feel TIRED, fatigued, or sleepy during the day?

Y or N

Has anyone OBSERVED that you have stopped breathing while sleeping?

Y or N

Do you have or are you being treated for high blood PRESSURE?

Y or N

BMI more than 35 kg/m2?

Y or N

Are you more than 50 years of AGE?

Y or N

Is your NECK 17 inches or greater for men (16 inches for women)?

Sleep Health Questionnaire Proprietary for Ez Sleep Client Only

Y or N

Male GENDER?

Y or N

Section 3 - Signs & Symptoms (Check all that apply):

Section 4 - Sleep History (Check all that apply):

n Hypertension

n Snoring

n Diabetes

Have you ever been diagnosed with a sleep disorder? n Yes n No

n Depression

n Grind Teeth

n Acid Reflux

Are you currently using a CPAP machine?

n Yes n No

Do you use your CPAP less than 5 times a week?

n Yes n No

Would you prefer an oral appliance?

n Yes n No

n Stroke/Heart Disease

n Unrefreshed Sleep

n Family history of Snoring or Sleep Apnea

Please Present Completed Form, ID & PPO Medical Insurance Card to Front Desk to Allow for Copies

Fax: 888-999-1887

Phone: 888-240-7735 SHQ Page 1 of 2

Rev. 6.12

Q. Are there enough doctors in America to treat sleep apnea?

Despite the fact that there is a growing awareness of sleep disorders and the number of persons that suffer from this condition is very prevalent, there aren’t enough physicians and dentists addressing this epidemic.

Q. How do dentists treat patients with sleep apnea?

Dentists may treat patients that suffer from sleep apnea through the use of FDA-cleared oral appliances. In fact, the American Academy of Sleep Medicine promotes the use of oral appliances as a viable option for patients that suffer from mild-to-moderate obstructive sleep apnea or severe patients

50 DSP | Fall 2014

If the patient shows enough risk of suffering from a sleeping disorder, dentists may prescribe a sleep study for the patient to rule out the condition.

It should be noted that dentists are often the first professional to become aware of a potential problem since they are usually in contact with their patients more frequently than physicians.

Q. How do I learn more?

Give yourself 45 minutes and find out how to “DEMYSTIFY DENTAL SLEEP MEDICINE” – A FREE WEBINAR SERIES PRESENTED BY Ez SLEEP Register for a free, 1 CE Credit, 45 minute webinar: Online: www.ezsleeptest.com/pillowtalk Email: webseries@ezsleeptest.com Phone: (888) 240-7735 Instructions on how to receive your CE Credit will be provided during the live webinar session.

IMPLEMENTATIONinsight

Dental Sleep Medicine Implementation: Puzzle or Mosaic?

by Dr. Gy Yatros

T

he clinical aspects of Dental Sleep Medicine (DSM) are relatively simple. There, I said it. From a clinical standpoint, DSM is much simpler than placing an implant, prepping a crown, or mounting casts for a full mouth rehab. If DSM is one of the most rewarding services that a dentist can bring into their practice then why aren’t more offices offering these services? And, why do many motivated offices eventually fail to realize their DSM vision? Is it because of commitment issues, clinical challenges, software, team education, testing issues, medical insurance billing, TMD management, or a myriad of other challenges? After consulting with thousands of dentists around the United States, I can tell you, the answer is simply ‘YES’ to all of the above.

In Dental Sleep Solutions’ collective 20+ years immersed in DSM, Dr. Richard Drake and I have discovered that to successfully practice DSM, only two things are mandatory; commitment of the dentist and the dental team and implementation of successful systems. Too often, we see dentists that attend a weekend program and return to the office on Monday only to encounter resistance and a lack of team buy-in. This is the death knell for the fledgling DSM practice.

Everyone must be on board. For those practices that achieve their DSM success the time and effort is always well worth the investment. Without this commitment to education and systems implementation involving screening, testing, communication, treatment, and follow-up, practices will fail. You know what motivates your team. Appeal to those sensibilities and get everyone revved up to move forward.

Once commitments have been made and a unified mission established, the next hurdle is implementation of simple, proven, repeatable systems. Each individual piece of this mosaic may be a minor hurdle but when viewed in aggregate, it often becomes an overwhelmingly complex puzzle.

Simplifying the pieces into repeatable systems results in a checklist to success that can make nearly anyone successful.

The challenges are the same for nearly everyone. How do you: • Identify these patients?

• Screen them?

• Get them tested without them falling into the “black hole of CPAP?” • Set appropriate fees?

• Present the case to increase patient acceptance?

• Decide which device to use?

• Mitigate side effects?

52 DSP | Fall 2014

• Decide on how and when to advance the device?

• Do follow up (titration) testing?

• Receive medical insurance reimbursement for your time and expertise?

• Document treatment?

• Communicate with referring physicians?

Once the challenges are understood a simple repeatable system for each hurdle should be defined. The entire team should be aware of these systems and what happens at each juncture. Falling short on just one hurdle can stop a DSM practice dead in its tracks. Imagine that you have your team educated, you begin to understand the links between OSA and medical comorbidities, you implement a seamless screening process and you now have patients who are ready to be tested!

The patient eagerly approaches your front desk expecting your team to be ready to help coordinate the sleep test but instead there is confusion and the patient leaves without direction.

This type of issue can occur at any step of the patient flow if systems aren’t clearly defined and followed by the entire team.

The bottom line is that providing sleep medicine in the dental office will flounder unless all the aspects are covered.

In subsequent issues, we’ll highlight DS3, an extremely effective implementation system that seamlessly provides solutions to all of the aforementioned hurdles, empowering you and your team to make dynamic strides towards realization of your DSM vision. From team education and pragmatic checklists to simple tools for every step from screening to testing to device selection and claims submission, DS3 is the most comprehensive Dental Sleep Solution available via the cloud or anywhere else. Stay tuned for the next issue when I’ll describe screening and testing protocols through the DS3 system.

PRODUCTprofile

MicroDental Introduces MicrO2™

T

he first CAD/CAM milled Obstructive Sleep Apnea device, MicrO2 is FDA cleared and offers dentists a new, innovative option for treating the growing number of patients diagnosed with Obstructive Sleep Apnea (OSA).

“The lingual-less design of the MicrO2 device ensures that tongue space is optimized and the comfortable, balanced, physiologic jaw position is maintained.”

Dr. Anne-Maree Cole, BDSC, LVIM

54 DSP | Fall 2014

“Dentists are the front line for screening and managing patients with Obstructive Sleep Apnea,” noted Kim Bradshaw, CEO and President of MicroDental Laboratories.

“Many of our partner dentists asked for a small, precise, and easy to use Mandibular Advancement Device. The MicrO2 device has been designed from the very beginning with these goals in mind.”

“I believe the MicrO2 will revolutionize dental sleep medicine,” stated Dr. William G. Dickerson, DDS, FAACD, LVIM. “I can honestly say that I don’t think there is a better appliance out there. With its lingual-less design, airway constriction preventing fins, and unobtrusive size, this device is a winner.”

Featuring a patent pending design and a precision milling production process, the MicrO2 is able to utilize a PMMA material that is cured under controlled conditions.

These aspects allow the MicrO2 to be small yet strong, precise, and predictable. The MicrO2 also features a unique approach to titration that is intended to make the device easier to use for the dentist and the patient.

“The MicrO2 does not require patients to manage any mechanical adjustments, such as turning screws, or changing positions with elastics. Instead the MicrO2 comes with one pair of Upper and Lower arches set to the prescription, and a second pair set in any amount of advancement increments.

Advancements are easily achieved by simply removing the current Upper or Lower arch device and inserting the next advancement device in the MicrO2 series,” commented Laura

Sheppard, Sr. Director of Compliance and Regulatory Affairs for MicroDental.

“It is important to treat Obstructive Sleep Apnea while also minimizing the risk of TMJ and other related cranio-facial complications,” testifies Dr. Anne-Maree Cole, BDSC, LVIM of Queensland, Australia. “The lingual-less design of the MicrO2 device ensures that tongue space is optimized and the comfortable, balanced, physiologic jaw position is maintained. The CAD/CAM design optimizes outcome but minimizes bulk – a true break through advancement in the treatment of snoring and Sleep Apnea.”

Obstructive Sleep Apnea is one of the fastest developing frontiers in dentistry. A report by the Institute of Medicine estimates that 50-70 Million Americans suffer from chronic sleep disorders. More than 18 million Americans have Obstructive Sleep Apnea. Obstructive Sleep Apnea has been linked with snoring, memory loss, headaches, depression, and an increased risk of stroke, heart problems, and motor vehicle accidents.

“MicroDental Laboratories has a legacy of partnering with dentists who are committed to enhancing the lives of their patients,” noted Len Liptak, VP of Sales and Marketing for MicroDental. “With our FDA-cleared MicrO2 device, we look forward to partnering with these dentists as they manage the growing number of patients who are diagnosed with this serious condition.”

w

N EW MicrO2 SLEEp DEvIcE. More sLeep. Less HassLe.

fda cleared & patent pending design

Digital simplicity and precision make the new MicrO2 OSA device the comfortable choice for dentists and patients. advantages

How effective are Cpap or sleep Devices if patients do not wear them? or if it is difficult for patients and dentists to use or adjust the device? With the goal of answering these questions, and more, the new Micro2 sleep Device offers:

Digital Simplicity Small yet Durable

Digital Simplicity. The first CaD/CaM milled osa device, Micro2 is precise, predictable, and easy to use.

eaSy to aDjuSt preciSe anD preDictable one-piece, lingual-free DeSign

comfortable profile. The only osa device made from control-cured pMMa, Micro2 is compact without compromising durability or retention.

Easy Adjustment. Featuring an adjustment method similar to changing aligners, Micro2 has a one-piece construction with no moving parts.

no moving partS biocompatible

Lingual-Free Splint. Micro2 offers a lingual-free design that is intended to offer the patient maximum tongue space.

Expert Design. The Micro2 design is based on the clinical expertise of leaders in the field of Dental sleep Medicine.

Learn more about how MicrO2 might fit into your practice.

Š2014_MDL_140858

Contact an authorized MicroDental Network Lab for more information and to pre-schedule a case.

USA, NATIONwIDE ......................800.229.0936 Boston, Ma (MicroDental)...................800.229.0936 Chicago, IL (MicroDental Chicago)........888.622.7835 Cincinnati, oH (Mitch Lab)..................800.767.5303 Dallas, TX (Westbrook Lab)...................800.718.3384 Detroit, MI (Ward Lab)..........................800.833.3865 Hermiston, or (Aesthetic Designs Lab) .541.567.1667 Indianapolis, IN (Mitch Lab)................800.767.5303 Lansing, MI (Precision Lab)...................800.292.0855 Las Vegas, NV (MicroDental at LVI).......800.933.6838 SMILES MATTER MicroDental.com SM

Los angeles, Ca (MicroDental)...................800.229.0936 Louisville, KY (ADL Lab)...............................800.456.1292 raleigh, NC (MicroDental Research Triangle) ..800 .840. 2651 rochester, NY (CQCLab)..............................800.724.1058 seattle, Wa (DiMartino Lab)..........................800.562.0300 saint paul, MN (Hermanson Lemke Lab).........800.328.9648 salt Lake City, UT (MicroDental Salt Lake)......888.344.9991 san Francisco area, Ca (MicroDental).......800.229.0936 st. Louis, Mo (Donnell Lab)..........................800.344.7866 Washington, DC (MicroDental)...................800.229.0936

SLEEPhumor

...The Lighter Side of Sleep Apnea

56 DSP | Fall 2014