Dental Sleep Practice - Fall 2015

MMA Surgery for OSA

by Jeffrey R. Prinsell, DMD, MD

What Documentation

Does a Physician Want from a Dentist?

by Rose Nierman

PLUS

FALL 2015

WEIGHT LOSS SURGERY Helps with Airway Management

by Brian Sung, MD

Using Overnight Pulse Oximetry to Manage OAT

Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Ronald S. Prehn, ThM, DDS

INTRODUCTION

What Else Is There?

D

entists learn skills with acrylic early in training – I think I spilled my first bottle of monomer in my second week at Baylor – and we tend to concentrate on doing what we know and what we are good at.

Oral Appliance Therapy is a perfect example – ordinary dental skills applied in new ways to help patients overcome anatomic problems with the airway, yielding health benefits far remote from the oral cavity. Every time I sit with a young person, however, I’m fully aware that providing this vitally necessary means of airway management also invites unwanted guests to the party – muscle problems, structural changes, shifting bites, and other common complications.

Wouldn’t it be better to fix the problem in the first place? Seems a simple thing to say, but what does that mean? Often, it refers to correcting the structural problem that causes the narrow airway in the first place. You know the patient – narrow, restricted maxilla, mandible that positions the genioglossus too far back in the oropharynx. Dentists all know about maxillomandibular surgery from orthodontic training – back in the day, it was therapy to fix the bite, or for esthetics. Today, we add to that correcting the structural impact on airway.

This issue of DSP includes essays from two brilliant surgeons who explain about MMA surgery so dental teams can have a good discussion with their patients. While some sleep physicians are well versed in jaw surgery, and certainly otolaryngologists are, discussing the finer points falls clearly in our field. Speaking of ENT, we’ll have a whole issue devoted to this topic down the line.

Obesity and OSA are closely tied, of course; weight loss (bariatric) surgery is one

of the most successful means of impacting OSA for the morbidly obese.

Do you know bariatric surgeons in your community? Here’s an essay to help you get a handle on this important treatment strategy.

In the bigger picture, dentists are becoming increasingly seen as vital members of the sleep therapy team.

This year the American Thoracic Society convened a special section of their convention to bring dental leaders together with their officers to explore Steve Carstensen, DDS how learning together benefits all par- Diplomate, American Board of ties. Kudos to Drs. Jim Metz and Fer- Dental Sleep Medicine nanda Almeida for spearheading this effort. The American College of Chest Physicians went looking for a new Education Coordinator and hired Dr. Rich Schuch, who has led the American Dental Association to exemplary CDE for the past 9 years. The Dentists are California Sleep Society has engaged Dr. becoming Todd Morgan to create a whole dental section of their website so dentists will see that increasingly seen they, too, belong in this group. I hear of as vital members sleep societies, formerly mostly respiratory therapists and polysomnographic technolof the sleep ogists, embracing sleep docs and dentists therapy team. across the country to engage in the mission we share: to enable better breathing to allow better sleep.

It’s never been a more exciting time to be a dentist treating sleep disordered breathing!

Thank you for looking to Dental Sleep Practice Magazine as part of your connection to this thrilling field.

Do you like what you are reading in DSP? Do you have ideas you want to share about what works in your practice? I would be happy to consider essays from any reader! Don’t be shy – we’ll help polish your ideas and spread the wisdom of Practical Sleep Education. Contact me at SteveC@MedMarkAZ.com.

DentalSleepPractice.com

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CONTENTS

10

Cover Story

What Documentation Does a Physician Want from a Dentist?

by Rose Nierman, CEO Nierman Practice Management

6

Jaw Surgery

Telegnathic Maxillomandibular Advancement (MMA) Surgery for OSA

by Jeffrey R. Prinsell, DMD, MD What do you say when people ask “Which treatment works best?”

30

Case Report

Using Overnight Pulse Oximetry to Manage Oral Appliance Therapy during Treatment for Obstructive Sleep Apnea

by Ronald S. Prehn, ThM, DDS Measuring progress helps the clinician and the patient guide therapy.

2 DSP | Fall 2015

26

Weight Loss

Weight Loss Surgery Helps with Airway Management

by Brian Sung, M.D. There’s more to surgery than the airway.

You need to know about this!

52

Legal Ledger

Insurance Fraud: Are You Guilty?

by Ken Berley, DDS, JD, DABDSM Sleep well when you know your policies are audit-proof.

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CONTENTS

20

Sleep Study

Your Patient Needs an Overnight Sleep Study.

What Should You Say?

by Dave Shirazi, DDS, MS, MA, LAc, RPSGT, DABCP, DABC-DSM How a Dentist who is also a Sleep Technologist prepares patients for the process.

14

Case Report

Nasal Surgery and Oral Appliance Therapy:

Fall 2015 Publisher | Lisa Moler Email: lmoler@medmarkaz.com

44

Editor in Chief | Steve Carstensen, DDS Email: stevec@medmarkaz.com

Reaching Out

Bring on the Snorers:

A Case for Entry-Level Sleep Collaboration is Key to Success Disordered Breathing Products

by Daniel Klauer, DDS, DABCP, in the Dental Practice DABCDSM Addressing the upper airway using best skills of two experts.

by Patrick Tessier, MBA Using other people’s money to build your sleep practice.

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46

Jaw Surgery

Team Focus

Which Patients Should You Surgical Procedures for Consider for Jaw Surgery to OSA Friend or Foe? Treat Obstructive Sleep Apnea? by Glennine Varga, AAS, RDA, CTA

by Bryce Williams, DDS, Oral and Maxillofacial Surgeon Way more patients than you think should consider definitive therapy.

35

Technology Update

3D Imaging of the Upper Airway with Cone Beam Computed Tomography

by Douglas L. Chenin, DDS Improved software allows us to learn more about our patients’ anatomy.

40

Clinical Focus

The Use of Vertical in Our Practice

by Dr. Todd Morgan Using a Temporary MAD, effective therapy can be more predictable.

4 DSP | Fall 2015

How your team can help skeptical, maybe fearful, patients choose wisely.

48

MD Connection

Building Relationships: The Key To Dental Sleep Medicine Success!

by Neal Seltzer, DMD, FAGD, D.ABDSM, D.ASBA, D.ACSDD, and Jeffrey S. Rein, DDS, FAGD, D.ABDSM, D.ASBA, D.ACSDD Patients are served best when their health care teams know and trust each other.

56

Sleep Humor

Managing Editor | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com Editorial Advisors Steve Bender, DDS Ken Berley, DDS, JD David Gergen, CDT Ofer Jacobowitz, MD Christina LaJoie Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA

National Account Manager | Adrienne Good Email: agood@medmarkaz.com Creative Director/Production Manager Amanda Culver Email: amanda@medmarkaz.com Front Office Manager | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Web: www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) 3 years (12 issues)

$79* $189*

*plus shipping

©MedMark, LLC 2015. 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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JAWsurgery

Telegnathic Maxillomandibular Advancement (MMA) Surgery for OSA

by Jeffrey R. Prinsell, DMD, MD

S

urgery for obstructive sleep apnea (OSA) is indicated when applicable conservative therapies are unsuccessful or intolerable and for patients with an underlying specific surgically correctable abnormality that is causing the OSA.1,2 It can provide definitive treatment and, thus, eliminate issues of patient compliance with other therapies, but only if performed competently, both in terms of technical skill and on the correctly identified area(s) of upper airway (UA) obstruction. Disproportionate UA anatomy may include specific single or multiple structures or areas (e.g. unilevel or multilevel) that can be diffusely complex, which varies between different patients.

OSA surgical procedures can be classified anatomically as intrapharyngeal or extrapharyngeal.3 Intrapharyngeal procedures are performed on soft tissues that compose or lie within the velo-orohypopharyngeal airway wall or lumen, whereas extrapharyngeal surgery involves skeletal structures that lie outside the UA. Common intrapharyngeal sites include an elongated or retropositioned soft palate in the velopharynx, and hypertrophied tonsils and macroglossia or a retropositioned tongue base in the oro-hypopharynx. Hypoplastic or retropositioned extrapharyngeal lower facial skeletal structures, including the maxilla, mandible, and hyoid, may also be causative of OSA because they support or stabilize these velo-orohypopharyngeal soft tissues. In contrast to extrapharyngeal surgery, intrapharyngeal procedures can produce life-threatening UA edema in the immediate post-operative period and are often subtherapeutic because they address isolated sites or limited areas and can result

6 DSP | Fall 2015

in cicatricial scarring and dysfunctional distortion of the UA. The soft palate is a tissue organ whose known primary function is to prevent reflux of air and liquids into the nasopharynx during speech and swallowing, respectively. Also, its role in snoring may be a self-protection warning “bell” (to the bedpartner), of partial or impending UA obstruction. Retropalatal narrowing and collapse, often induced by swallowing (eg., during nasopharyngolaryngoscopy), should be understood as normal velopharyngeal closure, rather than perhaps misinterpreted as a site of obstruction dictating surgery. A dysmorphic or abnormal-looking soft palate may be an anatomic variant of normal that ensures compensatory functioning and, therefore, may not always be a cause of OSA. Surgical ablation or distortion may produce dysfunction such as velopharyngeal insufficiency; stenosis; voice changes; dysphagia; and, in cases of “social” snoring amelioration, may produce “silent” apnea — either of immediate or delayed (with advancing age and/or weight gain) onset.4 In addition, pain, hemorrhage, and UA obstruction in the immediate postoperative period may occur due to velopharyngeal edema which, particularly if compounded with coexisting untreated hypopharyngeal narrowing, can result in death.5 Telegnathic maxillomandibular advancement (MMA) is a highly therapeutic multilevel treatment of OSA that utilizes LeFort I (LF) and bilateral saggital split ramus osteotomies (BSSRO) to “pull forward” the anterior pharyngeal tissues (eg., soft palate and tongue) attached to the maxilla, mandible, and hyoid in order to structurally enlarge

JAWsurgery the entire velo-orohypopharyngeal airway (Figure 1); and enhance the neuromuscular tone of the pharyngeal dilator musculature (eg., tensor veli palatini and genioglossus) – via an extrapharyngeal operation with minimal risks of postoperative edema-induced UA embarrassment or pharyngeal dysfunction.4 Telegnathic MMA preserves the functional integrity of the pharyngeal tissues and postoperative edema from the labial vestibular MMA incisions and tissue dissection is anatomically shielded from the UA by the underlying bony structures and, thus, is confined to the facial soft tissues.6 The entire velo-orohypopharyngeal airway is more patent at the moment of skeletal advancement, like the immediate UA opening produced by a CPR “jaw-thrust” maneuver.

While orthognathic surgery includes maxillary and mandibular osteotomies to treat malocclusion to improve mastication, speech, and esthetics, telegnathic surgery includes skeletal (i.e., maxillary, mandibular and hyoid) advancement to anatomically enlarge and physiologically stabilize the velo-orohypopharyngeal airway to treat OSA. Ideally, MMA may harmoniously satisfy the goals of both telegnathic and orthognathic surgery.3 However, this may not always be feasible and, accordingly, should not be viewed as failure, but rather, accepted as known limitations of telegnathic surgery. For example, telegnathic MMA may be therapeutic for OSA but yet maintains an existing, albeit “untreated,” malocclusion in a patient who does not pursue orthodontic therapy. In cases of hypopharyngeal narrowing in the absence of skeletal hypoplasia (a normal profile), MMA might create an unesthetic bimaxillary-protrusive face.

Counterclockwise rotational advancement of the maxillomandibular complex with anterior maxillary impaction allows for mandibular advancement greater than maxillary to increase orohypopharyngeal enlargement to treat OSA with an esthetically-acceptable facial appearance.7 The amount of mandibular advancement is typically the main determinant of MMA’s therapeutic efficacy because the hypopharynx is usually the most critical site of UA obstruction. However, the limiting factor for the amount of MMA advancement is typically the degree of maxillary protrusion, which causes thinning of the upper lip, excessive maxillary incisor show, alar base flaring, and nasal tip upward rotation. Esthetic

Figure 1: MMA with velo-orohypopharyngeal airway highlighted in yellow.

LF- LeFort I osteotomy, BSSRO - Bilateral saggital split ramus osteotomies, AIMO - Anterior inferior mandibular osteotomy

Jeffrey R. Prinsell received his DMD from Tufts University and MD from Vanderbilt University. He completed a Dental General Practice Residency, General Surgery Internship, and an Oral & Maxillofacial Surgery (OMS) Residency at Vanderbilt.

Dr Prinsell has published and lectured extensively on surgery and oral appliance therapy for obstructive sleep apnea (OSA). His most notable clinical research is a 100% success of maxillomandibular advancement (MMA) surgery in 50 consecutive patients (Chest 1999). His most recent chapter on MMA surgery is in the textbook Current Therapy in OMS (Elsevier, 2011), and most recent comprehensive literature review with MMA treatment recommendations is in J Oral Maxillofac Surg 70:1659-77, 2012.

Dr. Prinsell is a Past President and Distinguished Service Award recipient of the American Academy of Dental Sleep Medicine (DSM), Founding President of the American Board of DSM, Past Chair of the American Association of OMS Clinical Interest Group on OSA, Past Chair of the Multidisciplinary Treatment of OSA post-graduate courses at the Associated Professional Sleep Societies annual meetings, and served on the American Academy of Sleep Medicine Standards of Practice Committee Task Force that authored the practice parameters for OSA surgery (Sleep 2010). He is a Diplomate of the American Board of OMS, Diplomate of the American Board of DSM, President of the Georgia Society of OMS, and maintains an OMS private practice in Marietta, Georgia.

DentalSleepPractice.com

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JAWsurgery

Telegnathic MMA is the most successful surgical treatment for OSA, with a therapeutic efficacy comparable to Nasal CPAP.

enhancements of counterclockwise rotation include correction of excessive maxillary incisal show or gummy smile and lip incompetence in dolichocephalic faces, increased horizontal and vertical dimension of the lower face, accentuation of the lower jawline and hyoid elevation that raises the chin-neck angle in mandibular retrognathism cases, and tightening or rejuvenation of neck skin laxity in relatively older patients (Figure 2).

The primary anatomical criterion for MMA is hypopharyngeal narrowing that can be measured by the lateral cephalometric end-tidal volume posterior airway space (PAS) < 9 mm.8 Specific measurements for other imaging modalities as inclusion criteria for MMA have not been published. In the setting of hypopharyngeal narrowing, coexistent velopharyngeal narrowing, as well as other extrapharyngeal sites, may also be treated with MMA. OSA cases due to diffusely complex or multiple sites of disproportionate anatomy, create difficult dilemmas in terms of the staging and combinations of surgical procedures.

There exists variability in the use of MMA as a primary versus secondary (second stage)

Figure 2: MMA (LF and BSSRO with counterclockwise rotation and AIMO) case: before and after surgery facial photographs. Apnea-Hypopnea Index improved from 61 to 0, and lowest oxyhemoglobin desaturation improved from 70% to no desaturation events below 90%.

8 DSP | Fall 2015

operation and what concomitant adjunctive procedures can be performed safely to enhance therapeutic efficacy. Although highly therapeutic as a secondary operation,9 MMA may be also performed initially for selected cases of multiple or diffusely complex sites of velo-orohypopharyngeal obstruction, including coexistent soft palatal dysmorphism and mild-to-moderate tonsillar hypertrophy.4 This is done to enlarge and stabilize the entire velo-orohypopharyngeal UA to either: definitively treat the OSA and obviate the need for invasive segmental intrapharyngeal procedures; or to decrease the risk of postoperative edema-induced airway embarrassment after intrapharyngeal surgery that may be necessary later for clinically significant residual OSA, perhaps with advancing age and/or weight gain.10 In general, MMA therapeutic efficacy may be enhanced with concomitant adjunctive extrapharyngeal procedures such septoplasty with turbinate reduction, anterior mandibular lingual tori removal4 to increase tongue space in the floor of the mouth, cervicofacial lipectomy to reduce excessive adipose tissue (â&#x20AC;&#x153;weightâ&#x20AC;?) against the underlying anterior pharyngeal tissue particularly during supine sleep, and an anterior inferior mandibular osteotomy (AIMO) for additional advancement of the tongue-related and suprahyoid musculature (an indirect hyoid suspension without invasive hyoid surgery). An inferiorly-based trapezoid-shaped AIMO includes all these muscle insertions and preserves the esthetic contour of the chin4 (Figures 1-2).

On the other hand, intrapharyngeal procedures should probably not be performed concomitantly with MMA for several reasons.

First, intrapharyngeal postoperative edema may cause UA embarrassment that may be difficult to manage, particularly in the setting of maxillomandibular fixation (jaws wired shut). Second, intrapharyngeal pain, particularly when compounded with that of MMA, may require excessive use of centrally-acting opiate and opioids that may precipitate narcotic-induced respiratory depression. Third, intrapharyngeal pain may impede swallowing of liquids and pureed nutrition, which is already difficult for patients following MMA. Fourth, intrapharyngeal procedures may compromise the therapeutic efficacy of MMA. For example, uvulopalatopharyngoplasty (UPPP) with concurrent maxillary advancement may create excessive tension on the soft palatal wound that may exacerbate velopharyngeal

JAWsurgery cicatricial scarring and stenosis.3 Telegnathic MMA is the most successful acceptable (excluding tracheostomy) surgical treatment for OSA, with a therapeutic efficacy comparable to Nasal CPAP.1,3 As a comprehensive, safe, nondysfunctional, extrapharyngeal operation that structurally enlarges and physiologically stabilizes the entire velo-orohypopharyngeal UA, MMA may eliminate the need for (and thus circumvent the staging dilemmas associated with) multiple, segmental, subtherapeutic and invasive intrapharyngeal procedures. MMA should not be limited to cases of severe OSA or dentocraniofacial skeletal deformities or when other surgery have failed, but rather is also indicated as the initial surgical treatment of choice for (velo-oro) hypopharyngeal narrowing, even in the setting of relatively mild OSA and in the absence of retrognathism.7 MMA as a potentially definitive primary single-stage surgical treatment of OSA, particularly when performed in a relatively young adult population, may result in a significant improvement in quality of life and a reduction in OSA-related health risks (eg., hypertension, cardiovascular dysrhythmias, stroke and myocardial infarction, depression, and cognitive dysfunction, as well as hypersomnolence-induced injuries such as those caused by motor vehicle accidents) that, when projected over an average normal lifetime, should result in considerable financial savings for the health care system.11 Nevertheless, MMA should not be used indiscriminately, as it is technically difficult to perform and laden with potential morbidity such as bleeding and neurosensory deficits.

Although skeletal osteotomies when healed to a bony union are stable with no significant relapse, and the relatively long-term results of MMA are promising, the effect of soft tissue laxity that occurs with natural aging (with or without weight gain) in terms of possible progressive velo-orohypopharyngeal narrowing and worsening of residual OSA, is unknown.

“How far” to advance the maxillomandibular complex may be a combination of OSA severity and the degree of hypopharyngeal narrowing, limited by physiologic and esthetic constraints of the overlying facial soft tissue envelope.3 Titration of mandibular advancement via oral appliances or distraction osteogenesis may help predict optimal therapeutic efficacy of telegnathic MMA. Additional studies are warranted, with larger numbers of cases and longer follow-up periods.

References 1.

Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep spnea in adults: a systematic review and meta-analysis. Sleep 2010;33(10):1396-1407.

2.

Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep 2010;33(10):1408-1413.

3.

Prinsell JR. Primary and secondary telegnathic maxillomandibular advancement, with or without adjunctive procedures, for obstructive sleep apnea in adults: A literature review and treatment recommendations. J Oral Maxillofac Surg 2012;70:1659-1677.

4.

Prinsell JR. Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 1999;116(6):1519-1529.

5.

Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19(2):156-177.

6.

Prinsell JR. Telegnathic surgery for obstructive sleep apnea syndrome. AAOMS Oral & Maxillofacial Surgery Update 2006;4:88-97.

Prinsell JR. Obstructive sleep apnea – surgical treatment: Part II, maxillomandibular advancement for adults.

7.

Chapter 114 in textbook Current Therapy in Oral and Maxillofacial Surgery. Elsevier Saunders. 2012:10481063.

8.

Prinsell JR. Maxillomandibular advancement (MMA) in a site-specific treatment approach for obstructive sleep apnea: a surgical algorithm. Sleep Breath 2000;4(4):147-154.

Riley RW, Powell NB, Guilleminalt C. Obstructive sleep apnea syndrome: a review of 306 consecutively treated 9. surgical patients. Otolaryngol Head Neck Surg 1993;108(2):117-125.

10. Prinsell JR. Maxillomandibular advancement surgery for obstructive sleep apnea surgery. JADA 2002;133: 1489-1497.

11. Kapur V, Blough DK, Sandblom RE, et al. The medical cost of undiagnosed sleep apnea. Sleep 1999;22: 749-755.

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DentalSleepPractice.com

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COVERstory

What Documentation Does a Physician Want from a Dentist?

by Rose Nierman, CEO Nierman Practice Management

A

re you looking for a way to increase both the number of Dental Sleep Medicine (DSM) patients your practice sees and also improve patient care? Oral appliance therapy (OAT) for obstructive sleep apnea (OSA) involves colleagues from different healthcare professions with specialized skills and expertise working together. Being part of a multidisciplinary team of talented doctors saving lives can be an exciting and fulfilling way to grow your practice.

How do you join a multidisciplinary team in your community? There isn’t a signup form online or a meetup group to try out. The key to obtaining and retaining relationships with other medical professionals is through consistent communication regarding actual patients these physicians have an interest in and have seen. Why would a physician’s office refer more patients for oral appliance therapy if they don’t know whether OAT was successful for the first patient they referred, or whether they ever even started treatment? When you are part of a multidisciplinary treatment team, documentation and progress reports shared between referring and treating colleagues are essential to patient care. The great news is: there is already a well-established “medical-model” documentation and report writing standard. The same records used to communicate with physicians also verify the medical necessity of treatment. Using common language and report writing formats within your physician network helps to ensure smooth sailing. With the right tools, you’ll secure yourself as the go-to DSM professional for physicians to continually refer patients.

There are two standards for medical documentation and communications: 1. S.O.A.P. Notes and Reports 2. Documentation Guidelines for Evaluation and Management Services created by the Centers for Medicare and Medicaid Services (CMS).

S.O.A.P. reports

Dental S.O.A.P. notes and reports greatly improve communication among all providers and insurance carriers. The S.O.A.P. note was first created in the early 1970’s, under the acronym P.O.M.R. (Problem Oriented Medical Record). S.O.A.P. is by far the most common format used today. S.O.A.P.

10 DSP | Fall 2015

COVERstory About the Cover:

Rose Nierman:

On a Mission to Make Medical Billing in Dentistry Commonplace Having dedicated the past 30 years to her lifelong mission of helping millions of people gain access to the medically necessary dental treatments they need, Rose Nierman is on a quest to make medical reimbursement in dentistry commonplace.

As a hygienist and insurance coordinator in a busy general practice treating temporomandibular joint dysfunction (TMD), Rose was helping dentists get paid by medical insurers for TMD sufferers as early as 1980.

Rose’s Story

Many of Rose’s patients asked why medical insurance wouldn’t reimburse for their treatment when their previous treatment attempts for facial pain, headaches and referred ear pain stemming from the TMJ were covered with other healthcare providers.

Researching medical insurance protocols, Rose started making a case for coverage using the standard documentation insurance carriers are familiar with. “We felt these chief complaints were not related to the teeth but were muscular or orthopedic, in nature.” The medical insurance carriers concurred when given a full S.O.A.P. report of the chief complaints of the patient, exam findings, the assessment with ICD codes, and the dentist’s plan for treatment. “We were elated,” says Rose.

Patients started coming in the door seeking treatment, referred by healthcare providers who had received Rose’s S.O.A.P. narratives and progress reports on mutual patients. And most patients were accepting treatment due to both the financial relief and greater confidence in the therapy.

The Insurance Oracle

Once other dental practices began DentalSleepPractice.com

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COVERstory to find out that Rose was getting medical insurance coverage, she was receiving calls from dentists all over the United States, asking if she could help get reimbursement for TMD, oral surgery and other medically compromised patients. She could, and she did.

By 1988, Rose had built a reputation as the “Medical Insurance Oracle” and was spending every weekend either at her kitchen table in Jupiter, FL with dentists and their insurance cases, or speaking at dental meetings with her The Complete TMJ Manager™ and Successful Medical Insurance in Dentistry™ manuals in tow.

An Easier Way

Seeing the impact of being able to profitably provide affordable care to patients was having on the dental practices she helped, Rose was inspired to help thousands of dental practices to help millions of patients.

With a backlog of kitchen table and phone appointments, Rose knew reliance on her time was the limiting factor in helping millions. There had to be an easier and more efficient way to help more practices implement treatment and billing and create the S.O.A.P. narratives and medical claims on their own, she thought.

By the early 90’s, Rose had hit the road with 20 CE accredited Successful Medical Insurance in Dentistry™ courses, and DentalWriter™ Software had become the first and leading software solution for implementing medical necessity reimbursement. Leading dentists, treating sleep apnea & TMD throughout the US and Canada, credit much of their success to using DentalWriter to build their practice, develop referral relationships and establish efficient protocols.

“It changed the entire landscape,” says Steve Lamberg, DDS.

Sleep Apnea

By 2002, with increased Obstructive Sleep Apnea (OSA) diagnoses and oral appliance innovations, dental practices all over the US were getting reimbursement for OSA with the DentalWriter “Sleep” module and support from Rose and her team. “We had to fight tooth and nail to get reimbursement before there was an official CPT code or reference to OAT in insurance policies and guidelines,” says Rose. “Now with specific codes and policies, it’s much easier”.

12 DSP | Fall 2015

stands for Subjective (complaints & history), Objective (testing & exam findings), Assessment (diagnosis) and Plan (treatment plan). Many dentists have found that this way of organizing data and the critical thinking this format elicits has truly revolutionized their practices. S.O.A.P. is the preferred format to communicate with your network of physicians, especially when reporting the outcome of OAT for your mutual patients.

The American Dental Association’s documentation guidelines recommend that dentists take good medical histories, record the reason for the visit, chart findings and have detailed written plans of care. What’s missing? The assessment! It’s time to put the “A” in S.O.A.P. in dental practices, especially for practices providing OAT for OSA and for those billing medical insurance for other services such as TMJ appliances, CT scans and oral surgeries.

Dentists collaborating with ENT’s, maxillofacial surgeons, sleep physicians, pain management specialists and other providers find that a wellorganized letter format sets you apart and can be prepared with software.

Documentation Guidelines for Evaluation and Management (E&M) Services

Evaluation and Management Documentation Guidelines support Current Procedural Terminology (CPT) codes as well. It’s reasonable and common to bill CPT 99204 (level 4) for a new patient office visit: medical decision-making is moderate, the presenting problems are moderate and the provider typically spends 45 minutes face-to-face with the patient.

For this level be sure to document: • A comprehensive history • A comprehensive exam • Medical decision-making of moderate complexity You can find the AMA documentation guidelines and information on the CMS.gov website or from the link below (see references).

Dentists collaborating with ENT’s, maxillofacial surgeons, sleep physicians, pain management specialists and others find that a well-organized letter format sets you apart and can be prepared with software. It’s important that patients complete a questionnaire designed for DSM, TMD and when surgeries are billed as medically necessary. The patient signature should be obtained for verification of chief complaints, history of present illness, past history and the location, duration and frequency further describing their condition (these are some of the elements in the Guidelines). Your exam should be specific to the medical necessity of a service or procedure and include the ICD diagnosis codes as part of your assessment. It’s imperative that the provider sign the notes. Although your documentation is sent in advance to commercial medical carriers, some insurers perform post payment reviews checking for “insufficient documentation”. An insurance auditor’s “red flag” may be raised by a “cut and paste” template approach. This is referred to as a type of “cloning” by insurers and may involve using an online program or word processor with no questionnaire completed to validate medical necessity and level of care. Be sure to get direct input from your patients and make custom notes for each patient. These suggestions will help decrease the

COVERstory

Team Nierman

Rose Nierman with DentalWriter users and seminar attendees in Atlanta.

possibility of a compliance audit, as well as assist in a successful outcome to avoid refunds or penalties if you do undergo an audit.

International Classification of Diseases – ICD-10

With the transition from ICD-9 to ICD-10 diagnostic codes on October 1, 2015, (ICD-10 for OSA is G47.33), commercial insurance companies will process claims in a speedier manner when your documentation of medical necessity is sent with the claim or the preauthorization. Making it a habit to be on top of these changes and knowing what information is wanted and needed is your recipe for success.

Also, since TMD (Temporomandibular Disorder) issues and sleep issues coexist in so many patients, dentists who provide TMD treatment services will be pleased to know that over 34 states mandate that TMJ treatment be considered medically necessary. To find out if your state is listed, please contact me at contactus@DentalWriter.com or call 1-800879-6468. Also, feel free to contact me with questions on coding options for TMD since the code, S8262 for Mandibular Orthopedic Repositioning Device, was retired in July.

Ensuring your practice has accurate and detailed documentation and narrative reports will not only help you to provide better care to patients and support the medical codes you bill, but will also safeguard your practice. Just as importantly, remember that the medical community (your current and future multidisciplinary treatment team) expects it and will do the same for you.

References 1. 1971 Internal Medicine Grand Rounds, Emory University, S.O.A.P. notes introduction. Lawrence Weed, MD: https://www.youtube.com/watch?v=qMsPXSMTpFI 2. Documentation Guidelines for Evaluation and Management (E&M) Services: http://www.cms.gov/Out reach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

Nierman Practice Management (NPM) has become synonymous with cross-coding in the dental industry. With the largest team of medical billing, OSA, TMD, dental CT and oral surgery implementation experts on the quest to accomplish Rose’s lifelong mission of helping millions of people, thousands of dentists rely on the Nierman Team for their years of dedication, experience, and proven results.

Along with DentalWriter™ software and their continuing education courses on cross-coding, TMD and sleep apnea treatment, they provide medical billing and patient acquisition services, and boast the largest network of experienced consultants to help Nierman clients overcome any barrier to success.

“As the first and leading provider of solutions for dental practices implementing sleep apnea, TMD and cross-coding for over 27 years, we uphold the responsibility of keeping dental practices documenting and communicating while maximizing their reimbursement success at the same time”, says Rose.

It is this philosophy that has led to Nierman Practice Management’s position as a longstanding and ethical leader in the dental-medical arena, facilitating over $100 Million of reimbursement each year for patients getting access to treatment by Nierman dentists.

Crediting much of her success to the passion and dedication of the Nierman team, Rose says “We stand by our solutions and our clients, year after year, providing unparalleled support in helping practices overcome reimbursement hurdles.”

DentalSleepPractice.com

13

CASEreport

Nasal Surgery and Oral Appliance Therapy:

COLLABORATION is Key to Success

by Daniel Klauer, DDS, DABCP, DABCDSM

W

hen evaluating patients with sleep disorders, it’s ok to be nosy.

We have to be detectives, delving into the details of patients’ waking and sleeping hours. One of the most beneficial parts of my diagnostic exam involves evaluating the airway and the “Four Points of Obstruction” comprising the nasal valve, nasopharynx, velopharynx, and oropharynx.1 Literature illustrates the importance of proper nasal breathing as it relates to the success of oral appliance therapy.2 It makes sense to start our evaluation at the tip of the nose and evaluate those four points of obstruction.

Research on oral appliance therapy for OSA cites that the two most important factors to success are body mass index (BMI) and nasal airway resistance.2 3D CBCT imaging is integral to viewing possible obstructions of the airway.

A CBCT scan can show the vital details of the hard and soft tissues of the nose including turbinate hypertrophy (inflammation of the soft tissue of the nose), any possible bony obstruction such as a deviated septum or septal spur. Chronic sinusitis and chronic nasal inflammation are also visible on a CBCT. The only other way to evaluate this completely is via nasal endoscopy; however, as dentists we are not trained for this procedure. After seeing a potential area of concern, I always recommend a consulta-

14 DSP | Fall 2015

tion with a board-certified otolaryngologist (ear, nose and throat physician) who is adept at sleep breathing pathophysiology. I share my CBCT scans with these clinicians so that they, too, have full 3D information. Treating these patients depends heavily on collaboration with talented medical specialists.

The nose is the first line of defense for our immune system — it warms, moistens, and filters the air we breathe. Mouth breathers, who often have inadequate nasal airflow and lack adequate patency in that area, are

CASEreport

Figure 1

Figure 2

Figure 3

breathing in cold, dry, dirty air. Studies show that mouth breathers get upwards of 20 percent less oxygen in their bodies and are essentially breathing dirty, unhumidified air.

Additional literature shows that patients with nasal congestion are 1.8 times more likely to have moderate to severe OSA compared to those without symptomatic congestion.3, 4, 5, 6

Case study

Figure 4

Dr. Klauer is the Clinical Director at the TMJ & Sleep Therapy Centre of Northern Indiana located in South Bend, IN. He graduated from The Ohio State University College of Dentistry and completed a two year handson residency program with Dr. Steven Olmos of the TMJ & Sleep Therapy Centre International. He has taken over 1,000 hours of live CE in the areas of craniofacial pain and sleep medicine. You can reach him at DrKlauer@TMJSleepIndiana.com.

Disclosure: Dr. Klauer has no financial interest in i-CAT nor was he compensated for writing this article.

16 DSP | Fall 2015

The case study of a patient named Bill clearly demonstrates how nasal surgery and appliance therapy can help patients breathe and sleep more easily. Bill arrived at my office with several complaints: Frequent, heavy snoring; feeling unrefreshed in the morning; difficulty falling asleep; general fatigue; and excessive daytime drowsiness (Figure 1). His wife had moved out of their bedroom because Bill was frequently tossing and turning and grinding his teeth during the night. He had a pre-treatment AHI of 36.9 and had declined CPAP therapy.

After identifying nasal obstruction, Bill went to a board-certified ENT and Sleep Medicine Physician for Conservative Functional Nasal Surgery for a deviated septum repair with balloon sinuplasty. We fabricated an oral appliance utilizing a George Gauge, which is the industry standard for taking a protrusive construction bite for sleep apnea appliances. Currently, I am not aware of any literature to support the efficacy of utilizing a George Gauge.

After some time, this therapy proved to not be very effective for Bill, so I fabricated a new oral appliance utilizing a peer-reviewed published bite registration technique. This new appliance, that was clearly more effective for Bill, was fabricated using the Sibilant Phoneme registration protocol to prevent upper airway collapse.7 (See Figures 2-4.) The

Pre-treatment airway volume

“ I NOW CAN

ENJOY THIS

SO MUCH MORE... “

Post-treatment airway volume

– Fiaz, Patient of Dr. Robert Kaspers

©2015 i-CAT | IC-0003 Rev A

Fiaz wanted to improve his appearance – something he’d been thinking about for a long time. What he wasn’t expecting was uncovering something that would impact how he was breathing, eating, and sleeping. His life was changed in ways he never imagined as a result of his treatment and with data from his i-CAT scan analyzed with Tx STUDIO.

SEE THE FULL REPORT AT STORIES.i-CAT.COM

“We literally would have had no idea what his airway was like with a 2D X-ray.”

– Dr. Robert Kaspers Kaspers Orthodontics, Northbrook, IL

#their3Dstory Available exclusively through Product indications for use at i-cat.com/ifu No doctor or patient was compensated for their participation

www.i-CAT.com 800.205.3570

CASEreport

The nose is the first line of defense for our immune system

airway is not a garden hose; it’s 3 dimensional and collapsible, so in many cases, we don’t have to pull the jaw forward to prevent airway collapse. Since adapting the phonetic bite technique, I rarely titrate my oral appliance past an end-to-end anterior relationship. Subsequently, I do not encounter patients with jaw joint issues post-delivery of oral appliance. With a CBCT, we can see the position we have placed the patient in and subsequent changes utilizing the phonetic bite. Now we very well know the CBCT shows the patient’s airway in an upright and awake position. At the very least, we know the airway won’t be getting any better than this while sleeping. Utilizing a thoughtful

bite registration technique for our patients allows us to achieve a great starting point with these patients.

In order to fabricate efficacious and predictable oral appliances, the protocols I adhere to include the following: Comprehensive Exam – utilizing i-CAT™ CBCT within Tx STUDIO™ software, Joint Vibration Analysis (BioResearch), Motor Nerve Reflex Evaluation (orthopedic reflex evaluation), and detailed intraoral and extraoral documentation (Figures 2-4).

Acculator – all of my appliances are fabricated to a phonetic bite and mounted to HIP (Hamular Incisive Papilla Axis/Plane) on an Acculator (Figures 5-7). This helps to

Figure 5: Courtesy of Dr. Steven Olmos

Figure 7

18 DSP | Fall 2015

Figure 6: Courtesy of Dr. Steven Olmos

CASEreport ensure that the patients’ occlusal plane cant is taken into consideration so it is built to the patient’s anatomy, not on a bench top or to a facebow that assumes symmetry.

Note the photo above to see how the right side requires far more material than the left side (Figures 7-8). Without an Acculator, this could not be predictively fabricated. There is no other way to line up asymmetries because most of our patients aren’t symmetrical.

After surgery and receiving his oral appliance, Bill improved from severe apnea to within normal limits with a post treatment AHI of 4.5 (Figure 9). Bill is now walking 3 miles most days and is able to enjoy life.

When he goes on vacations with his family, he no longer has to have his own hotel room.

He is eager to speak with others about his successful treatment, and has even attended local community lectures to give live testimonials. He is more than a patient now; he is a friend to me and my team.

It is with the knowledge that I have gained from patients such as Bill, together with collaboration with my skilled medical colleagues that has allowed me to build a full-time TM/Sleep practice in less than 12 months. I never thought I’d retire from general dentistry at the age of 29! Every patient is different and requires a comprehensive evaluation and walking through the four points of breathing obstructions. The best outcomes are achieved by being “nosy” about how our patients are breathing and making thoughtful referrals to collaborate with our talented colleagues. We cannot do this alone, and our patients deserve a collaborative approach to achieve optimal health.

References 1. Olmos S. CBCT in the evaluation of airway – minimizing orthodontic relapse. Orthodontic Practice US. 2015;6(2):46-49.

2. Zeng B, Ng AT, Quian J, Petocz P, Darendeliler MA, Cistulli PA. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep. 2008; 31(4):543-547.

3. Gupta N, Goel N, Kumar R. Correlation of exhaled nitric oxide, nasal nitric oxide and atopic status: A cross-sectional study in bronchial asthma and allergic rhinitis. Lung India. 2014;31(4):342-347.

4. Michels Dde S, Rodriques AM, Nakanishi M, Sampaio AL, Venosa AR. Nasal involvement in obstructive sleep apnea syndrome. Int J Otolaryngol. 2104. 2014:717419.doi:10.1155/2014/717419.

Epub 2014 Nov 20.

5. Fitzpatrick MF, McLean H, Urton AM, Tan A, O’Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J. 2003;22(5):827-832.

6. McLean HA, Urton AM, Driver, HS, Tan AK, Day AG, Munt PW, Fitzpatrick MF. Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea. Eur Respir J. 2005;25(3): 521-527.

7. Singh GD, Olmos S. Use of sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath. 2007;11(4):209-216. DOI 10.1007/s11325-007-0104-3.

Figure 8: Courtesy of Dr. Steven Olmos

Figure 9

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DentalSleepPractice.com

19

SLEEPstudy

by Dave Shirazi, DDS, MS, MA, LAc, RPSGT, DABCP, DABC-DSM

H

ave you told a patient they need a PSG? Have you heard tales of fun and entertainment from your patients who’ve had one? Most physicians and dentists actually wince a little when referring a patient for an in lab sleep study (also known as a Polysomnogram) because they know the referral can be met with resistance, refusal, or unpleasant stories from the patient. We want the wealth of information that can be obtained from it, and our patients want us to help them without all that trouble.

As a dentist and registered sleep technologist, I’ve seen it from both sides; this essay is to give you insight into what happens to your patients so you can prepare them.

The first thing most patients think of is “I have to sleep where?” and “They’re going to be putting what all over my body?”, which then brings them to the next question, “Why do I have to do this?”. This is where educating the patient is so important, not just on the reason for the need, but also as to what’s going to happen.

The sleep lab can schedule the patient usually any night of the week, even if it needs to be a weekend, depending on how the lab is set up. All sleep labs have showers and bathrooms for those that need to go to work right after the study, more on why this is so, shortly. The sleep lab checks with the patient’s insurance to let them know of any fees, co-payments or deductibles; collections are usually the night of the test.

20 DSP | Fall 2015

I tell the patient that the room is very similar to a hotel (if the sleep lab near you is ancient, you can say it’s more like a motel). Check in is one hour prior to their usual sleeping time. Each patient has their own room, and then the ‘fitting’ begins. This is where the sleep technologist, your own personal concierge for the evening, places sticky sensors, called ‘leads’ to capture EEG signals, EMG muscle activity of the masseters as well as the limbs, EKG signals, and air flow and O2 sensors. There are motion and sound detectors on the patient as well. The patient then completes their usual night time procedures such as using the restroom, reading a book, or watching TV, then attempts to go to sleep. All necessary medications need to be taken, though if a diuretic is typically used in the PM instead of the AM, I recommend that they switch that up, for obvious reasons. No alcohol or recreational drugs are permitted, no matter how common that is in

SLEEPstudy their evening routine. Hypnotics are used only when absolutely necessary.

So that the best quality assessment can be made, during the sleep test the technologist is monitoring the data from each lead, reattaching any that come loose or pass bad data.

They are there to assist if the patient needs to get up during the night. Some physicians leave a standing order to apply a PAP device if high levels of OSA are found; they will have a specific protocol for the technologist to follow. Sometimes, this is the patient’s first, last, and only experience with PAP therapy.

Those are the patients who we hope get referred for OAT right away. If PAP is applied, the technologist adjusts the pressure until SDB is resolved and that pressure is noted in the chart, in all sleeping positions and stages of sleep, particularly REM. In the morning the sleep technologist takes off the leads and asks the patient for a subjective assessment of the test; such as how the night went for them, how usual it felt, or if they got more or less sleep than any other night. This is where most want to shower to take off the conductive gel from the EEG leads and begin their day, going to work, home, or school directly from the lab. Another technologist will usually “score” the study a second time, checking latency to sleep and REM sleep, counting events, and developing indices, passing the scoring and the raw data to an MD or DO for interpretation and diagnosis.

I do spend a minute or two explaining all this to my patients, not least of which because I have my own sleep lab and I want them to have the most comfortable experience possible. I use very direct words such as ‘there are no blood tests that can give us the level of information and detail about you that one night of a sleep study can.’ For the stubborn (usually) male patient who still thinks they don’t have apnea, or that their wife is the person with the sleeping issues, I look over at their home sleep study or overnight pulse oximeter and mention ‘your oxygen dropped to 76%! You are doing this every night, and it is not our recommendation that you prolong this for even a moment longer’. People are stubborn in these cases when they are not fully informed. Facts are facts.

Lastly, I want everyone to know about the ‘do not do’ list. A dentist that is not an MD cannot interpret a sleep study, neither an HST nor a PSG; however they can inform the patient of what the sleep doctor has di-

agnosed. Sleep technologists cannot, by law, tell the patient what sleep problems the test shows them to have or pronounce them free from SDB. It’s good for you to reread that last line. They can point out things like ‘your oxygen dipped to__%’, but it must always follow with ‘you need to follow up with your referring doctor’. They cannot even say ‘I did not see any apnea’ either.

Oftentimes, because the sleep technologist cannot tell the patient what they have, if they do see apnea, they are usually told to immediately schedule the patient for a second study with CPAP. That means the patient was not informed of what they have, and they’ve been told to come back a second night, with PAP therapy. This can often lead to resentment and anger by the patient, or even non-compliance, because they have not been informed. We need to let them know that this is a common practice, and to not be alarmed by it. The dentist has the option to just let the patient have a titration CPAP study when they have mild to moderate, or ask the lab not to, if the patient has already proclaimed they will never wear a CPAP. On the other hand, if the patient has severe sleep apnea, they in effect, must have a follow up titration study.

I find when patients clearly understand why they are expected to undergo the sleep test, are well informed of the process and can name the problem that is being searched for and/or to be solved, the entire experience can be an effortless one. After all, they are spending most of the night with their eyes closed!

I encourage you to reach out to the sleep technologists in the sleep lab near you; everyone benefits from a better understanding of the role each professional plays. Every contribution is different but important; each carries the responsibility of educating the patient.

Sleep technologists cannot, by law, tell the patient what sleep problems the test shows them to have or pronounce them free from SDB.

Dave Shirazi, DDS from Howard University College of Dentistry, Masters in Oriental Medicine from SAMRA University is also a board licensed Acupuncturist. He has completed over 2000 hours of continuing education in TMD and facial pain, craniomandibular orthopedics, and SDB. In 2011, he became a board licensed RPSGT, the first and so far only, dual degreed dentist and RPSGT. Dr. Shirazi is the director of The TMJ and Sleep Therapy Centre of Conejo Valley, limited to the treatment of TMD, craniofacial pain, sleep breathing disorders, and craniomandibular orthopedics.

DentalSleepPractice.com

21

JAWsurgery

Which Patients Should You Consider for Jaw Surgery to Treat

Obstructive Sleep Apnea?

by Bryce Williams, DDS, Oral and Maxillofacial Surgeon

J

im is a 42-year-old male who has been struggling with obstructive sleep apnea since he was diagnosed 8 years ago. He has tried CPAP, however, he removes it within the first hour of sleep and no modifications to the mask fit or machine type has improved his compliance. His greatest success was losing weight. He initially improved his BMI from 33 to 27, and has kept the weight off for three years. Regrettably, this only improved his apnea-hypopnea index (AHI) from 72 to 64. His sleep medicine physician, a pulmonologist who you are well acquainted with, referred him to your office for a mandibular advancement device, which you fabricated and delivered to the patient a few months ago. The patient has had improved compliance with the jaw advancement splint, wearing it throughout the night, most nights. His wife reports softening of his snoring, and the patient says he thinks he feels a little less tired during the day. The entire treating team considers this a success and his sleep medicine physician schedules a follow up polysomnography to quantify the amount of improvement that Jim has had. Unfortunately, the repeat polysomnography shows minimal improvement in the patientâ&#x20AC;&#x2122;s AHI, decreasing from 64 per hour to 51 per hour. The sleep medicine physician calls you to see if you have any additional recommendations for treatment. In your opinion, the device has advanced the jaw as far anteriorly as possible. The patient is becoming frustrated, but is willing to try something more invasive if it will improve his symptoms and prevent future systemic disease. What could you offer this patient?

Failure of conservative therapy in patients with severe sleep apnea (AHI > 30) is disappointingly common, with 20-40%

22 DSP | Fall 2015

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JAWsurgery

Figure 1A: Pre-op

Figure 1B: Post-op

rejecting treatment with CPAP, and up to 30% failing treatment with a mandibular advancement splint. For these patients, finding an acceptable treatment can be challenging.

Surgery may appear to be an attractive option to the patient, as it is may be perceived as an instant solution to their disease that does not involve wearing awkward or restricting medical devices. To the contrary, most medical and dental providers know that surgery for sleep apnea has a reputation of being very painful with disappointing results. The reputation isn’t unfounded – a systematic review of patients with severe sleep apnea undergoing soft palate surgery had a 33% reduction

in their AHI, but the mean post-op AHI remained 29 after surgery.1 Jaw surgery (also called “orthognathic surgery”) for sleep apnea can consist of a variety of surgical designs.

The most successful orthognathic surgery type for severe obstructive sleep apnea is maxillomandibular advancement surgery (MMA), which averages around a 90% reduction in AHI post-operatively. The surgery involves creating an osteotomy in the upper and lower jaws and the chin, and advancing the jaws anteriorly. This movement not only opens the airway in the anterior-posterior dimension, but also expands the airway laterally which is key for preventing collapse of the airway in patients with severe disease. Traditionally, orthognathic surgery is utilized in younger patients with a malocclusion – to correct an overbite or underbite, for example. In contrast, maxillomandibular surgery (MMA) is anterior repositioning of the jaws, usually in older patients, with the primary goal of expanding the airway. Oftentimes, these patients have a normal occlusal relationship, so that MMA surgery positions the jaw in an extreme anterior post-operative position. Despite the new, exaggerated anterior position of the jaws and chin, >90% of patients are very pleased with their post-surgery appearance as advancement of the jaws tightens facial wrinkles and produces a younger looking convexity of the face.2 Patients with pre-op mandibular retrognathia tend to have an anatomic cause for sleep apnea, and have the most esthetically pleasing and greatest airway expansion with maxillomandibular advancement surgery (see an example in Figure 1).

Dr. Williams was raised in Northern California and completed his undergraduate training at Brigham Young University. He received his dental degree from the University of the Pacific in San Francisco, graduating magna cum laude. He then completed an Oral Maxillofacial Surgery residency at Highland Hospital at Alameda County Medical Center. His residency included training at Children’s Hospital in Oakland and extensive experience in orthognathic surgery at Kaiser Permanente, also in Oakland. His clinical interests include treating patients with obstructive sleep apnea for which he offers multiple surgical procedures including maxillomandibular advancement surgery.

24 DSP | Fall 2015

JAWsurgery Jaw surgery may be viewed as a very major surgery. In actuality, there have been no reported deaths in the literature after maxillomandibular advancement surgery.

Major complications are considered to be rare (<1%) and minor complications (3%) are very uncommon and are temporary and reversible.3 The numbness that occurs of the lips, chin and cheeks is not especially debilitating for the patient and is temporary in >85% of patients. The <15% of patients that have permanent numbness usually only have a very small area of the cheek or chin that is numb, and is not particularly incapacitating to the patient. The transient numbness has the paradoxical advantageous effect of decreasing the severity of post-op pain, which is why MMA is generally considered less uncomfortable compared to a less invasive surgery such as isolated soft palate surgery.

Which patients should be considered for maxillomandibular advancement surgery?

The ideal patient has failed conservative treatment (CPAP, mandibular advancement device/splint), has a craniofacial deformity such as mandibular retrognathia, has a BMI < 30, is less than 50 years old, and has moderate to severe obstructive sleep apnea – similar to our patient Jim, introduced in the story above (see Table 1 highly positive predictor for MMA post-op success). Not every patient fits into the “ideal” patient categories listed above. Maxillomandibular advancement surgery is still considered one the most effective and safe upper airway surgery for patients with moderate to severe sleep apnea that have failed conservative treatment. This can include heavier patients who have had previous upper airway surgery that are > 50 years old. The reason is MMA surgery seems to result in the greatest overall reduction in AHI compared with other upper airway surgeries, so even more difficulty patients can qualify. These patients in the severe category of sleep apnea with difficulty complying with conservative treatment or failure of previous surgical therapies can and should, at least, be evaluated for maxillomandibular advancement surgery as they can have drastic improvements in symptoms, quality of life and AHI.

Table 1: Positive Predictors of Successful MMA Surgery Age < 50 BMI < 30 No previous upper airway surgery 1 cm minimum anterior movement of the jaws Less severe obstructive sleep apnea

References 1.

Caples SM1, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1396-407.

2.

Li KK1, Riley RW, Powell NB, Guilleminault C. Patient’s perception of the facial appearance after maxillomandibular advancement for obstructive sleep apnea syndrome. J Oral Maxillofac Surg. 2001 Apr;59(4):377-80.

3.

Holty JE1, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2010 Oct;14(5):28797.

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25 DentalSleepPractice.com 1/12/15 12:52 PM

WEIGHTloss

Helps with

Airway Management

by Brian Sung, MD

M

ore than half of Americans are overweight and roughly 12 million Americans have severe obesity (defined as being 100 pounds or more overweight). Obesity, categorized as a body mass index (BMI) of 30 or more, is linked to more than 40 diseases including type 2 diabetes, heart disease, stroke, and obstructive sleep apnea (OSA). Obstructive sleep apnea is a common condition in the general population with increasing prevalence in the obese and morbidly obese populations. Obesity is the most common risk factor for OSA, with over 50% of OSA cases attributable to excess weightš and overall incidence that is 12 to 30 fold higher in the bariatric population². As such, OSA commonly coexists with obesity and may exacerbate other obesity-related complications such as type 2 diabetes and hypertension.

26 DSP | Fall 2015

WEIGHTloss Weight loss by any method is a welldocumented treatment for OSA. Studies have shown that bariatric surgery (also known as weight loss surgery) is an effective tool for treating obesity, and for preventing, treating and even resolving sleep apnea. In general, many patients after bariatric surgery will develop clinical improvement or resolution of symptoms of OSA, regardless of whether a normal BMI is ever achieved, as even a modest weight loss of 10-20% has been associated with improvement of symptoms and greater than 26% reduction in apnea hypopnea index (AHI).³ Data in the literature demonstrates subjective improvement in symptoms of OSA after bariatric surgery which include: improvement in self-reported postoperative sleep quality, reduction in daytime sleepiness, improvement in validated quality of life scores, and improvement in Epworth Sleepiness Scores. And objective parameters regarding severity of OSA have been shown to improve after bariatric procedures including respiratory disturbance index (RDI), AHI, oxygen saturation, and both sleep efficiency and REM sleep on polysomnography testing.

More than two decades ago, the National Institutes of Health (NIH) recognized bariat-

ric surgery as the only effective treatment to combat severe obesity and maintain weight loss in the long term. Based on the NIH consensus, bariatric surgery candidates are patients with a BMI between 35 and 39.9 with at least one obesity related comorbidity or a BMI ≥40. Nearly two thirds of obese patients with severe OSA are good candidates for bariatric surgery.

Bariatric Procedures The most common forms of bariatric surgery are Roux-en-Y gastric bypass, adjustable gastric banding and sleeve gastrectomy. More than 95 percent of all procedures performed are performed using minimally invasive (laparoscopic) techniques. Minimally invasive surgery means faster operations, less anesthesia, much smaller incisions and less scarring, all of which contribute tofaster healing and recovery.

Laparoscopic Roux-en-Y Gastric Bypass This procedure involves creating a small stomach pouch, so less food can be consumed. The intestine is connected to the pouch and rerouted. Food bypasses the lower stomach, the first segment of the small intestine (duodenum) and part of the second

Laparoscopic Roux-en-Y Gastric Bypass

Brian Sung, MD, is the Medical Director for the Surgical Program at Swedish Weight Loss Services in Seattle, Washington. Dr. Sung is a board certified general surgeon and fellowship trained bariatric surgeon. Born and raised in Los Angeles, Dr. Sung continued his education in California at the University of California at Berkeley. He then completed his graduate and medical training at Boston University School of Medicine prior to returning to California for his general surgery residency training at the University of Southern California. During his residency, Dr. Sung was awarded a research fellowship in colorectal surgery in addition to the Resident Teaching Award in 2008.

He furthered his training at Stanford University, completing his fellowship in Minimally Invasive and Bariatric Surgery in addition to being appointed Clinical Instructor. His training in bariatric surgery included the gastric bypass, vertical sleeve gastrectomy, adjustable gastric band as well as revisional bariatric surgery.

As part of his minimally invasive training, he is also well versed in both general and bariatric surgery applications of robotic, single incision and endoluminal surgery. Dr. Sung played an integral role in the initial experience of the Per Oral Endoscopic Myotomy at Stanford.

Dr. Sung’s introduction to the power of bariatric surgery began as a medical student. He recalls caring for a bariatric patient who preoperatively was a brittle diabetic with significant insulin requirements but postoperatively had his diabetes put into remission.Having such a dramatic impact on a patient’s health and quality of life is why bariatric surgery became his vocation.

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WEIGHTloss segment (jejunum). A direct connection is created from the small stomach pouch to the lower segment of the small intestine. Patients generally can return to work within three to four weeks.

Laparoscopic Adjustable Gastric Banding (LAGB)

Laparoscopic Sleeve Gastrectomy

Laparoscopic Adjustable Gastric Banding (LAGB) The laparoscopic adjustable gastric banding procedure involves placing an adjustable, inflatable silicone band around the upper part of the stomach. The technique restricts the amount of food that can be eaten and, when properly adjusted, controls hunger. Patients generally can return to work after two weeks. The inner balloon of the band can be incrementally inflated after surgery to increase the feeling of fullness after eating and improve hunger control.

Patients generally recover quickly and return to work within one to two weeks.

Laparoscopic Sleeve Gastrectomy Laparoscopic Sleeve Gastrectomy (LSG) is a restrictive procedure that reduces the size of the stomach and limits food intake.

This procedure may be used as part of a staged approach to surgical weight loss.

Patients who have a very high BMI, who are at risk for undergoing anesthesia or who have a heart or lung problem and should not undergo a long surgical procedure may benefit from this staged approach.

As a stand alone procedure, there is significant evidence that sleeve gastrectomy is comparable in safety and efficacy to gastric banding. Unlike gastric banding, there is no silicone band and no return visits for adjustments are required. Patients generally can return to work within three to four weeks.

Overall, the risks are similar to those seen with the laparoscopic adjustable band, but lower than the risks associated with gastric bypass.

Conclusion

Bariatric surgeries result in long-term weight loss success. Most studies demonstrate that more than 90 percent of individ-

When combined with a comprehensive program, bariatric surgery is an effective tool to provide patients with improvement in their health and quality of life.

ual previously affected by severe obesity are successful in maintaining 50 percent or more of their excess weight loss following bariatric surgery. Several large population studies have found improved longevity in individuals affected by severe obesity who have bariatric surgery with a lower risk of death than those individuals affected by obesity who do not have surgery. In addition to mortality reduction, bariatric surgery also decreases morbidity with improvement or resolution of obesity related comorbidities including hypertension, sleep apnea, asthma, gastroesophageal reflux disease, fatty liver disease, lipid abnormalities, infertility, and more. In addition to improvement in health and longevity, surgical weight loss improves overall quality of life including measures of improved mobility, self esteem, and profession and social interactions. And given that the mortality rate for bariatric surgery (3 out of 1000) is similar to that of a gallbladder removal and less than that of a hip replacement, the benefits of surgery far exceed the surgical risks.

Regardless of which bariatric surgery procedure a patient and their surgeon decide on, it is important to remember that bariatric surgery is a “tool.” Weight loss success depends on many important factors such as nutrition, exercise, behavior modification and more. When combined with a comprehensive treatment plan and program, bariatric surgery is an effective tool to provide patients with long term weight loss and overall improvement in their health and quality of life.

References 1.

Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985) 2005;99(4):1592–9 2.

Kyzer S, Charuzi I. Obstructive sleep apnea in the obese. World J Surg. 1998;22:998–1001.

3.

Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284:3015–21

28 DSP | Fall 2015

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CASEreport

Using Overnight Pulse Oximetry to Manage Oral Appliance Therapy during Treatment for Obstructive Sleep Apnea

by Ronald S. Prehn, ThM, DDS

30 DSP | Fall 2015

I

t is estimated that obstructive sleep apnea (OSA) affects at least 25 million Americans.1 OSA occurs when a patientâ&#x20AC;&#x2122;s airway gets blocked during sleep. The benefits of physicians prescribing overnight pulse oximetry testing to pre-screen for OSA are well known.2,3 In addition, studies supporting the use of overnight pulse oximetry by dental sleep practitioners to confirm their patientsâ&#x20AC;&#x2122; response to oral appliance therapy (OAT) during treatment for sleep disordered breathing (SDB) are well documented.4 In fact, the American Academy of Dental Sleep Medicine (AADSM) recently recommended in its treatment protocol the use of pulse oximetry home sleep testing to manage mandibular advancement splint (MAS) appliances.5 However, the practice of using a pulse oximeter to manage MAS appliances has only recently entered the mainstream of care.

CASEreport Overview

Sleep disordered breathing (SDB) includes OSA and is part of the scope of temporomandibular disorders (TMD). Not to consider SDB would be ignoring an important factor in the pathology of TMD. Successful treatment of SDB can not only add years to a patient’s life, it can also greatly improve quality of life.6 The most common treatment for OSA is continuous positive airway pressure (CPAP) therapy prescribed by a physician. A CPAP mask is worn over the nose (and sometimes also the mouth) and the mask is connected to a hose that gently provides air pressure into the throat to keep the airway open during sleep. However, studies have shown that more than half of all patients who use a CPAP machine stop using it within a year due to discomfort.7 As an alternative to CPAP treatment for OSA treatment, oral appliance therapy (OAT) is often deployed by dental sleep medicine practitioners, working in partnership with referring sleep physicians. With OAT, the patient wears a mandibular advancement splint, which is a mouth-guard-like appliance that positions the lower jaw forward to open the airway continuously through the night. Studies have shown that patients comply better with OAT than with CPAP.8 The American Academy of Sleep Medicine recommends oral sleep appliances as first line treatment options for those with mild and moderate levels of sleep apnea as well as for individuals who are CPAP intolerant.9 Overnight pulse oximetry monitoring is essential in pre-confirming the effectiveness of OAT for OSA treatment.10 A pulse oximeter monitors a patient’s heart rate and blood oxygen saturation in arterial blood. Accord-

ing to the AADSM and the AASM, overnight pulse oximetry has been shown to be an effective sleep screening tool used to evaluate the response to OAT prior to sending patients back for follow-up polysomnography (PSG) testing at a sleep lab.11 As a specialist in Orofacial Pain and Dental Sleep Medicine, my patients are referred to me for temporomandibular joint syndrome (TMJ), headaches or sleep apnea.

After my patients have been diagnosed by a board-certified sleep physician, I use overnight pulse oximetry screening to manage the MAS that I typically prescribe. Specifically for this case study, I used the Nonin Medical WristOx2® wrist-worn pulse oximeter and Nonin’s nVISION® data management software to verify the appliance’s effectiveness before my patients return to their physicians for a final PSG. I have found that the WristOx2 is the best device for this purpose.

Case Example

Exam and History: A 48 year old woman presented with subjective symptoms of fatigue, frequent arousals and morning headaches. She reported waking up 3-4 times per night and returning back to sleep in less than 10 minutes. She reported mild snoring and waking up gasping for air at times. Her husband did not report any pauses in her breathing. An objective exam showed signs of jaw clenching at night to include scalloped tongue, teeth abfractions, gingival clefting, high vaulted palate and mandibular tori. The cone beam x-ray showed normal tonsils, a small airway, a high vaulted palate and a right septal deviation with turbinate hypertrophy.

Her Epworth Sleepiness Scale was 13 (elevated). Her BMI was 29 (overweight/borderline obese). Her temporalis and deep masseter

Dr. Ronald S. Prehn is the owner of REstore TMJ & Sleep Therapy, a patient-centered medical/dental practice that focuses on the diagnosis and treatment of Headaches/Facial Pain, Temporomandibular Disorders and Sleep Breathing Disorders in The Woodlands, Texas.

Dr. Prehn is a member of the American Academy of Orofacial Pain, the American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and the Appliance Therapy Practitioners Association. He is a Board Certified Diplomate of the American Board of Orofacial Pain (a proposed ADA specialty) and the American Board of Dental Sleep Medicine, for which he sits on the board of directors.

Disclosure: Dr. Prehn has not received any compensation from Nonin Medical, Inc. for authoring this white paper or endorsing Nonin Medical’s products.

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CASEreport muscles were tender to palpation, in addition to her temporalis tendons on both sides (from excessive clenching).

The treatment plan was to send her for a PSG with esophageal pressure monitoring (PES). She was instructed to return for a consult and review of treatment options to include OAT. NPSG Results: AHI 9, RDI 33, SpO2 88% (time below 90% oxygen saturation was 3.3% of the night), PES -45cm H2O (note: this indicates significant effort, as a normal reading would be -5cm H2O).12 The diagnosis was OSA; ICD-9 327.23.

Treatment: The recommended treatment was a Resmed Narval™ CC oral appliance.

Impressions were taken and the MAS was fabricated and inserted at 50% protrusion.

The patient was instructed to wear her morning aligner for 15 minutes or until her posterior teeth touch. She returned for a one week follow-up with no TMJ or tooth pain. Her occlusion was checked with and without the

morning aligner to confirm stability. She still had fatigue and arousals with the headaches less intense. She was instructed to advance the MAS until she slept through the night.

Titration: At the six-week point, she was advanced to 75% of maximum protrusion and sleeping through the night, but still reported fatigue. She was sent home with a WristOx2 wrist-worn pulse oximeter. The first pulse oximeter reading indicated a SpO2 of 91 with significant heart rate variability. The maximum heart rate spikes were about every 90 minutes with a corresponding drop in oxygen saturation. At no time was she reading under 90% SpO2. The ODI (oxygen desaturation index), based on a 3% drop in oxygen from baseline, was 6. I interpreted this data to mean that the airway was patent and most apnea was resolved, but that there was still respiratory effort occurring, which would explain the fatigue. The 90 minute cycles of increased heart rate indicated that most of her remaining effort was occurring during the

Exam and Treatment Routines When patients are referred for OSA: • I perform an exam, conduct a cone beam scan or Panorex X-ray and take the patient’s history. If patients have had a PSG already, then pre-verification of benefits will have been done. I will review the PSG with patients and recommend a MAS or combination therapy. If they have not had a PSG from a physician, I will refer them at this point and have them return to review results.

• I fabricate and insert the MAS in the patient’s mouth.

• I manage the MAS forward until symptoms are resolved – i.e., the airway remains open.

• I then send the patient home for a pulse oximetry home sleep test (HST).

• If issues are identified, then I will repeat the process and HST until symptoms are resolved and I can determine that the MAS is effective.

• I send the patient and HST reports to the physician for a final PSG. • If the issues are unresolved, I fabricate a TAP® PAP nasal pillow CPAP mask for combination therapy and send the patient to a physician for a CPAP titration.

32 DSP | Fall 2015

When patients are referred for TMD: • I perform an initial history and exam for TMD (or headaches) and SDB on every patient. I treat the pain or TMD, and if they have any signs and/or symptoms of SDB other than jaw clenching, I refer them for a PSG. If they have no other signs and symptoms of SDB, I will send them home with an HST just to make sure they are free of any issues.

I especially look at the heart rate variability in these cases, as that is an indication of respiratory effort.

• I will have the patient start with CPAP while I treat the TMD. • When the TM joints are stable, I will transition them into a MAS or combination therapy, depending on the severity of the problem.

• Finally, I manage the MAS therapy with a pulse oximeter as described above and refer the patient to a physician for a final PSG.

CASEreport rapid eye movement stage of sleep. She was told to advance the MAS two more units.

Results: After advancing the MAS two more units, the patient reported that her fatigue was resolved. She was again sent home with the same pulse oximeter. Her SpO2 was 94% with no heart rate variability; she experienced a normal steady decline of her heart rate throughout the night. She was sent to the sleep physician for a final PSG, which confirmed resolution of her OSA. The patient was put on a yearly recall with instructions to let us know if she experienced any change in her symptoms or bite.

HST Monitoring Worksheet Patient name:______________________________________________________________________ Weight:____________ DOB:________________ Age:________ BMI:_____________ Type of MAS: o TAP o Narvel o Other:______________ Date of insertion:____________ Pulse OX #:______ Date dsipensed:____________ Initial:______ Date returned: ____________ Original sleep MD/facility:__________________________________________________________ HST type on this report: o Pulse Ox Original PSG date _______________

34 DSP | Fall 2015

HST date ________

o Other:_________________________

HST date ________

PSO2

Clinical Assistant comments:

RDI

Conclusion

The need for diagnosing and treating SDB, including OSA, is critical due to the volume of potential patients affected, the associated health risks (diabetes, high blood pressure, heart disease, stroke, depression) and the potential for reduced quality of life (poor concentration, fatigue, increased risk of accidents).13 Diagnosis and treatment of OSA should not have to wait until patients’ symptoms are bad enough to drive them into their doctor’s office. Dentistry has, as part of its treatment structure, a yearly recall of patients. This presents an opportunity for sleep disorder dentists to partner with sleep physicians to improve patient quality of life and lower healthcare costs by working together to diagnose and treat OSA appropriately.

Pulse oximetry sleep tests are useful to dentists for managing MAS appliances but not for diagnosing or confirming resolution of OSA. Only a sleep physician who is board certified in sleep medicine can diagnose or confirm resolution of OSA.10,11 MAS is reimbursable, and overnight pulse oximetry sleep tests can be included as part of the cost-ofcare delivery.

Oximetry sleep tests are easy and inexpensive for dental sleep practitioners to employ using a pulse oximeter. Training is minimal, and patients appreciate the fact that their oxygen saturation levels are being monitored for verification of MAS effectiveness before they return to their physician for a final PSG. Performing these tests lets the physician know that the dental practitioner is serious about OSA treatment and knowledgeable about how to make treatment effective.

o Watch PAT

AHI ODI Percent time under 90%

Clinical Assistant initials:_______

ESS PGIC Original sleep complaints: o Fatigue Check one: o Patient satisfied Current disposition: o All symptoms resolved

o OSA

o Snoring

o Other:___________________

o Symptoms not resolved o Titration study to see if advancement needed

o MAS out as far as possible - what is next o Final to determine if MAS is effective

Dr. comments:_____________________________________________________________________ Current disposition:

o Adv MAS redo HST o Adv MAS then send for final HST/PSG with Sleep MD o Send for final HST with Sleep MD now o Send for PSG w/ PES to see why symptoms remain o Send for PSG with Sleep MD to consider Combination Therapy o Other: _______________________________________________________

References 1. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 May 1;177(9):1006-14.

2. Collup NA, Tracy SL, et al. Obstructive Sleep Apnea Devices for Out-Of-Center (OOC) Testing: Technology Evaluation.

Journal of Clinical Sleep Medicine, Vol. 7, No. 5, 2011.

3. Netzer , Nikolaus, Am H. Eliasson, Cordula Netzer, David A Kristo, Overnight Pulse Oximetry for Sleep Disordered Breathing in Adults, CHEST 2001; 120:625-633.

4. Fleury B, Rakotonanahary D, Petelle B, et al. Mandibular advancement titration for obstructive sleep apnea: optimization of the procedure by combining clinical and oximetric parameters. Chest 2004;125:1761-7.

5. AADSM Protocol for Oral Appliance Therapy for Sleep Disordered Breathing in Adults: An Update for 2013, American Academy of Dental Sleep Medicine, 2013.

6. Phillipson, EA. Sleep apnea: a major public health problem. N Engl J Med. 1993;328:1271–1272.

7. Gay, Peter, Terri Weaver, Daniel Loube, Conrad Iber, Evaluation of Positive Airway Pressure Treatment for Sleep Related Breathing Disorders in Adults, SLEEP 2006;29(3):381-401.

8. Ferguson KA, Ono T, Lowe A, et al. A randomized crossover trial of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest.1996;109:1269-1275.

9. Ramar, Kannan, Leslie C. Dort, Sheri G. Katz, Christopher J. Lettieri, Christopher G. Harrod, Sherene M. Thomas, Ronald D. Chervin, Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015, JDSM; Vol. 2, No. 3, 2015 10. Dieltjens, Marijke, Olivier M. Vanderveken, Paul H. Van de Heyning, Marc J. Braem, Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathing, Sleep Medicine Reviews; 16 (2012), 177-185 11. Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine, JCSM Journal of Clinical Sleep Medicine, Vol. 3, No. 7, 2007 12. Sukegawa, Mayo, Akiko Noda, Yoshinari Yasud, Seiichi Nakat, Tatsuki Sugiura, Seiko Miyat, Kumiko Hond, Yoshinori Hasegawa, Tsutomu Nakashima, Yasuo Koike, Impact of micro arousal associated with increased negative esophageal pressure in sleep-disordered breathing, Sleep Breath (2009) 13:369-373 13. Punjabi, Naresh M., The Epidemiology of Adult Obstructive Sleep Apnea, Proc Am Thorac Soc 2008; Vol 5. pp 136–143

TECHNOLOGYupdate

3D Imaging of the Upper Airway with Cone Beam Computed Tomography

by Douglas L. Chenin, DDS

O

bstructive Sleep Apnea (OSA) is a sleep related breathing disorder with a pathophysiology that is highly dependent on the form and function of the upper airway anatomy. The upper airway anatomy of patients can be visualized in 3D in great detail using Cone Beam Computed Tomography (CBCT).

The ability for clinicians to analyze and comprehend the anatomy of their patients is of the utmost importance. New CBCT software technology updates in the Invivo5.4 software by Anatomage Inc have just been released which push the boundaries of what CBCT imaging can do for upper airway assessments. The new tools and features provide very comprehensive visualizations, measurements, and visual graphs. This article provides a brief description of the new tools and features and demonstrates some of their clinical applications.

All CBCT software packages minimally provide tools and capabilities to visualize the airway in cross-sectional views and to preform linear measurements. The typical setting is to use a Multi Planar Reformatted view (MPR) where the sagittal, axial, and coronal views can be visualized simultaneously in a grayscale colorization scheme (Figure 1). Despite their simplicity these views can be of tremendous value to quickly assess patientsâ&#x20AC;&#x2122; airways and adjacent anatomical structures. This technology enables clinicians to easily identify patients with swollen tonsils, large or long soft palates, airway constrictions, nasal and sinus disease, septum deviations, and more (Figure 2). These MPR visualizations provide clinicians with a better understanding of how patient anatomy contributes to OSA and may help with determining appropriate referrals and thus also aid in the decision making process for combination therapy.

The next level up of advanced software tools involve airway tracing features that give the user the capability to delineate the airwayâ&#x20AC;&#x2122;s boundaries, measure its volume, and

Figure 1: Multi-Planar Reformatted (MPR) view with 3D rendering (Invivo5 by Anatomage).

Figure 2A: Sagittal slice showing patient with large soft palate.

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TECHNOLOGYupdate

Figure 2B: MPR view of patient with severe rhinitis and pansinusitis.

Figure 3: MPR view and traced 3D airway with measurements and graphs.

Figure 2C: MPR view of keratocystic odontogenic tumor.

Figure 4: 3D model of the airway with volume and MCA measurements.

calculate and locate the Minimum-Cross-Sectional Area (MCA) (Figure 3). Moreover, it is important to remember that although they are the more advanced and visually stunning assessments, the grayscale cross-sections previously mentioned still provide tremendous value in assessing the complete anatomical picture of the patient. The advanced segmentation tools essentially zoom in and focus solely on the airway apart from the rest of the anatomy and they provide very detailed information on the airwayâ&#x20AC;&#x2122;s size, shape, and constrictions if any are present.

However, these detailed airway assessments still need to be used in combination with the standard cross-sectional visualizations of the entire CBCT scan in order to properly conceptualize the complete anatomical picture.

There are significant advantages to the airway tracing and modeling features mentioned above. For instance, they can create a 3D model of the airway that can be visualized in order to give the clinician a better understanding of the airwayâ&#x20AC;&#x2122;s morphology and where problem sites are located (Figure 4). They make it very easy to visualize the

Douglas Chenin, DDS, is a graduate of the University of the Pacific Arthur A. Dugoni School of Dentistry. Dr. Chenin worked directly with Anatomage for five years as the Director of Clinical Affairs where he helped in the development of the Invivo5 CBCT Imaging software and the Anatomage Surgical Guide system.

He has earned a reputation of a CBCT technology expert with his extensive participation in study clubs, seminars, conferences, and his numerous professional publications about CBCT imaging for various dental specialities. Dr. Chenin founded his own CBCT Consulting and education company called Clinically Correct Inc. which focuses specifically on teaching CBCT imaging technology. He also works in conjunction with BeamReaders Inc directing the implant planning consultations and surgical guide facilitation services.

36 DSP | Fall 2015

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TECHNOLOGYupdate

Figure 5: Demonstration of the easy tracing steps for segmenting an airway.

Figure 6: New measurement capabilities and graphical displays.

anatomy that is directly impacting the airway and creating indentions in it which are typically caused by structures such as the soft palate, base of the tongue, and tonsils. Ad-

Figure 7A: Airway analysis of a ribbon shaped airway occluding near the base of the tongue.

Lateral measurements are much longer than the anteroposterior dimension.

Figure 7B: Airway analysis of a pediatric patient with swollen adenoids and tonsils. Graphical representation shows a longer anteroposterior dimension than the lateral dimension at the location of the tonsils. (All images created with Invivo5.4 by Anatomage Inc.)

38 DSP | Fall 2015

ditionally, 3D models of the airway provide further measurement and even automatic detection capabilities. In the Invivo5.4 software, when the airway is segmented both the volume measurement of the airway and the Minimum Cross-Sectional Area (MCA) are automatically detected and calculated.

The airway segmenting tool within Invivo5.4 functions by drawing a line down the middle of the airway in a sagittal grayscale view (Figure 5). After the line is drawn the software will automatically detect the airway space within the soft-tissue boundaries based on the Hounsfield Unit threshold of air. Once the airway lumen has been defined and the boundaries are well established the volume of the airway and the Minimum Cross-Sectional Area (MCA) are automatically generated. Amazingly, the entire process only takes a few seconds.

The new tools of the Invivo5.4 software go even a few steps further and provide several new automatic measurements and new graphical data representations as well. In addition to the volume and area measurements mentioned above the new 5.4 update also provides lateral and anteroposterior measurements of the airway. These measurements along with the MCA, are provided as increments along the entire length of the airway. The measurements are mapped out in a visual graph as well (Figure 6). By comparing the lateral and AP dimensions the clinician may obtain an appreciation for the general shape of the airway. For example, when the lateral dimension of the airway is significantly greater than the anteroposterior dimension the airway is more ribbon shaped (Figure 7A).

In the presence of swollen tonsils, the anteroposterior dimension can become greater than the lateral dimension (Figure 7B). When

TECHNOLOGYupdate the lateral and anteroposterior dimensions are roughly equal the airway will be appear square shaped.

Beyond the above mentioned applications, these new measurements also provide a new way of conceptualizing the airway by the means of quantifying the shape of the airway. The axial cross-sectional shape of the airway at any given vertical level can be expressed as a ratio of the lateral measurement over the anteroposterior measurement. With this equation, a patient with swollen palatine tonsils would stand out as having a ratio value less than <1 around the vertical level near the base of the tongue. While a patient with a ribbon shaped airway would have a ratio value of 3-4. If a value that is several times greater than 1 is present near the nasopharynx it could indicate swollen adenoids.

If that same value is present at the oropharynx level its most likely caused by the soft

palate, the base of the tongue, or both. Thus, this ratio and its location could be used in the future to expand the automatic detection and airway assessment capabilities of CBCT software even further. The new tools just released are a step in this direction and pave the way for airway shape quantification in future updates.

The Invivo5.4 software updates have pushed the boundaries of what CBCT technology can do for upper airway imaging and these boundaries will continue to expand as future updates are released. The new visualizations, measurement capabilities, and visual graphs not only provide great diagnostic tools, but also excellent patient education and presentation materials. The new updates and tools also provide new research potentials to explore and it will be exciting to witness the research that is produced with them and the correlations that are discovered.

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DentalSleepPractice.com

39

The Use of

in Our Practice

by Dr. Todd Morgan

VERTICAL

CLINICALfocus

40 DSP | Fall 2015

B

ackground

The importance of incorporating vertical dimension (VDO) into jaw positioning for treatment of OSA with oral appliances has been largely overlooked in the Dental Sleep Medicine community. Although some commercial bite registration products include a vertical component, there is little critical evidence to support their use. Additionally, early work by Peter Cistulli and his group showed that adding VDO did not improve outcomes with oral appliances. In that study the patients’ existing dorsal fin appliances were opened from a starting 4mm of inter-incisal distance to 14mm.1 More recent clinical evidence from our group, however, has demonstrated that selected patients may benefit from increasing VDO when adding smaller, calculated amounts.

Based on clinical experience using this approach, we have had considerable success improving patient comfort and outcomes. I have been asked to share our experiences along these lines with the readers of Dental Sleep Practice magazine.

In our practice we routinely deploy a calculated amount of vertical and protrusive positioning with each case using the Apnea Guard® system. This system is easy to use and was developed based on our work with OA titration and follow-up using Home Sleep Testing. The Apnea Guard trial oral appliance was designed to primarily serve three functions: 1) Provide determination of the correct jaw position for any design of custom oral appliance 2) Enable the dentist or sleep laboratory to provide immediate treatment for patients 3) Reduce the time and the number of appointments necessary to reach adequate treatment.

Based on our clinical trial demonstrating equivalency between AG and custom appliances2, some of our sleep labs have begun fitting and using the AG to assess a patient’s response to OAT during their overnight PSG. The sleep labs are then able to offer their patients more treatment options going forward, and perhaps even better is that the patient has immediate treatment for their OSA by using the AG out the door, and while waiting for their custom appliance! Other labs that do more home sleep testing are also helping dentists to identify good candidates for OAT prior to the purchase of a custom device. Besides this being good medical practice, insurance carriers in our region are very interested in this approach since it saves healthcare dollars by identifying responders to OAT ahead of making larger expeditures.

CLINICALfocus Our Approach

After the patient has been consulted and examined, several design options of the custom oral appliances are demonstrated.

We invite the patient to be involved in this process and ask questions. Based on clinical judgment, the sleep study data, and the patientâ&#x20AC;&#x2122;s oral presentation or preferences, a design is chosen. Following the usual impressions the Apnea Guard protocols are implemented, requiring approximately 10 minutes to complete.

Vertical tray height selection will depend on gender and tongue size (figure 1). Females start with less VDO (a low size tray) and Males start with a medium tray height. Then the tray height is increased by one size depending on whether obvious tongue scalloping is present (figure 2). Three simple steps are followed to center the patientâ&#x20AC;&#x2122;s teeth into the AG expanding trays that are filled with the recommended PVS putty.

Figure 1: Low, medium and high vertical tray heights are utilized for the correct VDO depending on gender and tongue size.

Figure 2: A scalloped tongue determines the correct vertical tray height.

Protrusive positioning is calculated to 70% using the AG slider (figure 3) and these settings are provided to the dental laboratory for custom appliance fabrication. Protrusive is reduced by 1mm for patients leaving with the AG as immediate treatment and they are given instruction to advance forward that same one millimeter before their next appointment. (The complete AG technique can be viewed at http://www.advancedbrain monitoring.com/apnea-guard/).

The patients often return with their jaws adequately conditioned and adapted to advancement, and are very happy to move to their custom appliance! For for those who will be tested by PSG or HST, the AG is left at 70% for that night of testing. Sleep technologists are instructed to titrate the patient forward on the night of PSG based on another protocol when response is not adequate. So far, we have rarely had to decrease protrusion when the AG protocol is followed, although before AGâ&#x20AC;&#x2122;s arrival I had plenty of concern about advancing patient immediately to the full predicted protrusion.

One surprising effect that we have seen is adding VDO consistently makes protrusion more comfortable with less muscle/joint soreness

Figure 3: The sliding element of the Apnea Guard precisely determines protrusive setting in 1 mm increments.

Dr. Todd Morgan is board certified in Dentistry and Dental Sleep Medicine. His goal for patients is very simple: to deliver the best dental care in a relaxing, comfortable, and enjoyable environment.

Dr. Morgan graduated from the Washington University School of Dental Medicine in 1985, promptly returned to his hometown San Diego and began his practice in 1986.

Dr. Morgan is internationally recognized as an expert in the field of Dental Sleep Medicine and has completed several clinical research studies and published many scientific papers on the treatment of snoring, sleep apnea, and headache with dental devices.

Dr. Morgan is the co-inventor and holds interest in the intellectual property associated with Apnea Guard.

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CLINICALfocus Time Savings in Reaching Optimal Outcomes When the correct combination of protrusion and vertical dimension is deployed at the outset of treatment we have seen a considerable reduction in the number of follow-up appointments needed for further calibration. In order to determine how much time was saved using AG, we performed a retrospective survey of charts prior to the time we began using the AG system, and looked at the number of appointments needed to reach an endpoint of calibration with acceptable outcome for the AHI. Then prospectively, we made the same observations using the Apnea Guard, comparing the two groups for differences with regard to number of appointments required to reach a treatment endpoint, costs, and outcomes.

Using Apnea Guard protocols we were able to improve our rate of successful out-

Figures 4A-4B: A lubricant is applied to the upper occlusal surface (4a.) that will allow burnishing the acrylic risers to the desired VDO (4b.).

comes from 79% to 93%. The elapsed time from the start of therapy until a successful outcome is achieved has been reduced from an average of 177 to 33 days. The reduction in office visits/chair time contributed to a savings of $455 per patient which more than covers the $60 cost for the Apnea Guard.

How Does VDO Improve Outcomes?

Theoretically, adding VDO may improve upper airway dynamics by one or two routes: 1) By putting the hyoid sling musculature under additional tension, primarily via the stylohyoid and styloglossus muscles, or 2) By increasing a phenomenal known as tracheal tug. My assumptions are based on the dynamic interaction of the infra and supra hyoid muscles and observation on lateral imaging that demonstrates a “smoothing” of the pharyngeal mucosal outline. Whatever the mechanism, we have found in clinical practice that VDO acts as a surrogate to further protrusion in bringing down the supine AHI. One surprising effect that we have seen in clinical practice: is that adding VDO consistently makes further protrusion more comfortable for the patient, and often mitigates muscle/joint soreness (I will let the gurus of the TMJ world figure this one out).

Adding VDO is easily accomplished at the chair with a lab handpiece and cold cure acrylic (figure 4). One exception is the Narval appliance, where VDO cannot be increased without the use of a novel vertical tab (figure 5). These V-tabs come in 1, 2 and 3mm thicknesses and are designed to fit over the fin on the lower component tray. You can contact your Narval lab to obtain the tabs and full application of their use.

I hope that the reader may gain some insight here to the use of VDO in their future cases. I am confident that more scientifically based guidelines for calibration of Oral Appliances will bring greater success and satisfaction among our colleagues and of course, our patients!

1.

2.

Figure 5: 3mm V-Tabs in place on demo. 2mm tabs (inset) ready for placement.

42 DSP | Fall 2015

3.

Am J Respir Crit Care Med. 2002 Sep 15;166(6):860-4. Effect of vertical dimension on efficacy of oral appliance therapy in obstructive sleep apnea. Pitsis AJ1, Darendeliler MA, Gotsopoulos H, Petocz P, Cistulli PA. Sleep Disorders & Therapy Levendowski et al. J Sleep Disord Ther 2011, 1:1. Initial Evaluation of a Titration Appliance for Temporary Treatment of Obstructive Sleep Apnea. Daniel J. Levendowski1, Todd Morgan and Philip Westbrook POSTER reference

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REACHINGout

Bring on the Snorers:

A Case for Entry-Level Sleep Disordered Breathing Products in the Dental Practice

by Patrick Tessier, MBA

S

leep disordered breathing (SDB) is certainly the most prevalent, under-diagnosed health issue of our time, affecting approximately 90 million Americans. Add in the second hand snore recipients and it’s difficult to find people who are unaffected by snoring or sleep apnea.

Most people that decide to take action to treat their sleep disordered breathing do not immediately think of their dentist to help them.

They don’t go to their primary care MD. Most people first go online.

With over $10 million spent by prefabricated oral appliance manufacturers per year marketing to consumers, it’s pretty easy to find a potential solution. Our fellow citizens purchase somewhere in the range of 750,0001,000,000 of these oral appliances and other SDB treatments every year. The DSM practices are delivering less than 75,000 custom appliances per year. This means that only about 10% of patients are obtaining treatment from a professional, 90% purchase something without any professional oversight.

Are they getting proper treatment? Would they be better off seeking out professional treatment? How do health care professionals reach these patients and get them engaged with their practices?

There are many questions and opinions about this subject. But, a couple observations

44 DSP | Fall 2015

are widely supported by research and literature: • Market demand for SDB treatment is huge and getting bigger.

• People are willing to spend $100s for simple SDB products.

• Very few professionals offer a low cost entry point for their treatment.

Like many of the professionals involved in treating SDB, our mission is get more people treated in a professional setting. The benefits to improving the lives of folks with SDB and their sleeping partners affects all of us. We need your help! The following lays out the health care and business argument to offering a low cost, entry point for SDB patients and their partners.

Health Care Case

The professionals engaged in treating SDB know the statistics. Only 10-20% of the population afflicted with sleep apnea have been diagnosed and been offered treatment.

Of the 90 million people in the US that have some form of sleep disordered breathing, includ-

REACHINGout ing snoring, only about 1% find treatment every year. And less than 0.1% each year are professionally treated with custom oral appliances.

Since the great majority of patients are self-treating with pre-fabricated appliances or other devices, the easiest method to getting more patients into the professional practice is to offer low cost products directly to the patients.

Our research has shown that if the provider offers small steps, then the patient is more likely to complete the SDB process. For example: A Stop-Bang questionnaire is a good starting point, easy to administer and clinically validated. Using a pre-fabricated trial appliance can provide validation of the oral appliance treatment strategy. It’s not long lasting or comfortable compared to the custom device, but gets the patient to the next step of HST or PSG. This leads to an MD evaluation, potential diagnosis and Rx. Finally, we have all the steps needed to treat with the custom oral appliance. This is just an example, your protocol may be different.

One of the pioneers in oral appliance therapy, Airway Management, is promoting this method. They have developed a protocol called the TAP Method™, which calls for the delivery of a low cost trial appliance at the beginning of the process. Using the TAP Method™, patients are engaged early with a low cost solution. Once connected, the professionals can keep them engaged with the practice all the way through successful long term treatment.

Whether the low cost solution is professional grade or consumer grade pre-fabricated oral appliance, the result is the same. More people getting professional treatment for SDB. If health care providers offer entry level treatments, they can help make the world a better place. Get the patients started and coming back for long term treatments.

Business Case

The business argument for offering low cost entry level SDB products is strong. Here is a simple breakdown of the advantages to those practices that offer low cost starting points.

• Take advantage of the marketing spend from manufacturers of pre-fabricated oral appliances. º Over $10 million a year is being spent in TV, Radio, Internet and print ads. º This has been going up at least 25 -50% per year for the last five years. º Divert that business into your practice.

• Dental practices are using low cost appliances to attract new patients. º This is a new market segment for dentistry. º Just like bleaching, cancer screening and Invisalign, treating SDB creates new opportunity to differentiate and expand a Dental Practice.

• A cash based service of treating benign snoring with pre-fabricated products can create excellent margins. º The actual delivery of the appliance is a simple operatory procedure. Less than 15 mins. º The consumer market has shown it will pay between $250 and $750 cash for the appliance and delivery service.

• If the patient purchases the prefabricated appliance from the DSM practice, they are much more likely to return for the custom appliance. º If they purchased the pre-fabricated appliance online, they are less likely to then move to a custom product from a professional. º Once they start treatment with a professional, they will stay with that professional. º To increase the conversion to a custom appliance, many successful DSM practices rebate the cost of the pre-fabricated appliance, if the patient accepts treatment using the custom appliance.

Summary

Dentistry is the ideal health care provider segment to serve the general public and get more people treated for sleep disordered breathing. Using pre-fabricated appliances with Dentist supervision is one of the best ways to get more people started on the path for successful treatment and life improvement.

“The man who moves a mountain begins by carrying away small stones.” - Confucius

Patrick Tessier, MBA, is the founder and CEO of SnoreMart, Inc., a SDB specialty distributor serving consumers and professionals. He founded Modern Dental Laboratory USA, a national dental lab, and brought the popular The Moses™ custom oral appliance to DSM professionals around the world. An epic snorer, he can be contacted at 425-250-6290 or patrick@snoremart.com.

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TEAMfocus

Surgical Procedures

Friend or Foe? for OSA

by Glennine Varga, AAS, RDA, CTA

D

ental sleep team professionals predominantly provide treatment for snoring and OSA with oral device therapy.

Therefore when asked about surgery as a treatment option, we may feel our therapy is superior to surgical procedures and with some surgeries having a low success percentage rate we can easily slip into the thought process that surgery is a foe to OSA. However, there are always two sides to every story.

We encounter patients, family and friends that have had surgery suggested as a treatment option and in most cases before an oral device. As team members we jump at the chance to educate them about oral devices and we may disregard the suggested surgical therapy. Well, let’s take a step back and evaluate what can we do as dental sleep team professionals to learn more about surgical procedures and what to say when asked about the therapy.

Our goal ALWAYS should be to help our patients succeed at OSA therapy. This means helping them with combination therapies in some cases. Some patients may need PAP therapy with an oral device to help reduce air pressures. Other patients may need surgery to remove obstructive anatomy and an oral device to maintain the airway. Some may need all three or any combination. Every patient is unique and depending on many factors may need one or multiple therapies.

46 DSP | Fall 2015

To be part of successful therapy, it is important to understand that any recommendation from a physician should be promoted.

Granted there will be times when patients are given treatment recommendations with no mention of an oral device in situations when it may seem to be the ideal choice.

However, it is never a good idea to disregard a physician’s recommendation in any way.

We never know the patient’s entire medical condition nor do we want to be responsible for it. Therefore, it is important to assume the patient’s treating physician has prescribed what is best for the patient. This may take some effort on your part to understand more about the various therapies so you can support the patient’s choices about what has been recommended.

Conversations with patients are the key to dental sleep medicine. Here are some facts about surgery for upper airway resistance that may help you educate patients regarding what’s been recommended:

Fact 1

There are about 7 types of surgical procedures for upper airway resistance. A dental team professional should know about them all. Visit http://www.aadsm.org/upperairway. aspx for more detailed information. Maxillomandibular Advancement (MMA) is currently considered the most efficacious surgical

TEAMfocus procedure for treatment of OSA, particularly severe OSA. Success rates ranging from 94100%. This procedure surgically repositions both jaws forward to increase the airway. Anterior Inferior Mandibular Osteopathy with Hyoid Suspension (AIMO). This procedure pulls the tongue forward involving the chin bone and anterior neck muscles. Various surgeries of the soft palate are the most common and aim to reduce specific anatomic obstructions within the airway including Uvulopalatopharyngoplasty (UPPP), Laser-Assisted Uvuloplasty (LAUP) and Radiofrequency Volumetric Tissue Reduction (Somnoplasty). Nasal surgery to maximize nasal airflow is common. Tongue volume reduction and weight reduction, including Bariatric surgery and Cervicofacial Liposuction to remove excessive fatty issue around the neck, are recommended for appropriate patients. Tracheostomy typically is a patient’s last surgical option to bypass upper airway blockages.

So when a patient asks about surgery to reduce snoring or OSA, it is hard to make a generalized statement since there are several different types of surgery. If possible try to get more specific information as to what type of surgery is recommended. It never hurts to suggest an oral device as means of preservation. A physician recently told me, “Your own anatomy is best and working with that as long as possible is most favorable. Once options are exhausted with your own anatomy then surgery is the next best choice.” This suggests less invasive treatment first before moving forward with an irreversible treatment option.

Fact 3

Most physicians love referrals. Reach out to your local Ear Nose and Throat doctors, Oral Surgeons, and other physicians to find out what to look for and what would warrant a referral for surgery. All patients are different and there will be those that require more than one way to reduce upper airway resistance. It is critical to work with a number of physicians that feel the same way. If you get a chance, ask to observe patients in friendly offices – you’ll learn a bunch.

In my opinion surgery is a friend to OSA. Like many medical issues, there are often many treatment choices available; the more focused the clinician, the more likely she/he is to see many pathways to success. So long story short.

Why not try the simplest approach when applicable and work your way up from there? Include lifestyle changes, sleep hygiene, sleep position, oral device therapy or PAP, surgery, or combinations of several therapies. Always remember every person is different and a full subjective and clinical evaluation is required for any treatment decision. Keep reaching for the goal of helping your patients succeed with OSA therapy!

This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. 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!

There are about 7 types of surgical procedures for upper airway resistance.

A dental team professional should know about them all.

Fact 2

Technology and procedures are advancing constantly. It is important to keep up with the latest surgical procedures as the sleep breathing industry is growing quickly. Check out http://www.sleepreviewmag.com/2014/09/ alternative-therapies-obstructive-sleepapnea/ to learn more. It’s astonishing to think of how much effort, money and skill it takes to develop an electric stimulator that is surgically placed within your body to stimulate the hypoglossal nerve to move your tongue forward when your sleeping. WOW! Yes I will try that, once I have exhausted oral device therapy since, after all, the end result is the same…keep the anatomy out of the airway.

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 19 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 tried the use of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp. She has trained and assisted hundreds of dental offices on practice management, TMD/Sleep Apnea concepts, medical billing and team training. For more information visit www.dsmbootcamp.com or email g@dsmbootcamp.com.

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MDconnection

Building Relationships The Key To Dental Sleep Medicine Success!Â

by Neal Seltzer, DMD, FAGD, D.ABDSM, D.ASBA, D.ACSDD, and Jeffrey S. Rein, DDS, FAGD, D.ABDSM, D.ASBA, D.ACSDD

D

ental Sleep Medicine became a passion of ours over two decades ago. The reason we open this article with that statement is because the key take away message is passion! That passion comes from the rewards we have had in helping so many patients improve the quality of their lives.

The number one reason we have had success in Dental Sleep Medicine is because our passion has enabled us to build great relationships.

48 DSP | Fall 2015

We feel great pride in the accomplishments we have enjoyed in our dental practice.

Dentistry is a magnificently rewarding career.

Our state of the art dental practice, utilizing cutting edge technology such as CEREC in office milling, Galileos 3D conebeam imaging, the CANARY caries detection system, rotary endodontic technology, STA single tooth anesthesia, buffered anesthesia, as well as investments in dental practice consultants and well trained and educated staff, has made it possible to deliver high end efficient treatment that is patient friendly, profitable and rewarding. Relieving pain and Improving quality of life through dentistry is a gift.

However, nothing we do in dentistry compares to the magnitude of satisfaction we both receive when we actually help saves lives through Dental Sleep Medicine.

Saving lives! Who knew this would become a major part of our dental practice over 20 years ago. Once you experience that feeling, itâ&#x20AC;&#x2122;s hard to let go of it and that feeling has fueled the passion and drive we have had to continually build our Dental Sleep Practice.

Long Island Dental Sleep Medicine is one of the largest providers of oral appliance therapy in the New York City area. This accomplishment has come out of the passion but even more it has come out of very hard work building relationships in the medical community.

MDconnection For the majority of our career treating Obstructive Sleep Apnea, the main source of patients has come via physician referral. The network of physicians who refer to us has been the backbone of our growth. It has taken years of perseverance to forge these connections and relationships but that effort has paid off in spades.

Over the years, we have spent a lot of time speaking with other dentists who are interested in incorporating the treatment of OSA into their practice. Many have expressed difficulty in getting physicians to get onboard and send patients their way. For those dentists passionate about building a Dental Sleep Practice, we want to share some of the things we feel are key to establishing great long-term relationships with our medical colleagues.

Education

This point is huge. If you want to impress physicians you need to have as much education about sleep medicine as possible. You are entering their arena: the medical world. Know your stuff and be able to converse in their language. They are responsible for their patients and they want to know they are sending a patient to a confident and knowledgeable doctor.

More importantly, be educated for your patients. As we said, this is life-saving medicine and it comes with tremendous responsibility.

There is no end to the learning. We continually attend courses in Sleep Medicine and keep

abreast of the latest and greatest in technology associated with oral appliance therapy.

Networking

At the end of the day, connecting with physicians and sleep labs comes down to one thing... meeting them face to face and letting them know who you are and what you bring to the table. At first, it can be a little intimidating.

Again, you are entering the world of medicine.

So come armed and let the physicians know you are educated, passionate and dedicated to helping their patients. Most physicians have had little exposure to sleep medicine themselves. They have been frustrated that there have been few options for their patients struggling with CPAP. For the most part, you will be a new connection for their practice and a welcome option for many of their patients.

We have spent years pounding the pavement, going door to door and being missionaries for Oral Appliance Therapy. We have hosted study clubs, done lunch and learns, visited sleep labs, and offered our time to educate medical office staff about what we do and options patients now have. In essence, we have tried to be a team player with all the physicians we meet and help them deliver better care to their patients. We truly bring our passion to the physician and we believe that message has bonded our relationships with so many of our dedicated referral sources.

MDs are responsible and want to know they are referring to a confident and knowledgeable doctor.

Dr. Neal Seltzer received his Doctor of Dental Medicine degree from the Tufts University School of Dental Medicine in 1982. He continued his education with a residency program in New York City at Bird S. Coler Memorial Hospital. After this, he continued his academic affiliation as an assistant clinical professor at New York University College of Dentistry. An expert in removable prosthetics, Dr. Seltzer is currently the clinical director of the Equipoise Dental Center in Bergenfield, New Jersey. This is a world famous teaching facility that trains dentists and laboratory technicians the Equipoise philosophy of prosthetic design. He lectures internationally on this topic and has written articles that have appeared in dental journals. Dr. Seltzer is a member of the American Dental Association, New York State Dental Association, Nassau County Dental Society; a Fellow of the Academy of General Dentistry, Academy of Sleep Medicine; a Diplomate of the American Board of Dental Sleep Medicine, American Sleep and Breathing Academy, and Academy of Clinical Sleepdisorder Disciplines.

Dr. Jeffrey S. Rein received his Doctor of Dental Surgery degree from Loyola University School of Dentistry in 1982. He furthered his studies as a resident at Bird S. Coler Memorial Hospital in New York City where he met Dr. Seltzer. Then, together in 1984, they opened their private practice in restorative dentistry in Williston Park. Dr. Rein also served on the faculty at New York University College of Dentistry in both the Katherine S. Milbank Special Patient Care Clinic and the Department of Oral Medicine. He has served as a distinguished committee member in the Academy of Dental Sleep Medicine. As a member, he actively worked to develop Insurance Reimbursement Guidelines and contributes to manuals used by dental professionals across the nation. Dr. Rein has extensive computer knowledge and has been involved as a consultant to many dental software companies aiding them in the development of software programs to more efficiently treat patients. He is a member of the American Dental Association, New York State Dental Association, Nassau County Dental Society; a Fellow of the Academy of General Dentistry, Academy of Sleep Medicine; a Diplomate of the American Board of Dental Sleep Medicine, American Sleep and Breathing Academy, and Academy of Clinical Sleepdisorder Disciplines.

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MDconnection As our Dental Sleep Practice grew, we decided to really focus our practice in this area. We made a decision to head in a direction in which we would be leaders in our area in treating OSA. In order to accomplish this goal we reached out for help. We needed people who could propel our ability to make connections with physicians to a new level. This meant working with a marketing team.

Marketing

One valuable connection with a good referrer can make the investment in marketing pay for itself.

50 DSP | Fall 2015

As professionals, we suggest always aligning yourself with professionals when you can in business. If you needed help in a legal matter you would hire an attorney. For your finances you use an accountant or financial planner. For insurance needs you consult an insurance agent. To market yourself, it is invaluable to invest in a marketing team.

We met the SLEEP APNEA MD marketing team about five years ago at one of the AADSM meetings. Their game plan of internet marketing, newsletters via the mail, and reaching out to physicians with personal skilled phone contact, impressed us.

Website: We put our trust in SLEEP APNEA MD and they created a website for us dedicated to our Dental Sleep Practice. This website, under their guidance, has kept us in the top search profiles in our area year after year. It has also become a proud reference and information source when meeting physicians and for our patients to use also.

Branding: By branding the sleep medicine half of our practice into LONG ISLAND DENTAL SLEEP MEDICINE, we established a distinction of commitment and experience and an image of what we wanted the public and physicians to recognize us as; EXPERTS in this field. So we separated everything in our practice into two divisions. Our dental practice had its own identity and sleep medicine would have its identity. Business cards, brochures, stationery, and most of all the website would represent our vision of LONG ISLAND DENTAL SLEEP MEDICINE. If you are seriously going to try to make an impact in your area we would suggest doing the same.

Leverage: This is the term SLEEP APNEA MD used to guide us into becoming a prominent force in our area. It means getting the most bang for the buck, as you would say, in reaching out to physicians and the community. You need to spend money to market

your practice. The key is to leave it to the professionals to leverage that money so that it is well spent and it pays off.

Newsletters: Keeping your name out there and on their minds. That’s what the monthly newsletters do. It’s important to keep our medical colleagues abreast of what’s new and exciting in our field and specifically what we are doing in our practice that’s cutting edge. It’s a great communication tool that keeps reminding the physicians that we are there for them and their patients.

Phone Calls: Short of meeting a physician in person, nothing is more efficient in making a connection with a new medical office than a professionally made custom script that the marketing team creates and executes to make contact by phone. Reaching a receptionist, an office manager, or even the doctor are all golden opportunities to educate. It is still amazing to us how many physicians are not knowledgeable about sleep issues and OSA. These cold calls are very often met with gratitude and curiosity to learn more. Most of the time, they result in an eventual meeting or at minimum, a request for our office info including referral cards. One valuable connection with a good referrer can make the investment in marketing pay for itself.

Remember as a provider of oral appliance therapy for obstructive sleep apnea, you are a specialist in a medical world. However, no one is better suited for this task than a well qualified, well educated dentist. Our knowledge of the oral cavity, with all its complexity from periodontal issues, restorative considerations, and TMJ function, to name just a few, makes us the ideal practitioner to deliver, monitor and maintain oral appliances. It is your job to educate yourself, as well as you can, to enable yourself to treat your patients with the utmost of care. Once you are saving lives we know the passion will be sparked in you as it was in ourselves. Building relationships will come as your medical colleagues embrace your passion.

Building a successful Dental Sleep Medicine practice takes a lot of hard work. It also takes time.

Create a strong presence in your area.

Connect with a great experienced marketing team. We hope some of the advice we have shared will bring you success and most of all help people in a way you never knew dentistry could. We promise you, it will all be worth it in the end.

LEGALledger

Are You Guilty?

by Ken Berley, DDS, JD, DABDSM

52 DSP | Fall 2015

LEGALledger

F

requently I am questioned about billing practices. This area of the law which encompasses insurance fraud and abuse is too large to cover in one small article. Therefore, this overview may be the first of several articles on this subject as I am sure there may be a great deal of interest and confusion generated as a result of this writing. You should be aware that the law on this subject is covered by state and federal statutes, state and federal contract law and can result in civil and criminal penalties. In other words, you can go to JAIL if you are found guilty!

Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit. An example would be billing for services that are not rendered.

Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. An example would be performing a restoration on a patient when there was no pathology present or charging insurance an exorbitant price for a service.

Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with an intent to deceive the insurer. A conviction based on fraud requires a finding of intent, where a conviction based on abuse does not. If a jury cannot determine that your goal was to receive an unauthorized benefit you should not be found guilty of fraud, however, you could be held liable for insurance abuse by simply overcharging for services. Civil and criminal convictions based on fraud carry much stiffer penalties than a conviction for insurance abuse.

Reportedly, fraud and abuse are widespread and very costly to Medicare and the medical insurance industry. The United States Government Accountability Office (GAO) estimates that $1 out of every $7 spent on Medicare is lost to fraud and abuse and that in 1998 alone, Medicare lost nearly $12 billion to fraudulent or unnecessary claims. Although no precise dollar amount can be determined, some authorities contend that insurance fraud constitutes a $100-billiona-year problem.

According to BlueCross & BlueShield United of Wisconsin: What is health care fraud? Nov 30, 1999, false claim schemes are the most common type of health insurance fraud. The goal in these schemes is to obtain undeserved payment for a claim or

series of claims. Such schemes include any of the following when done deliberately for financial gain: • Billing for services, procedures, and/ or supplies that were not provided.

• Misrepresentation of what was provided; when it was provided; the condition or diagnosis; the charges involved; and/or the identity of Civil and criminal the provider recipient.

• Providing unnecessary services convictions based on or ordering unnecessary tests. fraud carry much In Dental Sleep Medicine, it appears that the most common issues stiffer penalties than that I have observed involve failure a conviction for to balance bill and charging different rates for different patients. So we will insurance abuse. briefly discuss these issues.

May a dental sleep medicine practitioner: (1) as a general rule, waive an insured patient’s co-payment amounts, if based on the patient’s financial hardship; (2) charge its uninsured patients lower rates than it charges its insured patients for the same services; and/or (3) charge patients who pay by cash lower rates than it charges patients who pay by credit card for the same services?

Many insurance policies cover a percentage of the sleep dentist’s “usual” fee. Some

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 is a Diplomate of the American Sleep and Breathing Academy and a Diplomate for the ABDSM. He 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.

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LEGALledger dental offices routinely charge insured patients more than uninsured ones but represent to the insurance companies that the higher fee is the usual one. This practice is illegal. It is also illegal to routinely excuse patients from copayments and deductibles.

(A copayment is a fixed dollar amount paid whenever an insured person receives specified health-care services. A deductible is the amount that must be paid before the It is illegal to routinely insurance company starts paying.) If insurance company is paying the excuse patients from the Sleep Dentist a percentage of the usucopayments and al and customary fee, then waiving co-payment on a regular basis, as deductibles. the well as charging lower rates to non-insureds or patients who pay with cash, is generally construed as insurance fraud. These practices may suggest that the Sleep Dentist’s usual and customary fee is not being accurately reported to the insurance company. When a discounted rate is charged to the patient, the question arises as to whether the discounted rate is actually the provider’s usual and customary charge.

Is this a true discount or is the office misrepresenting their real fee? Thus, routinely waiving co-payment amounts and charging higher rates to patients with insurance compared to non-insureds is illegal. It is legal, however, to waive a fee for a patient with a

genuine financial hardship or give free services to your pastor, but do not routinely waive deductibles and co-payments and use the financial hardship clause as the vehicle.

Discounts may routinely be offered to: family; clergy; professionals and long-term established friends. However, you should keep in mind that it would be difficult for the Sleep Dentist to prove in a court of law that an excessively large percentage of his patients were eligible for a discount. If you approve a discount for a patient, record in the patient’s record why the discount was given. If possible, you should document why the discount was appropriate. For example, if a discount is provided for a patient based on financial hardship, it is prudent for the Dental Sleep Provider to maintain proof of the financial hardship. Therefore if your office determines that you would like to offer a discount to an elderly patient on Social Security with no other source of income, the patient’s financial problems could be documented by an affidavit of financial need and a copy of the patient’s social security check. These documents would then become a permanent part of the patient’s medical record.

Studies have shown that if patients are required to pay for even a small portion of their care they will be a better patient. Patients who have a financial stake in their

S8262 Update

LEGALledger

Morning Unfortunately change is the only certainty that we have in life. As Winston ChurRepositioning chill said; “There is nothing wrong in change, if it is in the right direction. To improve Is This Therapy the is to change, so to be perfect is to have changed often.”

Standard of Care?

Sadly not all change is in the “right direction.” As of July 1, 2015, CMS has deleted S8262. As stated in our summer edition of DSP, I have employed S8262 to file medical insurance for custom lab fabricated morning repositioning appliances S since entering the field of DSM. However, I was informed in mid June that CMS was deleting S8262, just after my last article went into the hands of the attendees at the AADSM. Rose Nierman and I are working on another code to use and we have written CMS for S8262 to be reinstated. However, as of July 1, 2015, S8262 is no longer available. CMS manages the HCPCS codes and they can add or delete codes quarterly as needed. S8262 has been listed in the “temporary” code section for some time, but for some unknown reason has now being deleted. Please join us in writing CMS regarding this deletion. It is unlikely that CMS is aware of the need for that code for TMD, DSM and Oral Surgery. The address for Medicare is: Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore MD. 21244.

— Ken Berley, DDS, JD

by Ken Berley, DDS, JD, DABDSM

tandard of Care (SOC) is defined as: “What a reasonable and prudent practitioner would do in the same or similar circumstances.” SOC is a curious concept among medical professionals. Frequently, I discover that health care professionals do not understand that Standard of Care is a legal concept and is ultimately determined by a jury. Most professionals firmly believe that they determine the standard of care for their profession. To some degree that is correct. Health Care professionals (experts) present medical opinions in a court of law outlining what, in their opinion, should have been done to prevent a particular injury. Then a jury determines the standard to be applied. Until a jury rules on a particular therapy, no legal precedent or standard exists.

That begs the question; “Is the fabrication of a Morning Repositioning Device (MRD), within the SOC for the practice of Dental Sleep Medicine?” If not, should it be? Obviously, at this point no jury has determined that the inclusion of an MRD is legally mandatory, however, wouldn’t a reasonable and prudent practitioner fabricate an MRD to minimize the effects of mandibular advancement? In preparation for this article, I took an informal poll and found that only 52% of those polled routinely fabricated a MRD. When asked why MRDs were not routinely fabricated, I received excuses ranging from: not necessary; no reimbursement; don’t work, and patients don’t want another device.

In Dental side effects of mandibular advancement appliances – a 2-year follow-up.

J Orofac Orthop. 2008 Nov;69(6):437-47. doi: 10.1007/s00056-008-0811-9. Epub 2008 Nov 11. It was concluded that: Clinically small but statistically significant dental side DentalSleepPractice.com

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LEGALledger treatment make medical decisions based on need rather than because they are free. Routine waivers raise overall health costs. Such waivers are considered fraudulent because averaging them with the Sleep Dentist’s full fees would make the “usual” fees lower than the amounts actually billed for. For example, if a patient’s medical policy will reimburse 80% of the UCR fee and the dental sleep practice charges the insurance company $100 then the insurance company would be obligated to pay $80 and the patient pay $20.

If however, the sleep dentist were to routinely waive the $20 co-payment, the dentist’s usual and customary charge would be $80 and not the $100 submitted to the insurance company. Under those circumstances, the reimbursement from the insurance company would be $64. Thus resulting in fraudulent reporting.

Additionally, if a medical policy requires the patient to pay a $1,000 deductible before any benefits will be paid and the sleep den-

tist submits a claim for $1,500, the insurance company would pay the dentist $500 expecting that the dentist would collect $1,000 deductible from the patient. By waiving the $1,000 deductible, the dentist would be charging less for the services than he reported to the insurance company. This practice is fraudulent.

Insurance fraud is a serious crime with serious consequences. Please ensure that your office is compliant with state and federal laws. You are ultimately responsible for all of your medical insurance claims, even if you employ a billing service. Unfortunately, it is my opinion, that many of the billing practices routinely employed by medical insurance billing companies operating in Dental Sleep Medicine may be exposing trusting dentists to an audit. If you are audited, you could be charged with insurance fraud or abuse. Do not assume that your billing service knows the law! That could be a costly mistake.

DentalSleepPractice.com

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