Page 1

It’s the Picture Not the Words

That Moves Them by Erin Elliott, DDS

FALL 2017

Continuing Education

Breathing

is a 24 Hour Activity by Randy Clare

Co-Referrals

by Mayoor Patel, DDS, MS

Screening for TMDs Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Samuel J. Higdon, DDS


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INTRODUCTION

Take a Deep Breath

R

espiration. One of our body’s fundamental requirements, yet so much can go wrong. As dentists involved in airway therapy, we evaluate and treat a small portion of the respiratory system, yet our part influences the whole body far beyond its physical size. Close the airway at its only vulnerable point and the organism fails and dies. Pretty awesome that a dentist has this ability to impact health! And the earlier, the better. People thrive when their airway stays open all the time, from as young an age as possible. When our youngest suffer from a compromised airway, their health status is thrown off course – and the more nights (and days) they breathe poorly, the more their health can be affected. While it’s easy to measure health dollars and other costs associated with chronic disease, it’s difficult to come up with reliable statistics for the value of preventing the disease in the first place. That gives interventional, preventive efforts like children’s airway development a hard task to prove value in dollars. I know it feels good to help an adult have a better night’s sleep, and it feels awesome to help a child do so. Even with all the excitement about airway growth and development, millions of our patients, neighbors, friends and family are sleeping every night unable to breathe well. This restriction has gone on for years, decades sometimes, and only when there’s a health scare or a significant challenge to their quality of life do they seek treatment. As we consider what therapy is best, knowing how much their compromised airway has affected their whole physiology makes us better providers, coaches and solution-finders for them. Are you aware of the limitations to respiration that arise from COPD or chronic rhinitis? If you’re not thinking in 3D, perhaps imaging your patients in that comprehensive way, then it’s difficult to say you are involved in respiration. Handing over an appliance on prescription from a ‘higher’ medical authority is not the same as collaboratively working with differentially-trained peers to solve a complex medical problem. The challenges to reach that level are within the reach of any committed health professional – it’s just a lot of work to get there. Medical providers don’t need to know about teeth, gums and TMJ, but we dental professionals need to learn more about what our medical colleagues are trained in from early in their professional education.

Twenty years ago, when I was first learning about airway problems, my teachers told me about the 85% of undiagnosed sufferers around me. Sadly, that statistic is still thrown around today. Raising the youngest generation with open Steve Carstensen, DDS airways through growth and development will Diplomate, American Board of eventually move that needle – healthy young Dental Sleep Medicine adults replacing those who die too early from chronic disease. We can’t wait that long when we can have an impact today on the quality of life, health crises, and unnecessary expenditures related to those obstructed airways. Adults whose medical pathway has taken them far away from homeostasis and health may never be everything they could have been, but they can be healthier than they are now. That’s worth a lot. Patients with big problems in respiration often need complex solutions. What our airway profession needs is a triage tool that can be employed across the patient care spectrum to stratify risk for patients identified with compromised respiration. There are far more people with mild OSA or UARS than there are those with severe disease and significant comorbidities. Sleep physicians, highly trained and increasingly overbooked, can best be used to treat the sickest patients; let the well-trained and qualified non-physicians cover the mild disease and allow the body to heal with an open airway. Those whose comorbidities persist can engage the medical community with a better chance of therapy being effective. That’s not the system we have today. Maybe our leaders will see the value in that triage tool, in having more trained medical professionals looking to help our population. That’s the way I see we can move the needle on that 85% figure. Meanwhile, we ready ourselves by thinking beyond mandibular advancement, to growth and development, to understanding the respiratory system, and to forging strong relationships across the medical profession. DentalSleepPractice.com

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CONTENTS

10

Cover Story

It’s the Picture, Not the Words, That Moves Them by Erin Elliott, DDS Expand your vision to connect better with your patients.

20

Continuing Education

Breathing is a 24 Hour Activity

41

by Randy Clare Respiration is more than OSA.

Practice Growth

2 CE

#MADFanClub by Chris Bez Building your practice, one fan at a time.

CREDITS

48

Nasal Health

Chronic Rhinitis and the Sleep Dentist by Warren J. Schlott Nasal breathing is a vital function.

2 DSP | Fall 2017

52

Combination Therapy

Physician and Dentist Co-Referrals Improve Patient Outcome by Mayoor Patel, DDS, MS Working together is always better.


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CONTENTS

6

Practice Management

Test your Knowledge with our Medical Billing for DSM Quiz by Rose Nierman Excellent staff learning exercise.

14

TMD Series

Screening Patients for TMDs in a Sleep-Oriented Dental Practice by Samuel J. Higdon, DDS Look not just for snoring, but joint history also.

19

Industry Awards

26

Practice Vision

Cellerant “Best of Class” Technology Awards 2017 (Re)Defining Success in Dental Sleep Medicine by Barry Chase, DDS It’s not about getting the device to fit well.

30

Product Spotlight

Better Sleep Through Brain Wave Training by Patrick K. Porter, PhD

33

Product Spotlight

Aussie Dentist in OSA Breakthrough

Perfect solution for some patients.

34

Laser Focus

38

DSP Interview

Direct to Consumer Advertising for Sleep Therapy Aimed at getting more people sleeping better.

42

Fall 2017

Team Focus

Top 5 Things Team Should Know About Working with ENT MDs by Glennine Varga, AAS, RDA, CTA ‘Team’ is more than just in your office.

44

Team Engagement

Dentistry’s Value Added to Sleep Disorders by Bradley Eli, DMD, MS Living up to high expectations means optimum service.

46

Practice Development

The Importance of Website Lead Conversion

Helping the little ones off to a healthy start.

4 DSP | Fall 2017

Editor in Chief | Steve Carstensen, DDS stevec@medmarkaz.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkaz.com Editorial Advisors Steve Bender, DDS                           Ken Berley, DDS, JD Howard Hindin, DDS                          Ofer Jacobowitz, MD                       Christina LaJoie Steve Lamberg, DDS, DABDSM 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

by Ian McNickle, MBA How your website can lead patients to your practice.

56

Case Report

Treatment of a Patient Diagnosed with Severe OSA with an Oral Appliance in a Pre-Doctoral Student Clinic by Paul D. Levine, DDS Be encouraged that our new dentists are learning about airway.

60

Legal Ledger

Medicare DME/Telemedicine: 10,600-nm CO2 Laser Friend or Foe? Part 3 Frenectomies in Pediatric by Ken Berley, DDS, JD, DABDSM Patients with Compromised What do the rules say about in-person doctor visits? Airway & Swallowing by Martin Kaplan, DMD, and Peter Vitruk, PhD

Publisher | Lisa Moler lmoler@medmarkaz.com

64

Seek and Sleep

DSP Word Search

National Sales Director Kristin Sammarco | kristin@medmarkaz.com Manager – Client Services/Sales Support Adrienne Good | agood@medmarkaz.com Creative Director/Production Manager Amanda Culver | amanda@medmarkaz.com Website Manager Anne Watson-Barber | anne@medmarkaz.com E-media Project Coordinator Michelle Kang | michellekang@medmarkaz.com Front Office Manager Terri Burud | terri@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 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2017. 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.


Some things you shouldn’t do yourself Find the weak spot in your sleep practice with a consult from N3Sleep®. Are you just starting your sleep practice? Have you been treating sleep for years? Truth is, we could all do better. What would transform your practice? Sometimes it takes an outside perspective to see what needs to change. We’ve helped practices across the country transform their sleep programs, From screening to billing to marketing, we’ve helped practices like yours increase efficiency, increase effectiveness and see more patients. Hands-on training from N3Sleep is the fastest way to get your team working from the same playbook, on your systems, in your office, where they work every day. Maybe you have enough patients?

Marketing

Billing

Screening

Treating

Testing

Consulting

If you want more, call N3Sleep at 844.363.7533 today.

We set up your office and train each member of your team on their part in the Dental Sleep Medicine playbook: Screening

Medical Billing

Cloud Systems

Home Sleep Testing

3D Technology

Wellness Programs

Sleep Medicine Software

Medical Records

Marketing for Sleep Medicine

Join us at the 8th Annual DSM Collaborative & 2018 DSM Symposium Visit n3sleep.com/events/ for more information. 844.363.7533 | n3sleep.com | Help people. Save Lives. Consulting division of DreamSleep


PRACTICEmanagement

Test your Knowledge with our Medical Billing for DSM Quiz Revised ABN Form is Now Mandatory for DSM Treatment by Rose Nierman, CEO Nierman Practice Management

W

hen teaching medical billing to dental practices, I encounter quite a bit of confusion about Medicare for Dental Sleep Medicine (DSM). In our sleep and temporomandibular joint (TMJ) treatment lectures and Medical Billing for Dentists course, we endeavor to dispel Medicare and DSM billing myths as well as make updates available to DSM dentists. One area of mass confusion is the Medicare Advance Beneficiary Notice (ABN) form. Most dental practices are not aware of the ABN form which is understandable since we don’t use it for dental insurance – but the ABN needs to be part of your toolkit for DSM. For those who are aware of it, there still seems to be quite a bit of confusion surrounding the proper use of the form.

For DSM practices, it’s important to avoid a situation in which you may have to refund fees for your services or supplies. That is the main purpose of the ABN.

6 DSP | Fall 2017

For DSM practices, it’s important to avoid a situation in which you may have to refund fees for your services or supplies – and in short – that is the main purpose of the ABN. Whether you are new to the form or have it in your toolkit already, it’s important to know that Medicare has recently released a new version of the ABN, effective June 21, 2017. If you are a Medicare provider or supplier, you are obligated to use this new form. One of the changes is the addition of an expiration date of 03/20/20. Another change is this nondiscrimination clause: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov. You can download a copy of the new ABN form from this link: https://www.cms. gov/Medicare/Medicare-General-Information/BNI/ABN.html. The following quiz is helpful to test your Medicare billing knowledge: Since Medicare’s policy places oral appliances for Obstructive Sleep Apnea (OSA) under the

Durable Medical Equipment (DME) category, the quiz will reference DME. 1. Our office doesn’t have to follow the Medicare OSA guidelines since we are only “referring and ordering providers.” True or False 2. We are not a Medicare DME supplier, so we can simply charge Medicare patients cash for OSA oral appliances without the patient signing a form. True or False 3. Since we opted out of Medicare, our patients do not have to sign any forms. True or False 4. We can use any type of appliance that our dentist feels is appropriate and still be within Medicare guidelines. True or False 5. If we sign up as a DME supplier, then we also must file TMJ treatment claims to Medicare DME. True or False The answers to the all of the above questions are false. Explanations are below: 1. A referring and ordering provider is for Part B for billing Medicare services. Since most dentists do not provide services that Medicare Part B covers, the majority of dentists have enrolled as referring and ordering providers so that prescriptions will be covered for the Medicare beneficiary. Becoming a DME supplier is a separate application process. The DME application is available at https://www.cms.gov/Medicare/ CMS-Forms/CMS-Forms/Downloads/ cms855s.pdf. It is a minimum of 90day process to become a DME supplier and the application can be quite complicated. To ease the burden of the paperwork, Nierman Practice Management has a service for enrolling dentists as DME suppliers. More


PRACTICEmanagement

The ABN will ensure that if Medicare ultimately does not cover the oral appliance for OSA, you have the ability to charge the patient.

information about this service can be found at www.NiermanPM.com 2. If you are not a Medicare DME supplier and you provide oral appliance therapy, the patient must sign an ABN form that tells them that the device would potentially be covered if the patient went to a Medicare DME supplier. 3. The Opt-Out option is a 2-year period where the provider agrees that they (nor will the patient) file any Medicare claims for supplies or services. The patient must sign a different form which is called a private contract for practices which are opted out of Medicare. 4. Medicare maintains a list of cleared appliances called the PDAC list. Only appliances found on this list are eligible for reimbursement for E0486, the HCPCS code used to bill a custom made oral appliance for OSA. 5. Since Medicare DME does not cover appliances for the diagnosis of Temporomandibular Joint Disorder (TMJ), you do not need to bill TMJ orthotics to DME. An ABN does not need to be executed for items that Medicare never covers. The purpose of an ABN is to inform the beneficiary that Medicare will not likely pay for a certain item or service in a specific situation on the basis of medical reasoning and necessity, even if Medicare might pay for the item or service under different circumstances. This allows the beneficiary to make an informed consumer decision about whether to receive the item for which they may have to pay out-of-pocket. The ABN includes: • The items or services that Medicare isn’t expected to pay for

Rose Nierman, RDH, is the Founder and CEO of Nierman Practice Management, an educational and software company (DentalWriter™ and CrossCode™ Software) for Medical Billing for Dentists, TMD and Dental Sleep Medicine advanced treatment, and co-founder of the SCOPE Institute, a non-profit educational organization dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry. Rose and her team of clinical and medical billing experts can be reached at Rose@Dentalwriter.com or at 1-800-879-6468.

8 DSP | Fall 2017

• An estimate of the costs for the items and services • The reasons why Medicare may not pay • Three options for the patient to choose for moving forward with treatment… or not In the DSM setting, here are a few examples of situations in which an ABN may be used: • The dental practice is not a DME supplier • A Medicare approved (PDAC cleared) appliance was not used • The patient does not meet the criteria for coverage • The patient does not have a Detailed Written Order (DWO) from their physician • Services are not covered (where in another situation they may be covered) The main reason the ABN is so important: the ABN will ensure that if Medicare ultimately does not cover the oral appliance for OSA, you have the ability to charge the patient. The ABN proves that you informed the patient before providing services that it may not be covered, and why. If you do not have an ABN on file for the patient and Medicare ultimately does not cover the oral appliance, you cannot charge the patient – you must eat the cost! So why is Medicare such an important topic in the DSM arena? Of course, Medicare is largest insurer in the United States, but another reason revolves around how patients will end up in your practice for treatment. Sure, you can market your services to patients, but a common denominator in the most successful DSM practices we see is a strong referral base from physicians in the local medical community. The sleep physicians you will be working with typically look for a dentist who is enrolled in Medicare, as most physicians do base where they refer their patients on insurance type. From a referral standpoint, the more medical insurers you work with, the better. Dispelling some of the Medicare and Medical Billing Myths will not only help your practice treat patients who are suffering from OSA, but also gain reimbursement for them!


COVERstory

It’s the Picture Not the Words

That Moves Them by Erin Elliott, DDS

I

am a nice person. In fact I’m so nice that I told my front desk team members to always let sales reps through. My team doesn’t need to be a gate keeper because I’m always willing to at least meet them. I most likely will not buy from them, but hey, they’re just trying to make a living. I was known as the nice dentist to pay a visit to until the day a distributor representative came by. We are a very busy general dentistry PPO practice. We do all facets of dentistry including extractions and implant placement. My niche however is screening and treating sleep apnea. Dental Sleep Medicine has revolutionized my practice and my life. I love it. That day, the distributor representative was trying to sell me on cone beam. His angle? He was trying to sell me on cone beam’s use in DSM. I about became unglued. “There is no correlation to someone that is upright and awake to someone that is horizontal and sleeping!” He walked, almost ran, away as soon as possible and never brought it up or visited again.

Comparative airway view

10 DSP | Fall 2017

Fast forward two years to the day I started teaching a Dental Sleep Medicine 101 course with Dr. Tarun Agarwal at his teaching center in Raleigh, NC. His courses center around 3D and digital dentistry workflow. Of which I had none. I told him from the start I would teach the sleep apnea, but I wouldn’t teach that a dentist should own a CBCT in order to treat sleep apnea. In fact, he could do all of the instruction in that area. I had every objection in the book and admittedly I was very closed-minded. As I already said, how could an upright awake airway give us an idea of what is happening at night? This shouldn’t even be used for screening. What if the patient happened to swallow during the scan? Why expose a patient to extra radiation? Why spend the extra money on a bigger field of view? Guess who is now a proud owner of both a CEREC and Orthophos SL with SICAT AIR? I saw how drastically this technology can benefit my patients. At first my business partner thought I was crazy. That’s a huge investment for a small town PPO practice, but we are already seeing returns. I often get asked the best way to screen existing dental patients for potential OSA. Many offices have every patient fill out an Epworth Sleepiness Scale as a screener. Some offices measure necks. Some offices look at Mallampati. The problem with these techniques is that patients don’t make a connection and it’s one more thing for the team to do. The patients don’t see the value and rarely accept any ownership of a potential life-threatening disease. “I don’t have a problem with snoring, it’s my spouse that has a problem with my snoring.” You’ve all heard


COVERstory

DentalSleepPractice.com

11


COVERstory that before, right? A visual picture of their airway on a huge screen in front of their face opens their eyes and can start to connect the dots for the patient. The software is so easy to use that the team gets excited to incorporate this educational tool to their flow. The patients make a connection, they want more information, and they start the conversation. The awareness in my practice was already high but adding SICAT AIR airway images during an exam has elevated it that much more. The patients move forward. Each of my objections to utilizing 3D has slowly melted away. We take a 3D image on every new dental and sleep patient. As a general dentist office, the 3D image has helped us find restorative work we wouldn’t have found until the patient was symptomatic. We have found abscesses, resorptions, fractured roots, failing endo and helped plan predictable implants we might have referred out before. The patients are thankful and case acceptance has increased because the patients aren’t just being told what they need, they have participated in the discovery of it. Our practice is set apart. And guess what? The radiation is minimal. You could almost compare the exposure to radiation from a patient scan in my office to the flight I’m on right now, minimal. In sleep, I get the advantage of having a baseline of the patients’ joints. In addition, I can get a better visualization of soft tissue that may compromise our treatment with an oral appliance. In the past I would do a visual exam of the nasal passage and evaluate the patient for nasal patency by having the patient breathe deeply through their nose.

Airway before treatment with appliance

12 DSP | Fall 2017

Dr. Elliott preparing a patient for a scan using the ORTHOPHOS SL 3D

A visual picture of their airway on a huge screen in front of their face opens their eyes and can start to connect the dots for the patient.

Now I can visualize their nasal passageways much more effectively. I can prepare the patient that the appliance alone may not fully treat their snoring and an ENT referral may be necessary. My dad always said that if you don’t prepare the patient beforehand and must explain it afterwards it just looks like you’re making excuses. I would rather the patient had realistic expectations in their treatment and I have better information.

ORTHOPHOS SL 3D


COVERstory

OPTISLEEP

Doug is a typical patient in our practice and happens to be a good family friend. He has been in our practice long enough that it was time to update his full mouth series. We did a scan, 4 bitewings and some anterior PA’s. First, we found external resorption on tooth #4. In the past, we would have seen something that looked suspicious on the PA, possibly send to the endodontist or wait and watch. The endodontist would have taken their own scan, deemed it hopeless, and then try to decide who was going to extract and place the implant. Phew… I’m tired and I’m not even the patient! Or we would have waited, “watch” it get bigger and have Doug call me on a Saturday in a ton of pain. We extracted the tooth at our office, immediately placed the implant and restored the tooth just last week. Doug is what we call a little bit of a “scaredy cat” but could not stop talking about how seamless and painless the process was. Even better is the conversation we had regarding his snoring. His wife, Cindy, and I have been conspiring about his snoring for years but he was always in denial or never saw the perceived benefit. He was relatively young, fit, never tired and “slept just fine.” He had some sleepless nights because of stress at his job, not sleep apnea. That’s an “old person’s disease” he always said. But I also knew about his frequent visits to the urgent care for sinus infections and Cindy’s complaints of his snoring that made it impossible for her to sleep. By utilizing the tools that I was already using for dentistry, I could show him his obstructed nasal passageways, his thickened mucosal lining, and a volumetric scan of his narrowed airway. Suddenly, the light bulb went off. He was finally willing to do a home sleep test that revealed moderate sleep apnea. He started to “own” that he had a problem and we created a sense of urgency. He even said, “I came in here trying to solve

SICAT AIR screenshot showing airway volume

my snoring for my wife and now I realize I need to do this for my health.” With my new digital workflow, we could make this happen in less time than my traditional impression workflow as he was anxious to get help. I took a scan prior to a protrusive bite and then another with the bite in place. I imported his digital impressions into the SICAT software and clicked “Order.” It was very simple. After ENT treatment and an appliance, Doug and Cindy both sleep more peacefully… and so do I knowing that I could lead one more person toward better health. The distributor rep and I have long since made up, and he no longer tries to bypass me to talk to my business partner. Because of the investment we made in our practice, my patients feel the value we put on their health, and that makes me feel like a nice person once again.

He even said, “I came in here trying to solve my snoring for my wife and now I realize I need to do this for my health.”

Dr. Erin Elliott grew up in Southern California but went away to a small NAIA school in Western New York where she played collegiate soccer and graduated summa cum laude from Houghton College. After Creighton Dental School, she settled in North Idaho to begin her general dentistry career. She has a special interest in Dental Sleep Medicine and Short Term Orthodontics (Six Month Smiles). She has lectured extensively on this topic and loves to help general dentists extend this life-saving service to their patients. She is an active member of her local American Dental Association, the American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and is the past president and a diplomate of the American Sleep and Breathing Academy. She’s teaching sleep apnea with 3D-Dentists and Dr. Tarun Agarwal as well as privately coaching practices about sleep.

DentalSleepPractice.com

13


TMDseries

Screening Patients for TMDs in a Sleep-Oriented Dental Practice by Samuel J. Higdon, DDS

A

s the subspecialty of dental sleep medicine has evolved and matured, reasonable concerns have been voiced regarding potential undesirable results from doing mandibular advancement during sleep as a long-term treatment for sleep disordered breathing (SDB). Several studies have been done on long-term changes that may occur, including not just TMD-related effects, but also skeletal changes and changes in the dental occlusion.1 Skeletal and dentoalveolar changes have been reported.2

From a long-term perspective, the risk for developing TMD signs and symptoms because of treatment with a mandibular advancement device (MAD) seems to be low. Apparently, the masticatory system has a good capacity for adaptation if MAD use continues, with an overall reduction in TMD symptoms as well as a slight increase in range of motion.3 However, in the short term (up to 6 months), risks remain. The sleep dentist should be aware of these studies and be prepared to discuss them with patients being considered for treatment using a MAD. However, long-term problems are not the focus of the present article. Identifying the potential for short-term development of a temporomandibular disorder (TMD) prior to undertaking MAD treatment will lessen the need to explain to the patient what has occurred and what may happen if treatment with the MAD is to continue and whether the TMD symptoms may persist even if MAD treatment is terminated. After-the-fact explanations are best avoided, if possible. In the previous article (DSP Spring 2017) I made the argument that most dentists primarily think of temporomandibular disorders (TMDs) as pain problems. The risk associated with this limited perspective is the assumption that if the patient isn’t complaining, there currently isn’t, and that there won’t be, a problem. The potential for TMD problems often can be detected in an incipient state, based on certain clinical signs that can be present before there is any pain and before the patient is otherwise aware of a problem. The need for a careful evaluation of the patient for potential TMD problems is of particular importance when MAD treatment is being considered. As discussed in the previous article, several dental organizations, including the ADA4,5,6,7,8 have for years advocated that ALL dentists screen ALL of their patients for TMDs, yet it appears that few dentists do so routinely. One reason for this may be that

most dentists may not know what it means to screen their patients for TMDs nor how to incorporate a screening protocol into their practice. A protocol for introducing a routine screening procedure for TMD into any dental practice will be described (see Fig. 1). In a conventional dental practice, screening of patients for TMDs would initially require only the routine use of a screening questionnaire. If given to each new patient, and again at regular recall visits with all patients, significant changes that may develop over time will be identified at the earliest possible time while continuing to provide routine dental care. If there are positive findings, or indications of progression over time on the screening questionnaire, the next step would be a TMD screening exam. All SDB patients should not only complete the screening questionnaire but also

All of the forms recommended in this article can be downloaded for use in your practice at https://dentalsleeppractice.com/forms-higdon/. Figure 1: Screening Protocol

14 DSP | Fall 2017


TMDseries have a TMD screening exam, for indications of possible incipient TMD problems, prior to consideration of possible use of a MAD. Certain findings on a screening exam may suggest that the use of a MAD may be contraindicated, at least until the TMD issues have been adequately addressed. It is worth mentioning, in this context, that a dental hygienist can be trained to do a screening TMD exam, the results of which can then be conveyed to the dentist for consideration.

The Screening Forms

Because the Screening Questionnaire (download at https://dentalsleeppractice.com/ forms-higdon/) can be adminisThe feedback that the patient tered by front office staff, it can easily become a part of routine can provide regarding how office procedure for all patients their bite actually feels to without requiring any additional time on the part of office staff, inthem will often add a level cluding the dentist. The author’s background has of clarity to the occlusal involved extensive training in the assessment over and above clinical application of dental octhe results of a conventional clusal principles. However, in spite of having been well-trained occlusal examination. in these concepts, in addition to 30+ years of experience in doing a comprehensive occlusal examination, I have come to recognize that the feedback that the patient can provide regarding how their bite actually feels to them will often add a level of clarity to the occlusal assessment over and above the results of a conventional occlusal examination. For this reason, in my TMD practice, I now ask every patient who has been referred to me to complete the Patient Self-Assessment of Occlusal Condition

Dr. Samuel J. Higdon’s practice, for over 30 years, has been devoted to the non-surgical management of TMDs and other problems related to the function of the jaw system. He practices in Portland, Oregon. He is the author and illustrator of, “Illustrated Anatomy of the Temporomandibular Joint in Function/Dysfunction”, an education aid for both patients and dental professionals regarding the unique functional anatomy of the TMJs. It is available at TMJAnatomy.com. He is also the co-author of an educational website related to temporomandibular disorders for professionals and patients, at DrawbridgeDDS.com.

16 DSP | Fall 2017

questionnaire as part of their intake procedure. Responses to these questions have added immeasurably to our otherwise comprehensive TMD history and examination. It is important that this Patient SelfAssessment of Occlusal Condition (download at https://dentalsleeppractice.com/formshigdon/) is not seen as a substitute for either the screening questionnaire or the screening exam. It simply adds to what may be found when a proper TMD screening history and exam are done. The Patient Self-Assessment of Occlusal Condition form can provide important information regarding the patient’s perception of their own dental occlusion. Following forward posturing of the mandible during sleep using a MAD, it is generally expected that the patient’s mandible will be able to return to their previous intercuspal position (ICP) shortly after awakening. Current accepted protocol advocates providing the patient with an “AM repositioner” to aid in this process. If the patient, on the Patient Self-Assessment of Occlusal Condition questionnaire, has in some way indicated that their existing ICP has been uncomfortable (not necessarily painful – perhaps uneven, uncomfortable, strained) to them before MAD treatment, or if there has been an intracapsular problem involving limited range of motion or catching of the joint, such problems may represent a complicating factor when the patient attempts to return to their ICP upon awakening. Identifying potential issues in advance of MAD treatment can avoid some challenging outcomes that would otherwise be difficult not only to explain to the patient, but also to resolve in a satisfactory manner. One example: If the pre-existing ICP had been maintaining the mandible in an asymptomatic but retruded jaw (condylar) posture, upon removal of the MAD in the morning, it may become apparent, even with encouragement provided by use of the “AM repositioner”, that the mandible does not easily return to the previous ICP. When properly evaluated, this may indicate that a somewhat more protrusive position is a more physiologic position for the mandible. This is not to suggest that the jaw will maintain the full protruded position that the MAD provides, but only that the mandible may not easily return fully to the pre-existing ICP. If on the Patient Self-Assessment of their Occlusal Condition, the patient had indicat-


TMDseries ed that their jaw is more relaxed and comfortable in a somewhat forward position, or if they indicate that they have heavier contact on their anterior teeth vs. the posterior teeth, this may also suggest that a potential problem involving joint position may need to be evaluated and addressed as a separate issue. There may not be any joint pain, but if pain is present in combination with a description of this kind, it represents a TMD problem that must be addressed before considering MAD treatment. Because MAD treatment under these circumstances could potentially result in a permanent change in condylar position and a resulting change in the patient’s dental occlusion, it may represent a contraindication for MAD treatment, at least until the joint/bite condition has been adequately addressed. Other means of managing the diagnosed airway problem should be used in the interim. When findings of this kind are present and the patient is otherwise relatively symptom-free, TMD issues may be less a problem

of joint pain and more a problem of joint mechanics and jaw posture. Because of the implications regarding potential related bite changes, there will need to be a discussion of this with the patient, including treatment options. One option would be to address the problem of joint mechanics as a separate issue before undertaking MAD treatment. These circumstances can be rather complex and a decision regarding a path forward to appropriate treatment will be dependent on the circumstances, on good clinical judgement, but particularly on the experience of the dentist in managing non-painful but dysfunctional TMD problems.

Decreasing TMD Symptoms with MADs

It has long been recognized that in some instances intracapsular TM joint pain can be relieved with mandibular advancement. If there are accompanying headaches and other muscular symptoms, these, too, may be relieved with mandibular advancement. A finding of intracapsular pain is commonly indicative of adverse loading of the retrodiscal tissues. Relieving this joint pain by alteration of the load on pain-sensitive tissues with a MAD may also decrease the muscular response to the joint pain, thereby affecting muscle symptoms such as headaches. Even with a decrease in symptoms in response to MAD treatment, it is important for the sleep dentist to recognize that they have not “cured” a TMJ problem. It is more likely that these improvements in symptoms will be transitory and that more definitive treatment of the TMD, to address the underlying source of the pain issues, may be indicated, possibly before undertaking MAD treatment for SDB. To describe this set of

Dentists, Physicians, Physical Therapists, Nutritionists, Speech and Myofunctional Therapists, and Team members will come together for the

2017 AIRWAY SUMMIT San Juan, Puerto Rico September 14-16, 2017

The Condado Plaza Hilton For more information: www.aapmd.org

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TMDseries circumstances succinctly, TM joint pain may be relieved by the MAD treatment and this may be accompanied by a “reluctance” of the mandible to return to the pre-existing ICP.

Increased TMJ Symptoms with MAD Treatment

Under certain circumstances, mandibular advancement may increase joint pain, particularly if done in the presence of certain intracapsular conditions. As described in the Discussion of the Significance of History Questionnaire and Exam Findings form (download at https://dentalsleeppractice. com/forms-higdon/), the potential for these condition to develop are likely to be identified with a careful TMD screening exam. Pain-free clicking and popping in TM joints that otherwise move well may be inconsequential. Finding joint sounds Under certain circumstances, on examination, however, is not a reason for complacency. They mandibular advancement are always an indication of a loss may increase joint pain... of normal structural integrity of the joints structures and may have further implications. With the patient being considered for MAD treatment, of particular importance would be any finding of limited opening, limited excursions, or deviation and/or deflection on opening. Pain from the TM joints, particularly with palpation through the ear canal to the distal of the joint(s), and/or pain with jaw movements, especially if localized to the TM joints, should be carefully considered as to whether the patient is appropriate for MAD treatment. However, coarse grating and grinding (hard tissue crepitation) will usually be a contraindication for MAD treatment, particularly in the presence of pain from the same joint, as this is an indication of advanced degenerative joint disease (osteoarthritis). While signs and symptoms of TMD do not necessarily increase during longterm therapy using a mandibular advancement device, patients with clinically detected TMJ crepitation have been shown to discontinue their mandibular advancement device therapy more often due primarily to TMD symptoms.10 The examples described above are not necessarily the only potential problems that might be identified with a TMD screening history and exam. They do, however, suggest the necessity for the sleep dentist to exercise care

18 DSP | Fall 2017

and good clinical judgement before undertaking MAD treatment for a SDB condition. As described in the first article of this series (DSP Winter 2016) “Sleep Appliances and TMDs: Are You Ready?”, the importance of having a complete understanding of the potential for your patient to develop a TMD in response to MAD treatment, should that occur, is that you will need to be able to explain to the patient what may have happened. But out of an abundance of caution, not only do you need a well-worded informed consent, you need to be able to explain to your patient, prior to beginning MAD treatment, what you have found that may have the potential to lead to TMD issues. When you are well-informed, and can present your findings in a knowledgeable manner, your ongoing relationship with your patient will be much less likely to result in an uncomfortable condition for either you or your patient. In the next article, in the Winter 2017 issue, I will discuss more specifically both normal and dysfunctional anatomy of the temporomandibular joints and how an understanding of this anatomy is of importance to not only the sleep dentist, but to every dentist.

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Knappe SW, Bakke M, Svanholt P, Petersson A, Sunniness L: Long-term side effects on the temporomandibular joints and oro-facial function in patients with obstructive sleep apnea treated with a mandibular advancement device. J Oral Rehabil online library 2 Feb. 2017/DOI: 10.1111/joor.12485. Robertson J: Dental and Skeletal Changes Associated with Long-term Mandibular Advancement. SLEEP, 2001; 24 (5):531537. Fransson, A.M.C., Tegelberg, Å, Svenson, B.A.H., Wenneberg, B., Isacsson, G. Validation of measurements of mandibular protrusion in the treatment of obstructive sleep apnoea and snoring with a mandibular protruding device. Eur J Orthod. 2003;25:377–383. ADA — Clark GT: The President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders. JADA 1983. ADA — McNeill C, Mohl ND, Rugh JD, Tanaka TT: Temporomandibular Disorders, Diagnosis, Management, Education, and Research JADA 1990; 120(3):253, 55, 57. Academy of General Dentistry — Howard WW: Craniomandibular Disorders: No One Responsibility? Gen Dent 1987; 35(4):260. American Academy of Orofacial Pain — Okeson: Orofacial Pain Guidelines for Assessment, Diagnosis and Management. Quintessence 1983. American Academy of Craniofacial Pain — Talley RS et al: Standards for the History, Examination, Diagnosis and Treatment of TMD: A Position Paper. J Craniomand Pract 1990; 8(1):60-77. Näpänkangas, R et al. Effect of Mandibular Advancement Device Therapy on the Signs and Symptoms of Temporomandibular Disorders. J Oral Maxillofacial Res 3(4) (2012): e5. PMC. Web. 13 Mar. 2017.


INDUSTRYawards

W

ith a barrage of emerging technologies in the dental marketplace, clinicians seek expert advice to guide them toward the most innovative, impactful products that can provide significant benefits for their practices, their teams, and their patients. For the past 9 years, the prestigious Cellerant “Best of Class” Technology Awards have been doing just that — distinguishing outstanding products and services from the competition and establishing true leaders in their categories. The awards have received acclaim for their integrity and have been recognized by every major dental journal in North America and the American Dental Association. The winners are decided by the Best of Class Advisory Board, comprised of respected experts in dental technology. The Cellerant “Best of Class” Technology Awards provide dentists with a “go-to list” of products that they can trust as remarkable and critical components of their technology-forward dental practice. Dental Sleep Practice is excited to showcase these winners.

2017 WINNERS

Cellerant “Best of Class” Technology Awards 3Shape Trios Platform 5-time winner Ultradent Gemini 810 & 980 Diode Laser Bien-Air Tornado DEXIS CariVu 4-time winner SimplifEye Emerging LED Velscope Vx 7-time winner MMG Fusion 2-time winner Q-Optics Platform Emerging Orascoptic Ease-In-Shields Orascoptic OmniOptic Orascoptic Spark 2-time winner Shofu EyeSpecial CII Camera 3-time winner Smile Line USA Smile Lite MDP Emerging WEO Media 2-time winner Form Labs Form 2 3D Printer DentLight FUSION Twinhead Curing Light Emerging Valo and Grand Valo Curing Lights 5-time winner Phillips Sonicare DiamondClean Smart Zest Dental Solutions LOCATOR F-Tx Fixed Attachment System Blue Sky Bio Emerging

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CONTINUING education

Breathing is a 24 Hour Activity by Randy Clare

Educational aims

Dentists treating sleep apnea are concerned about opening the oropharynx during all phases of sleep so respiration can happen without compromise. Many patients, having had trouble breathing for years, have comorbid conditions such as chronic obstructive pulmonary disease. Being aware of such problems and understanding the relationship with sleep apnea helps the dentist know their patient and interact with other providers at a higher, more precise level.

Expected outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 24 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Implement advanced knowledge about airflow • Recognize COPD • Understand the relationship of airway and COPD with obstructive apnea

20 DSP | Fall 2017

Y

ou are probably paying close attention to how your patients breathe during sleep, but have you been curious about how they breathe during the day?

I have spent most of the last 25 years thinking about the diagnosis and treatments for sleep disordered breathing and related conditions. Recently I gave a talk where I made the statement that breathing is something we do 24 hours a day. This statement should not have been a shock, but like me, my audience hadn’t really put nighttime breathing and daytime breathing into the same category. It is widely reported that, a person at rest takes about 16 breaths per minute. This means we breathe about 960 breaths an hour, 23,040 breaths a day, 8,409,600 a year. The person who lives to 80 will take about 672,768,000 breaths in a lifetime. Since a person sleeps for a third of their life this 80 year old person will have taken 222,013,440 breaths while asleep (one third of their breaths). Sleep apnea, asthma or Chronic Obstructive Pulmonary Disease (COPD) all impact breathing quality, life expectancy and quality of life. When we consider the sleeping patient we know that a cessation of breathing of 10 seconds or longer is an apnea which means there is no airflow. When we measure chest and abdominal effort we can separate an obstructed breath from times when the brain isn't stimulating any breathing


CONTINUING education activity. A hypopnea is a shallow breath with a corresponding oxygen desaturation. The Apnea Hypopnea index or AHI is the sum of these events divided by the number of hours of sleep. But what if the patient has a compromised breathing pattern during the day? If the patient presents with wheezing, chronic cough, shortness of breath or blueness of the lips or fingernail beds the patient may have COPD, comorbid with their Sleep Apnea. This is a condition known as overlap syndrome. For a patient to respond well to any sleep apnea therapy it is critical that the patient have sufficient lung function to breathe properly on their own. COPD affects approximately 20 million people in the United States and is the nation’s third leading cause of death. Xavier Soler, MD, PhD, Assistant Professor of Medicine, Pulmonary and Critical Care Division, University of California San Diego, reports in his national COPD foundation Blog that: “Patients with severe COPD commonly exhibit abnormal sleep contributing to chronic fatigue, daytime sleepiness. Additionally, medications used to treat COPD, such as albuterol or prednisone, may affect sleep quality. A reduction of nocturnal oxygen levels commonly seen in patients with COPD can have profound effects and contribute to long-term sequelae, producing arrhythmias, myocardial stress, and, possibly, lower survival. OSA occurs in about 10 to 15% of patients with COPD, a condition referred to as the “overlap syndrome”. Although the prevalence of OSA is similar in patients with COPD as in the general population, individuals with both conditions without CPAP treatment have an increased risk of death and more hospitalizations from acute exacerbations.” Lung function can be objectively measured using a lung function test called spirometry (CPT 94375). A Spirometer is a device that measures the largest volume of air that can be moved into or out of the lungs. Lung function testing has been around since the mid 1800’s when the water-seal spirometer was developed. This simple device measured the patient’s Vital Capacity (VC). In the 1930’s it was observed that patients with emphysema exhaled more slowly than healthy subjects. The shift was

A Spirometer is a flow measurement device that consists of a flow transducer and a small computer to do analysis. The patient takes a deep breath in and blows through the tube. Flow is measured and the data is compared to predicted sets

Randy Clare is a sales and business development manager for Carefusion, and is based in Yorba Linda, California. He has been involved with the development and distribution of sleep therapy products including CPAP supplies, oral appliances and sleep diagnostic devices for over 20 years. He can be reached at randy.clare@ carefusion.com. For more information, follow thesleep andrespiratoryscholar.com.

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CONTINUING education

This is a normal flow volume loop that shows flow on one axis and volume on the other. As the patient exhales quickly, flow is rapid and achieves a peak as the patient blows out longer the amount of flow diminishes as the volume gets smaller. The shape of the flow volume loop is often used to diagnose COPD and related lung diseases

22 DSP | Fall 2017

made then to a Forced Vital Capacity (FVC) measurement to calculate the patient’s ability to clear the air out of their lungs and measure the time it took to do so. It was soon learned that healthy patients exhale 80% of their FVC in 1 second, this calculation is called Forced Expiratory Volume in 1 second (FEV1) and is used to identify and assess airway obstruction. Pulmonary function data is generally presented a flow-volume curve. Normal values for spirometry tests have been compiled into tables called normograms which are based on age, height, sex and race. Most computer based spirometer devices have these tables and can calculate percent to predicted values. In adults, an FEV1that is lower than 80% of predicted value is considered abnormal. The department of pulmonology at Hospital de Hautepierre in Strasbourg France conducted a study called “Association of Chronic Obstructive Pulmonary Disease and Sleep Apnea Syndrome”, where patients with known sleep apnea were tested with a spirometer and 11% were found to have an FEV1 <60%, putting them at high risk of being Overlap patients; they tended to be older and all were male. It is interesting to note that Body Mass Index (BMI) in Overlap patients was identical to the non-overlap patients. In other words, the FEV1 data might be a critical identifier that would be very useful in managing this patient population. Treating SDB alone may be less effective in achieving maximum health. “When both COPD and OSA are present, there may be an additive (synergistic) effect on the clinical picture, but it has not been established at what level of severity this occurs. For example, it is not clear if patients with severe COPD and mild OSA should be treated in a similar fashion to those with the opposite pattern — mild COPD concurrent with severe OSA. Both COPD and OSA have been linked to vascular endothelial dysfunction, increased levels of inflammatory mediators, and more rapid development of atherosclerosis. Other factors that link the two diseases include a worsening of both entities with increasing age, the shared risk factor of smoking, and worsening conditions when gastrointestinal reflux disease (GERD) is present. There are many possible reasons why COPD can either cause OSA or make it worse in patients already suffering from the disease, and vice versa. COPD often involves


CONTINUING education

In many cases, patients have been ill for a long time and have more than one condition that require management.

chronic hypoxemia, which worsens during the night. (In addition, hypercapnia increases during the night for overlap disease patients, linking to greater nighttime desaturation and higher AHI.)” - Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a senior instructor and director of clinical education in the department of Cardiorespiratory Sciences, College of Allied Health Sciences, at the University of South Alabama in Mobile. COPD patients tend to have very specific respiratory patterns which have adapted in some cases over many years. Dr. Soler and his team at the University of California San Diego recently hypothesized in their study “Age, gender, neck circumference, and Epworth sleepiness scale do not predict obstructive sleep apnea (OSA) in moderate to severe chronic obstructive pulmonary disease (COPD): The challenge to predict OSA in advanced COPD”, that COPD patients are in fact so specific that their indications of OSA may in fact be distinctly different from the general population. In their observational study, 44 patients who were receiving treatment in UCSD’s Pulmonary Rehabilitation Program who had a diagnosis of advanced COPD, were measured against traditional risk factors that include Sleepiness, Male Gender, Older age and neck circumference and were not associated with OSA in this group. This compares with elevated BMI, the presence of cardiovascular disease and FEV1+/-18.2% pred which were found to be very predictive of OSA in this population. Patients in dental offices are often screened with the Epworth Sleepiness Scale (ESS), neck circumference and BMI are also often calculated. These simple screening tools start so many sleep conversations in the

dental office. I was particularly struck by the comment in this study that, “Although Epworth Sleepiness Scale grades the severity of sleepiness, this symptom alone may be very common in COPD and, thus, lacking in predictive value.” When I discuss spirometry with dental teams I am often asked if I believe that dentists should be screening patients for COPD. My answer is an unqualified YES. I believe that the dentist who is treating patients with sleep disordered breathing is in fact managing the obstructed airway. The more information at the clinician’s disposal can only improve clinical decision making and positively impact patient outcomes. Sleep apnea treatment requires a team approach. In many cases patients have been ill for a long time and have more than one condition that require management. COPD and OSA in combination affect over 20% of the general population. The risk of mortality for untreated COPD and OSA is elevated. A simple spirometry test may show a patient who needs a referral for evaluation of an underlying breathing disorder that may seriously affect patient outcomes. The Dental office manages jaw position, and upper airway issues while the pulmonary physician manages the patient’s COPD. 1. 2. 3. 4. 5.

6.

Sleep-Disordered Breathing and COPD: The Overlap Syndrome Robert L Owens, MD and Atul Malhotra, MD Sleep Apnea and COPD: What You Should Know COPD Foundation blog post written by Xavier Soler, MD, PhD, Assistant Professor of Medicine, Pulmonary and Critical Care Division, University of California San Diego Ruppel, G., & Ruppel, G. (2009).  Manual of pulmonary function testing(7th ed., pp. 1-26). St. Louis, MO: Mosby. A Deadly Duo: When COPD and OSA Overlap: RT Magazine May 9 2014 Bill Preuit http://www.rtmagazine. com/2014/05/deadly-duo-copd-and-osa-overlap Age, gender, neck circumference, and Epworth sleepiness scale do not predict obstructive sleep apnea (OSA) in moderate to severe chronic obstructive pulmonary disease (COPD): The challenge to predict OSA in advanced COPD Xavier Soler, Shu-Yi Liao  , Jose Maria Marin, Geraldo Lorenzi-Filho, Rachel Jen, Pamela DeYoung, Robert L. Owens, Andrew L. Ries , Atul Malhotra, Published: May 16, 2017 https://doi.org/10.1371/journal. pone.0177289 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0177289

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CONTINUING education

Continuing Education Test

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Breathing is a 24 Hour Activity Randy Clare 1. The key attribute of managing sleep apnea is ______ a. Improving airway caliber b. Optimizing jaw position c. Achieving maximum airflow d. Establishing airway patency 2. For a patient to respond well to any sleep apnea therapy, it is critical that __________ a. They have sufficient insurance benefits to cover treatment b. They can breathe well through their nose c. There are enough solid teeth to support a mandibular advancement device d. There is sufficient lung function for them to breathe on their own 3. Asthma, COPD or Obesity can influence the patient’s AHI because _______________ a. Coughing during a sleep test creates artifact that distorts the index b. Shallow breathing from poor function counts as hypopnea events c. These conditions affect SpO2 d. Patients with asthma, especially, are mouth breathers 4. Symptoms associated with COPD include a. Chronic fatigue, daytime sleepiness and poor sleep quality b. Low nocturnal oxygen levels and enuresis

24 DSP | Fall 2017

c. Poor sleep quality and periodic limb movement disorder d. Night terrors, daytime sleepiness and hypoxemia 5. Overlap syndrome refers to ___________ a. Obesity leads to abdominal tissue overlapping their belts b. Patients having both COPD and OSA diagnoses c. Persistence of hypoxemia from sleep into wakefulness d. Elongated palatal tissue causing airway blockage 6. Dyspnea means ____________ a. Lack of effort to breathe b. Reduced bronchial diameter c. Shortness of breath d. abnormal breathing due to diaphragm damage 7. The Forced Expiratory Volume (FEV1) is ____ a. The amount of air the patient can forcefully exhale in 1 second b. The maximum volume the patient can exhale c. A standard measurement not in current use d. Measured with a nasal cannula as an average during a sleep test

8. Respiratory Therapists and Physicians use flow volume loops to ________ a. Determine which CPAP masks are most effective b. Manage doses of asthma medications c. Diagnose effectiveness of sleep therapies d. Provide biofeedback for breathing training in COPD patients 9. Respiratory Inductance Plethysmography is listed ________ a. As RIP because no one can pronounce “plethysmography” b. As a diagnostic tool for leg movement disorders but has been adapted for airflow c. By the AASM as a required instrument for site accreditation d. As ideal for identification of respiratory effort 10. Use of spirometer testing is indicated to ____ a. Establish baseline flow to gauge effectiveness of oral device therapy b. Evaluate lung function in the awake patient to rule out Overlap Syndrome c. Generate another data point for justifying greater exam fees d. Prove that CPAP is ineffective and other therapies should be considered


吀䴀䐀 吀唀匀䐀䴀 椀猀 瀀爀漀甀搀 琀漀 瀀爀漀瘀椀搀攀 琀栀攀 氀愀琀攀猀琀  椀渀 吀攀洀瀀漀爀漀洀愀渀搀椀戀甀氀愀爀 䐀椀猀漀爀搀攀爀猀 愀渀搀  䐀攀渀琀愀氀 匀氀攀攀瀀 䴀攀搀椀挀椀渀攀 攀搀甀挀愀琀椀漀渀⸀ 嘀椀猀椀琀  搀攀渀琀愀氀⸀琀甀昀琀猀⸀攀搀甀⼀䌀䔀 昀漀爀 挀漀甀爀猀攀 搀攀琀愀椀氀猀⸀

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⨀䌀䔀ⴀ䔀氀椀最椀戀氀攀 昀漀爀 琀栀攀 䄀䄀䐀匀䴀  儀甀愀氀椀ǻ攀搀 䐀攀渀琀椀猀琀 䐀攀猀椀最渀愀琀椀漀渀 

匀瀀愀挀攀 椀猀 氀椀洀椀琀攀搀⸀ 瀀栀漀渀攀㨀 ⠀㘀㄀㜀⤀ 㘀㐀㠀ⴀ㤀㜀㘀㘀 攀洀愀椀氀㨀 搀攀渀琀愀氀䌀䔀䀀琀甀昀琀猀⸀攀搀甀 眀攀戀㨀 搀攀渀琀愀氀⸀琀甀昀琀猀⸀攀搀甀⼀䌀䔀 䄀氀氀 挀漀甀爀猀攀猀 挀漀渀搀甀挀琀攀搀 愀琀 吀甀昀琀猀 唀渀椀瘀攀爀猀椀琀礀  匀挀栀漀漀氀 漀昀 䐀攀渀琀愀氀 䴀攀搀椀挀椀渀攀⸀


PRACTICEvision

(Re)Defining

Success in Dental Sleep Medicine

by Barry Chase, DDS

I

n 1976, as I was graduating from Georgetown University Dental School, I received the most powerful nugget of wisdom that influenced the rest of my career. It came from Dr. Moore, a practicing dentist of many years who taught parttime at the dental school. He simply said, “Dr. Chase, never forget that there is a patient attached to that tooth.” Although I knew what the words meant, I really did not fully comprehend the impact of that sage advice until many years after practicing general dentistry. What I now understand is Dr. Moore was telling me not to get caught up in the technical details of fixing teeth but remember that my purpose as a dentist is to restore dental and oral health to the patient. That may include restoring a tooth, doing a particular procedure, and paying attention to the micro-details of the technical protocols. But in the end, I must always ask myself if I improved the health, welfare and/or the quality of life of the patient. Over the years I have come to realize Dr. Moore did not have the original thought. 2500 years ago, Hippocrates (yes, the same Hippocrates of the Hippocratic Oath) is credited with saying, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Just a different way to express the same idea – don’t forget that there is a person attached to that disease. I have combined what Dr. Moore and Hippocrates have said into our dental sleep

26 DSP | Fall 2017

medicine practice philosophy. Dental sleep medicine, in my opinion, is not about putting a piece of plastic in a patient’s mouth, it’s not about moving the mandible forward, it is not about what appliance I use. It is all about how I make the patient FEEL, treating the patient, not the disease. I do not treat Obstructive Sleep Apnea, or the apnea-hypopnea index (AHI). I treat people who happen to have a sleep breathing disorder. Along with hypertension, diabetes, obesity and overall misery because their quality of life is being disrupted by sleep apnea. Toni Morrison, the Nobel Prize winning author is often quoted: People will not remember what you said People will not remember what you did But people will always remember how you make them feel. The “feeling” we want to create for our patients begins with the phone call requesting an initial appointment. My staff, trained in dental sleep medicine, take that call. It is not about just making the appointment. The call is an interview, a carefully scripted dialog of how we can best serve the patient and then sending the patient forms and literature about our office, our credentials and our philosophy of practice. At the first visit, a dedicated patient care coordinator trained in sleep medicine welcomes them, gives them her card with her personal email and phone number and informs the patient that she will be following their case from the first visit through the in-


PRACTICEvision

sertion of the device, managing the medical insurance and all payments, setting up adjustment visits and coordinating post insertion care with their referring physician. My consultation is 1 hour long, with the majority of the appointment getting to know the patient and reviewing the sleep study (which is very welcomed as most patients have no idea what the numbers mean and how they manifest into their physical disease). My consultation is calculated and choreographed. It is structured with a specific flow of questions in an exact sequence including surveys, forms and semantically charged language to trigger certain emotional responses in the patient. Our objective is to clearly communicate that we are here to walk them through the difficult and long process of employing an oral appliance while following all the protocols demanded by our Academies. (In another article I can discuss the specifics of the consultation and how to get conversion and case acceptance).

(Re)Defining Success in Dental Sleep Medicine

cessful OSA therapy, whether with oral appliance therapy or another treatment option, is to reduce the AHI to stated Academy targets and relief of symptoms. However, I can tell you quite clearly that, after many years of experience, there is not always, or even often, a direct correlation between reducing AHI and relief of symptoms. Yes, the patient expects medical data in the form of improved AHI, oxygen saturation, and sleep staging. Most of the time, I can accomplish those objective medical goals by understanding and working with appliance selection, appliance titration, tongue position with minimal mandibular

Dr. Barry Chase has a practice dedicated to dental sleep medicine with locations in New York City and Long Island, NY. He holds 3 Diplomates in dental sleep medicine and is a Clinical Associate Professor of dental sleep medicine at Stony Brook University. Dr. Chase is also an Attending doctor at New York Eye and Ear, Mount Sinai Hospital, NY and a staff member of St. Johnâ&#x20AC;&#x2122;s Riverside Hospital, Yonkers, NY. Additionally, he is Board Member to several sleep medicine companies, a consultant, and on the Editorial Board of a health care magazine.

Our industry standard definition of sucDentalSleepPractice.com

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PRACTICEvision

I do not treat Obstructive Sleep Apnea, or the apnea-hypopnea index (AHI). I treat people who happen to have a sleep breathing disorder.

movement, using vertical relationships and managing the temporomandibular joint. But not always. I have non-responders and partial responders along with limitations of mandibular movement affecting or not affecting various sites of obstruction, and the ubiquitous issue of compliance. It is also easy to forget that there is a person attached to the sleep study. As you treat more patients suffering from OSA, you will find as I do that there are patients with high, severe AHI, with few to no symptoms and other patients with low AHI, perhaps even with no diagnosed sleep apnea, just many arousals, and who are very symptomatic. We want a correlation between AHI and symptoms, but often that is not the case. We have to critically think about why that is, and not try to apply a statistical analysis that has little to do with managing the disorder. But I can always make the patient feel better and cared for. I can get into discussions of sleep hygiene, talking to them about their sleep environment, what they eat before bedtime, the use of electronics and the influence of light on sleep. I can talk about sleep aids and the medications the patient is taking for comorbidities that may be affecting sleep quality. Positional therapy is sometimes a good adjunct to improving OSA symptoms. In other words, I have taken the time to understand more about the patient than just their AHI.

Therapy vs. treatment In dentistry, we treat/fix teeth. If a clinical crown is fractured, we can place a full coverage restoration, with proper embrasures, balanced occlusion, well-fitting margins, and that tooth is fixed. In dental sleep medicine, we do not treat/fix anything – we manage a chronic, progressive sleep disorder that is negatively affecting people’s quality of life and is potentially life threatening. I consult for an oral appliance manufacturing business that is owned by a parent company based in Tokyo. They comment that there is a big philosophical difference between their Eastern view of medicine and our Western view. We are criticized for having a mechanical, technical vision of health. They say the difference in our healthcare per-

28 DSP | Fall 2017

spectives is that in the West we fix cars, in the East, they grow trees. What they mean is that in the West we think that if we replace a defective, diseased body part with a new replacement part, we have created health. Perhaps in certain aspects of medicine and dentistry that is true, but that approach to creating health does not translate to dental sleep medicine. We do not put in a piece of plastic into the patient’s mouth and they are magically and successfully treated for the malady of obstructive sleep apnea. We provide a lifelong therapy to manage a disorder that will continue to get worse, is influenced by the patient’s lifestyle, is multifactorial in origin, and often requires additional therapies by other healthcare practitioners. Many years ago, when I first started in general dental practice, my wife I were in a restaurant and overheard someone at another table say they did not like their doctor. She felt he did not give her his time, his attention, and did not make her feel cared for. Another person at the table said they loved their doctor. He was interested in them as people, not just patients; they felt cared for. At no time did they say that either doctor was technically good or bad in medicine. It was all about being cared for; how the doctor made them feel. Please do not misunderstand. I am not by any means advocating changing the definition of success for oral appliance therapy. Improving AHI and other parameters of sleep medicine, and meeting the standard medical targets, are important and required. The ideal, and we can reach it most of the time, is to both improve the objective data on the post insertion sleep study and at the same time provide a level of unsurpassed care for the patient. Too often when I consult with or teach other dentists about dental sleep medicine, they perseverate on the type of appliance to order, how to take the impressions and make bite registrations, find proper mandibular protrusive positions, and, unfortunately, most of the time, forget that there is a person attached to that appliance. Dental sleep medicine is rewarding, and challenging, and remember, in the echoes of Hippocrates and Dr. Moore, never forget that there is a person attached to that disease.


PRODUCTspotlight

Better Sleep Through Brain Wave Training by Patrick K. Porter, PhD

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ou stare at the ceiling and wait for sleep to come. You know you must get up in the morning and face another day, tired and out of sorts. Desperate, you strive for sleep. The harder you try, the further it slips away. The clock beside the bed pulses away hour after hour…one A.M., two A.M., three… If this sounds like you, know that you’re not alone. It’s estimated that over a third of the adult population is having trouble sleeping. At times, it can feel as if you’re destined to suffer sleepless nights forever, but I’ll let you in on a little secret: It all starts with your thoughts! Fortunately, the field of brain wave technology now offers a drug-free solution for producing the kind of restful and restorative sleep we all need. Brain wave training is effective because it works on multiple levels, both mental and physical, by using synchronized pulses of light and sound. The pulses, delivered through a specially equipped headset, transport people’s minds into the deepest meditative states, allowing users to experience all the benefits of meditation, including exceptional sleep, without the disciplined effort. That may sound like technical jargon, but the bottom line is quick recovery from those sleepless nights. Twenty minutes of brain wave training can equal a few hours of sleep. That means the effects of stress and sleepless nights begin to reverse immediately. When I invented the first portable light and sound machine and combined it with my guided visualization audios, I had no idea that 30 years later thousands of people would be listening to my brain entrainment algorithms. Today, with the mobile app platform, just about anyone can benefit from brain wave training with just a phone or tablet and headphones. This specialized matrix of sound guides you from the brain wave state of beta, the wide-awake state, and into alpha and theta, the relaxed, meditative states. From there, your brain regains its ability to experi-

30 DSP | Fall 2017

ence the deep state of delta the deepest sleep possible. We call this process braintapping, and you can experience it for free at www. MyBrainOffer.com. For those who want to supercharge their braintapping experience, the BrainTap Headset adds the dimension of light therapy through closed eyes to guide your brain through the entrainment process. This is all designed to improve your energy levels and help you return to your natural sleeping pattern.

Braintapping Accelerates These 5 Simple Steps to Optimal Health

The most dangerous health epidemic we face today is Super-Stress. This epidemic is a result of the fast-paced lifestyle in this new era of total connectivity. Stress often manifests in disorders such as ADHD, obesity, diabetes, insomnia, headaches, and high blood pressure to name but a few. When we’re under stress, our bodies pump out adrenaline and cortisol, an effect of the fightor-flight response, which is the mechanism our bodies employ to keep us safe from injury or attack. Problems arise when the daily onslaught of stress leaves us stuck in this highly-aroused state where all resources are focused on survival. Sadly, we’ve become so accustomed to this super-stress lifestyle that we don’t even realize the damage it’s doing to our mental and physical health. Since we can’t escape the fast-paced, high-tech lifestyle of the 21st Century, we must learn new ways to deal with the stresses of life to prevent it from causing problems for us, both physically and psychologically. Our bodies must return to a state of homeostasis (balance) for recovery, repair and healing to take place, but few people know how to do that. Keep reading, though,


PRODUCTspotlight because the 5 Simple Steps to Optimal Health couldn’t be easier.

Tip #1: Breathe Deeply

Deep breathing is one of the best ways to lower stress because when you breathe deeply, it sends a message to your brain to calm the body. The stress responses that are so detrimental to our health – such as increased heart rate, increased hormone production and high blood pressure – all decrease as you breathe deeply to relax. For this reason, every audio session in our library includes deep, relaxing, guided breathing designed to bring your body to ultimate relaxation. With your free trial, we recommend BrainTap session: SR01 – Create Your Enchanted Forest for Stress Reduction

Our bodies must return to a state of homeostasis but Tip #2: Focus on the Moment When you are stressed and anxious, few people know you’re most likely dwelling on a past event how to do that. or a future one. You’re regretting something

you’ve already done or worried about what comes next. This can cause immense stress from which our bodies need recovery time. One way to lessen this type of stress is to bring yourself back to the moment. Rather than seeing only the negatives, focusing on the moment offers you a space to think differently about stress and respond in a more appropriate manner without past regrets or future worries. With your free trial, we recommend BrainTap session: SR04 – Putting Future Events into Perspective

Tip #3: Reframe the Situation

When we are stressed or overwhelmed, it may seem impossible to find a positive

Patrick K. Porter, PhD, has been on the cutting edge of brainwave entrtainment technology for 25 years. His newest device, BrainTap, is distinctively designed to take the Brain Tap Technology sessions to the highest possible level with the addition of light and sound frequencies. Dr. Porter is known for developing Positive Changes, the largest self-improvement franchise using mind-based technology. Dr. Porter’s successes have been featured in The Wall Street Journal, BusinessWeek, People, Entrepreneur and INC magazines, as well as ABC, NBC, CBS and the Discovery Channel. He is a licensed trainer of NeuroLinguistic Programming and is the head of mind-based studies at the International Quantum University of Integrative Medicine (IQUIM).

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thought, but it’s not as hard as you think. When you reframe a situation, you’re simply looking at the same situation in a new way that highlights the possibilities. Viewing our stressors as opportunities can help us stop feeling trapped and reduce the physical effects of stress on our bodies almost immediately. With your free trial, we recommend BrainTap session: SR05 – Reducing Uncertainty and Doubt

Tip #4: Keep Problems in Perspective

We tend to stay in stress mode when we focus too much on a specific problem. It’s important to remind ourselves of the positives in our lives – we woke up this morning; we can see; we can walk; we have family and friends to support us. It might seem a little silly at first, but the next time you’re feeling stressed, consciously make the effort to think about the things you’re grateful for. This can be a surprisingly easy way to reduce the stress in your life. With your free trial, we recommend BrainTap session: SR06 – Eliminate Negative Thinking

Tip #5: Practice Mindful Meditation and Visualization

By practicing mindful meditation and visualization, you can achieve the relaxation response, a physical state of deep rest that changes the physical and emotional responses to stress. Once you enter the relaxation response, the brain sends out neurochemicals that neutralize the effects of stress on the body, allowing you to change your reactions to the stressful events going on around you. By braintapping once a day, you can reduce or eliminate brain fog and negative mind chatter, have more energy, relax and develop positive sleep habits. With your free trial, we recommend BrainTap session: SR10 – Developing Spontaneous Relaxation Braintappers not only rediscover their innate ability to achieve deep delta sleep, but also enjoy all the benefits of brain balance such as freedom from stress, less pain, peak performance, an optimistic attitude, and an overall great quality of life. To experience braintapping for yourself, sign up for your complimentary trial here: www.MyBrainOffer.com.


PRODUCTspotlight

Aussie Dentist in OSA Breakthrough O2Vent™ unique airway acts as second nose

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ustralian dentist Dr. Chris Hart was a chronic sleep apneic with severe nasal congestion. In an act of desperation one sleepless night, he fashioned the prototype of what would become the O2Vent™ T. This “light bulb” moment led to developing a customized oral appliance with an internal airway to treat obstructive sleep apnea (OSA) and snoring – the first of its kind.

How the Oventus Airway Technology works: 1. Air is drawn in the front of the appliance 2. Air passes through to the back of the appliance 3. The appliance advances the mandible, bringing the tongue forward and opening the airway

Dr. Chris Hart O2Vent™ W – now available

Like all oral appliances that bring the jaw forward, the O2Vent™ T stabilizes the jaw position and brings the tongue forward to reduce airway collapse. Additionally, the O2Vent™ T’s unique built-in airway design allows for breathing through the device. This ultra-low resistance pathway enables additional flow in the presence of increased nasal resistance and a bypass in the event of a soft palate obstruction delivering unobstructed air flow below any nose and soft palate issues. Using CAD software each device is created from 3D records of the patient’s dentition and bite. Using 3D printing technology, a custom-made medical grade mouthguard is then fabricated from titanium and polymer.

Oventus received FDA clearance to market and sell the O2Vent™ T in April 2016 and the O2Vent™ W in July 2017. “The recent clinical data strongly supports O2Vent™ and its superior performance and clearly demonstrates its effectiveness in treating a range of sleep disorders. The study also showed similar compliance and response rates in those with and without nasal congestion, while also improving oxygen levels for patients,” confirms Dr. Hart. Current studies are looking at upper airway physiology, and the effect of Oventus’ low resistance airway on pharyngeal collapsibility, and when used in combination therapy, not just the reduction in pressure requirements but also the ability to breathe physiologically while simultaneously applying CPAP. If the clinical data continues to support these early findings these two advances may represent a paradigm shift in the treatment of OSA. Early data presented as an abstract at SLEEP 2017 in Boston showed that as a standalone oral appliance the O2Vent™ T reduced AHI by 78% from 37 to 8, normalized pressure swings in the oropharynx to the same level as optimized CPAP and as a CPAP interface reduced pressure requirements by 66% and negated the need for a mask. As Oventus Airway Technology can be incorporated into virtually any oral appliance design this technology and data represents a significant addition to oral appliance therapy in the treatment of obstructive sleep apnea. To learn more, visit www.oventusmedical. com, e-mail info@oventusmedical.com or call 844-780-5957.

The O2Vent™ uses 3D titanium printing technology

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LASERfocus

10,600-nm CO2 Laser Frenectomies in Pediatric Patients with Compromised Airway & Swallowing: Case Reports by Martin Kaplan, DMD, and Peter Vitruk, PhD

T

he 10,600-nm CO2 laser provides effective and spatially accurate soft-tissue incisions, with excellent coagulation ability due to close match between photo-thermal coagulation depth and the diameters of oral soft tissue blood capillaries.1-3 The case studies reported in this article (see Figures 1 and 2) successfully utilize the 10,600-nm CO2 lasers in the SuperPulse mode, which enables both precise sub-millimeter depth of cut and a miniscule sub-100-micrometer depth of coagulation/ hemostasis (see Figure 3) to maintain bloodless surgical site. Following CO2 laser maxillary labial frenectomy, the treated area heals without complications and with minimal to no scarring.1-3 The CO2 laserâ&#x20AC;&#x2122;s ability to achieve hemostasis affords the clinician the improved visibility of the surgical field and allows for more precise and accurate tissue removal than scalpel surgery. Reduced postoperative pain and minimized wound contraction and less keloid and scar tissue formation (attributed to notably fewer myofibroblasts) are among the most beneficial outcomes of CO2 laser treatment, compared to scalpel surgery. LightScalpel CO2 laser frenectomies for the following case studies were performed by Dr. Kaplan with contra-angled 0.25mm focal spot size laser handpiece (see Figure 3), delivering 2 watts SuperPulse laser beam gated at 50-60% duty cycle

34 DSP | Fall 2017

at 20 Hz. Similarly gated non-SuperPulse settings were used for enhanced hemostasis (without cutting). To facilitate the laser procedure, gentle tension was applied to the lip during the labial frenectomy and to the tongue during the lingual frenectomy. All laser surgeries were performed by a surgeon wearing 6x magnification loupes for enhanced visualization of the surgical site (Dr. Kaplan recommends 3.5x magnification is the minimum).

Case Study 1: Infant with Laryngomalacia

A newborn girl was presented for severe choking. At 2-days old, she almost choked to death on her formula (breastfeeding was difficult and supplemental bottle feeding was recommended), but was saved by her 11-year-old sister who had just learned CPR. The baby was rushed to the hospital and was further evaluated and diagnosed with laryngomalacia; and the mother was told that the girl would eventually outgrow the problem. Dr. Kaplan reached out to the family and volunteered to evaluate and treat the girl free of charge, if there was the problem that he had suspected. After a thorough evaluation, tongue-tie and a lip-tie were diagnosed. The baby had a class 3/4 corded maxillary lip-tie; her lips were very tight


LASERfocus

A.

B.

C.

D.

E.

Figure 1. A: Class 3/4 corded maxillary lip-tie with no flanging and tight lips. B: Premaxilla with flattened alveolar ridges caused the baby’s inability to retain the nipple due to the nipple sliding out. C: Immediate post-op. The infant’s upper lip flange has notably improved and mouth gape has increased. D: Posterior tongue-tie was a tight, corded and shallow tense membrane. E: Immediately post-release view. Note the significantly improved elevation of the tongue.

and there was no lip flanging (Figure 1A). The premaxilla with flattened alveolar ridges (seen in Figure 1B) caused the baby’s inability to retain the nipple due to the nipple sliding out. The posterior tongue-tie was a tight, corded and shallow tense membrane (Figure 1D). Both ties clearly exacerbated the baby’s nursing difficulties and choking. The release of the lip-tie and tongue-tie (immediate post-op photos in Figures 1C and 1E) was a simple in-office procedure with a LightScalpel CO2 laser. Immediately after the procedure, the baby’s lip flange noticeably improved and mouth gape increased by approximately 25%; this made it easier for her to obtain enough of the nipple and areola to initiate a latch. During the post-op exam, Dr. Kaplan noticed that that the mother was hyperflexing the baby and the throat was not in a neutral position. This simple correction immediately provided quiet swallow and improved intake. A private IBCLC (International Board Certified Lactation Consultant) appointment was arranged for the mother and baby to assist with proper breastfeeding or bottle feeding guidance. At a checkup a few days later, the mother reported that they had received proper education and the baby nursed better. Her breathing was quiet and choking was no longer a concern.

Case Study 2: Autistic Patient with Turner Syndrome with a History of Snoring and Restless and Fractured Sleep

A fifteen-year-old autistic female with Turner syndrome was a patient who had required hospital admission for treatment

of dental caries under general anesthesia due to her combative behavior and extensive caries at age 11. She had always been a gagging patient with oral aversion to any dental care. Her latest exam revealed a previously unrecognized restrictive tongue frenum, which was thought to be a source of her oral aversion and gagging (Figure 2A shows the thick and fibrous lingual frenal attachment). Since becoming more knowledgeable about apnea and the potential impact of the restrictive lingual frenum on the airway, Dr. Kaplan’s ability to diagnose this previously overlooked tongue-tie associated issue has improved. He was able to recognize the thick and short tongue frenum and consider surgery as a possible treatment to improve not only the reported pattern of restless sleep and snoring, but also the enhanced gagging reflex. Martin Kaplan, DMD, practices exclusively in Stoughton, MA. He is a Diplomate of the American Board of Laser Surgery and its current Director of Dental Laser Education and Development. He is also an Adjunct Clinical Instructor at Tufts University School of Dental Medicine in the Post-Graduate Pediatric Dental Department. He is a member of the American Academy of Pediatric Dentistry, the Massachusetts Academy of Pediatric Dentistry, the American Dental Association, the Academy of Laser Dentistry, the Massachusetts Dental Society, the Massachusetts Breastfeeding Coalition, and Breastfeeding USA. Peter Vitruk, PhD, MInstP, CPhys, is a founder of LightScalpel, LLC in Woodinville, WA. He is a member of The Institute of Physics, a Diplomate of the American Board of Laser Surgery USA and its current Director of Laser Physics and Safety Education. He is also a founder of the American Laser Study Club. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com.

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LASERfocus Per routine safety protocol, since the patient was autistic and the airway was the primary focus of the treatment, medical clearance for sedation was obtained. The patient received orally administered midazolam (Versed) for anxiolysis and sedation in an attempt to complete the procedure in the dental office setting. The patient was mildly sedated. For control of possible resistant behavior, she was placed in a loose-fitting adolescent-sized protective restraint which did not inhibit her breathing. The parent was present to assist in the behavior management. The patient was only mildly cooperative, but accepted administration of a minimal amount of topical anesthesia. She would not tolerate local infiltration with a local anesthetic. A molt mouth prop and a Miltex grooved tongue director was used to control oral access for the tongue treatment

and to maintain tension on the lingual frenum, as is required for the procedure. Immediately after the lingual frenectomy procedure was completed, tongue mobility was increased (Figure 2B). The two-week follow up confirmed a better sleeping pattern, no more snoring and noticeable improvement in temperament, as reported by her mother. In addition, the patient was now less flatulent, likely indicating an improvement in swallowing mechanics. Treatment was accomplished due to the clinician’s ability to manage this patient in the least threatening and safest outpatient environment. The sedation, although never without risks, was the safest way to attempt treatment and obtain desired clinical results. Since the laser frenectomy procedure, the patient has been able to undergo additional dental restorative treatment with much improved co-operation. She still has her disability, however, the improvement in sleep has allowed her to demonstrate better day-to-day behavior.

Acknowledgement

The authors greatly appreciate the support and contribution from Anna “Anya” Glazkova, PhD, in preparing this material for publication. 1.

2.

A.

B.

Figure 2. A: Pre-operative view of the thick, fibrous lingual frenum. B: View immediately after CO2 laser release of the lingual frenum

3.

Convissar R, Hazelbaker A, Kaplan M, Vitruk P. Color Atlas of Infant Tongue-Tie and Lip-Tie Laser Frenectomy. PanSophia Press, 2017. Fabbie P, Kundel L, Vitruk P. Tongue-Tie Functional Release. Dent Sleep Practice. Winter 2016;40-5. Kaplan M, Vitruk P. Soft tissue 10,600 nm CO2 laser orthodontic procedures. Orthodontic Practice US. 2015;6(6):53-7

Figure 3: Laser incision/coagulation with focused (250-µm spot size) and defocused (500-800-µm spot size) laser beam delivered from a pen-sized, autoclavable handpiece.

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DSPinterview

Direct to Consumer Advertising for Sleep Therapy

N

o doubt, if you have turned on a TV in the last 24 hours, you have seen a direct-to-consumer (DTC) advertisement. Overseen by the Food & Drug Administration, these ads are typically targeted at the public with the goal of getting people to ask their doctor for a specific drug, joint implant, or even a surgical procedure. Direct to patient advertising on television, radio, in magazines, and more recently online, has largely had a positive impact on increasing the general population’s awareness of specific therapies that may be right for them.

Historically, the majority of DTC advertising has been aimed at patients who are seeing a physician for a medical condition and, in a 500-physician survey conducted by the FDA in 2004, most physicians thought that DTC ads made their patients more involved in their health care and felt that they had better conversations with their patients, who were more aware of treatment options when they arrived for their visit1. Sleep dentists across the country have also been advertising their practices to patients, both current and potential, for several years. With the potential number of obstructive sleep apnea (OSA) patients in the US needing treatment being between 10 and 15 million, there is a significant opportunity to improve awareness and access to care for those desperately seeking treatment other than CPAP. Because of this unmet need in the market, dental sleep specialists have begun reaching out to the masses via radio, TV and internet advertising. To give you an example of how this could work for you, we caught up with Dr. Kien Nguyen, the President of SomnoMed North America to get his perspective on growing a sleep practice. In the greater Dallas Fort Worth area, where SomnoMed – the global

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leader in COAT (Continuous Open Airway Therapy) has their North American headquarters, there has been a noticeable increase in patients receiving a SomnoMed device in the last 3 years.

DSP: Kien – can you tell us about the growth your company has seen in the DFW area in the last couple of years? A: When I look at our business in the DFW area from July 2014 to June 2015 and compare it to July 2015 to June 2016, I see a growth rate of greater than 25% year over year. This is the growth of individual sleep dentists and does not take into account any of our corporate sleep dental customers. If we include our corporate clients, I would expect to see a growth of over 50% year over year. These growth rates are higher than the national average for oral devices.

DSP: Do you have any dental sleep customers who advertise their practices directly to patients? A: We have dental customers throughout the country, as well as here in North Texas, who actively promote their sleep practice to patients. The most common DTC advertisements are print ads in local newspapers and magazines. I have seen several in my travels. Other doctors have tried billboard advertising and some have even used radio advertising. Radio is more expensive and requires a good understanding of the listening audience, but can be very effective to reach a broader group of patients.

DSP: Have you seen growth from a specific customer or many customers in the metro area? A: Here in North Texas, we have had many customers (over 20) who have grown their sleep practices with us over the past


DSPinterview few years. Some have recently started treating sleep patients, while other have been working in sleep medicine for many years. It is wonderful to see more trained and educated dentists entering the sleep space. There are thousands of potential OSA patients in North TX who need to be diagnosed and offered the appropriate clinical treatment. Of course, this is also true in every other part of the country.

DSP: Do you believe the growth across these customers can be attributed to DTC advertising? A: The growth experienced by customers who regularly conduct DTC advertising is directly linked to driving greater patient awareness of their practice and services. However, the benefit of DTC advertising can also expand to other dental practices doing sleep who do not advertise to patients. For example, there are anecdotal cases where some customers have gained new patients who were exposed to the DTC advertising, learned about oral devices, and conducted their own internet search for local dental sleep providers rather Greater awareness of than going to the ‘advertising’ dentist. the problem via DTC Greater awareness of the problem via DTC advertising leads to more patients advertising leads to choosing treatment. I believe that when more patients CPAP non-adherent patients become aware of an alternative to CPAP, they choosing treatment. also contact their sleep physicians and seek a prescription for an oral device. The latest AASM/AADSM guideline on oral device states the following: “We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.2”

DSP: How does SomnoMed support the dental sleep practices in your local market? A: SomnoMed has, and will continue to, support our dental customers by providing the highest quality oral devices and customer services. In addition, our field sales representatives will call on local sleep physicians to

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promote oral devices and direct the referrals to our customers’ dental sleep practices. We continue to educate sleep physicians on the latest clinical data on oral devices and invest in clinical research to generate more clinical data on oral devices for OSA. Our marketing team, working closely with Dr. Jagdeep Bijwadia (SomnoMed Chief Medical Officer), are developing tools to help sleep physicians and their clinical staff discuss oral devices with their patients. This critical patient education at the sleep clinic minimizes patient leakage from their medical doctor to their sleep dentist. Furthermore, we continue to drive greater patient awareness of oral devices with our social media efforts.

DSP: What do you think the longterm impact of more dental sleep practices advertising directly to the patient will be? A: Longer term, targeted DTC advertising will lead to more and more patients becoming aware of different treatment options, including oral devices, for their OSA condition. I believe this will lead to more patients seeking a clinical diagnosis and eventually treatment. At the same time, greater understanding of oral devices could also lead to less leakage of patients who have received a referral for an oral device but have not moved forward with treatment. We see leakage rates of greater than 50%, due to patients not fully understanding the health impact of no treatment or the value that educated sleep dentists can provide. As more patients with OSA become aware of convenient, high-quality and comfortable oral devices, sleep dentists in the US are well poised to enhance their role in helping these at-risk people return to restful nights and refreshing days. 1. 2.

https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ ucm143562.htm Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. An American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guideline. Kannan Ramar, MBBS, MD1; Leslie C. Dort, DDS2; Sheri G. Katz, DDS3; Christopher J. Lettieri, MD4; Christopher G. Harrod, MS5; Sherene M. Thomas, PhD5; Ronald D. Chervin, MD6 1Mayo Clinic, Rochester, MN; 2University of Calgary, Calgary, Alberta, Canada; 3Atlanta, GA; 4Walter Reed National Military Medical Center, Bethesda, MD; 5American Academy of Sleep Medicine, Darien, IL; 6University of Michigan, Ann Arbor, MI


PRACTICEgrowth

#MADFanClub by Chris Bez, opportunity engineer

R

emember the first time you looked at an oral appliance, and a voice in your head exclaimed, “Wow, Sexy! I can sell a million of those!!” – It would be so much easier to sell oral appliances if they carried the cachet of the latest model Ferrari, but it simply isn’t so. There are no Mandibular Advancement Device Fan Clubs, and no such thing as #waycool searches that return a picture of a Tongue Stabilizing Device.

However, for anyone who wears one, a MAD can mean the difference between the big bed and exile, or an invitation to the fishing weekend or not. Helping patients reclaim healthy sleep gets to the real cachet of an oral appliance, but it’s your brand that does the heavy lifting in representing you to your referral network and to potential patients. As a consultant, I often pose brand questions, “How much time have you spent developing your brand? If it’s not about the visual appeal of the appliance, what picture are you painting for potential patients?” I’ve seen successful campaigns waged around becoming the friendly, neighborhood doc who is relied upon to listen to patient stories. Other clients have educated on the need for sleep. Representing the image of ageless, healthy, athletic competitors crediting a good night’s sleep for their wins has been the route for others. A study involving 300,000 participants recently came to some striking conclusions about companies that invest the time and effort to build brands and connect with customers. It was determined that brands that connected enjoyed increased brand awareness, sales, and overall higher returns than competitors and other companies. The study revealed the brands were judged on 3 criteria: 1.) value, 2.) what the brand did for individual customers and 3.) what the brand did for society. Study participants were clear on the message that “meaningful brands” could realize a 46% higher “share of wallet.” That is, they would spend more money on a brand if it is meaningful to them. Other relevant findings indicated that: Sales, marketing and the development of the enhanced communication skills that support both of those efforts, has been the focus of Chris Bez’s career since inception. From a start as a Sales Manager for a national manufacturing company, she became an award-winning Marketing and Advertising Executive, a Professional Executive and Team Coach and a national speaker on marketing and promotions. Today she focuses her attention on niche marketing for dentists – specifically for those practices that have incorporated Dental Sleep Medicine into their patient offering. She writes and advocates on the imperative of consulting versus selling, and the development of individuals and teams. For more information, contact Chris at cbez@chrisbez.com.

• Company size was not a limiting factor – smaller companies in some instances bested larger ones • Most companies fell short by failing to establish a direct connection with the consumer • Consumers only trust 22% of US brands • 74% of brands could disappear and people wouldn’t care. When you take these study results into consideration, there are substantial benefits for the dental sleep medicine practice who develops a meaningful brand. • In a time when insurance issues often cloud care options, people are willing to spend on brands that speak to them personally • When appliance choices are involved, if your brand has integrity, and the appliances have value, patients are more likely to opt for what will benefit them vs. what they can cost justify • Practices that speak to the health and well-being of the local population in addition to the other criteria for “meaningful brands” improve their potential for patronage – geometrically. So, if fans are already knocking your door down asking for the latest in mandibular advancement devices you’re most likely doing something right. If they’re not, while OAT may not yet have the high profile of a dream car, it can be the key to accessing a dream state for those who find it elusive. In this country that translates to 22 million potential patients – 80% of whom are undiagnosed, just waiting for you to develop your meaningful brand. #MADFanClub . . . it could happen. DentalSleepPractice.com

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5

TOP

TEAMfocus

Things Team Should Know About Working with

ENT MDs by Glennine Varga, AAS, RDA, CTA

42 DSP | Fall 2017

A

couple of years ago I lost my voice 4 times within 12 months. My Primary Care Physician diagnosed me with acid reflux and gave me a referral to one of the best and well known otolaryngologists (Ear, Nose, and Throat (ENT) docs) in the area. After he and I talked about my voice, I asked him about surgery for OSA. He said he sees about a 40% success rate. Recently, I talked with him and posed the same question. His answer may surprise you…

He said his success rate has risen dramatically! How, he said, was because his case selection is very specific for surgery – he dropped the percentage of procedures he does, making each one more likely to succeed. He also added he feels oral appliances are a solid option for patients and according to his continuing education provider (the American Academy of Otolaryngology Head and Neck Surgery Clinical Practice Guidelines) …A custom-fit oral appliance, which repositions the lower jaw forward, may also be considered for certain patients with snoring/OSA. This should be fitted by an otolaryngologist, dentist, or oral surgeon with expertise in sleep dentistry. He continued: “Only send me dentists that are qualified and can bill medical insurance including Medicare.” He said he’d love to make them himself…if he got paid. Since Medicare is only paying dentists, he’d rather refer out. Wow. That brief conversation was very educational. As I thought more about it and reflected on past conversations with other physicians and dentists, the same points came to mind. Hence:


5 4 3 2 1

The Top 5 Things Team Should Know About Working with ENT MDs

5. The percentage of procedures dropped and success rate increased. There are a certain surgical procedures that can benefit patients greatly. Generally speaking, surgery may not be the first option for most patients but for those with specific conditions, it may be the best strategy. Surgery and oral appliances as combination therapy may be a viable option as well. Adding a simple nasal procedure to oral device therapy may be a match made in heaven for some folks! 4. ENTs are making oral appliances. My doc was not interested in learning how to take impressions or manage periodontal issues, especially if payment is not secured. When connecting with an ENT, find out what is the best way to work together. If your ENT is making oral appliances, it’s best to make sure she/he understands you are there to help if they get in ‘over their head.’ 3. “I’d love to make oral appliances myself…if I got paid.” Although their Academy is stating ENTs should fit oral devices, Medicare is not allowing reimbursement to MDs. Medicare states the device is provided and billed for by a licensed dentist (DDS or DMD). Private insurance companies have been known to follow Medicare’s policy. However, each insurance company has its own policy and limitations. 2. Oral Appliances are a solid option for patients. WAHOO! It’s great that oral appliances are becoming more recognized as successful management of sleep disordered breathing! Although this is one physician’s opinion and not all feel the same way, many docs are coming around to this position. It’s our dental industry that can prove a dental solution is possible for a medical condition to achieve Maximum Medical Improvement (MMI) for our patients and more. 1. “Send me qualified dentists. Dentists that can bill medical insurance including Medicare.” This is the most consistent response I get with regards to physician’s request for a dentist relationship. Send me a dentist that knows what they are doing clinically and can handle insurance matters specifically Medicare. After all, there is a high percentage of Medicare patients with diagnosed and undiagnosed OSA.

He continued: “Only send me dentists that are qualified and can bill medical insurance including Medicare.”

TEAMfocus How can we team help knowing the Top 5 Things Team Should Know About Working with ENTs?

We can learn more about the surgical procedures our referring ENT doctors can provide. This will allow us to communicate with patients once recommendations are made and help orchestrate appointments for combination therapy. We can help our dentists identify our practices as resources and referral options for surrounding physicians. We can understand medical insurance policies to know when reimbursement is allowed and what indications, limitations and or medical necessity is required. We can learn as much as we can about sleep and the importance of maintaining a healthy sleep airway (similar to what we have done in dentistry) to be able to educate our patients ultimately to see them succeed in airway management. We can celebrate our patient successes! If we witness or experience patient’s improvement, let’s share on social media and with other patients. We can ask for online reviews, or even record a short video with a smartphone. Of course, we need to make sure we have a signed consent from the patient. If it’s a patient who has seen the ENT doc we’ve worked hard to cultivate, sharing the success with them is great! By the way, anyone who knows me knows my voice is healthy now! Editor’s Note: 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: SteveC@MedMarkAZ.com, while we can’t respond to every individual. Your feedback will help us create the most useful Sleep Team Column we can!

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 has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and a trainer of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp and a Total Team Training instructor for Arrowhead Dental Lab. For more information, visit www.dsmbootcamp.com or email g@dsmbootcamp.com.

DentalSleepPractice.com

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TEAMengagement

Dentistry’s Value Added to Sleep Disorders by Bradley Eli, DMD, MS

How Important is Dentistry to the Sleep Community?

In a word, VERY! In the early 1990’s, dentists became interested in Sleep Medicine. I remember those days well. The field was new and exciting, meetings were held annually, and attendance was small. The familiar few returned each year. Today, the field has grown significantly and most importantly, it has changed. Sleep, its quality and quantity, have become a message that now is carried daily by the many players within the field. We can now measure better, faster, more completely and with more methods than ever before with no real end in sight; and with this opportunity, the options for the dental team is limitless. Dental providers have a unique relationship with patients that is one of health maintenance, not disease, interactions. For this reason, the dental team that truly knows and understands their value is critical to their success and success for their patients. Many of the current programs introducing or expanding the knowledge of the dentist’s role in this field focuses solely on a treatment. It is true that oral devices are a treatment option of sleep disordered breathing and that compliance with this treatment option exceeds the most ubiquitous option, PAP (positive air pressure). It is also true that dentistry has additional tools to assist in both current anatomy findings and the ability to monitor progress (CBCT, panoramic x-ray, etc.). Finally, there are new options that continue to enter the market daily.

So You Want to be a Sleep Provider?

As with any other professional services, you need to understand your value so your role will be well-defined. I have often used the example of periodontal disease as a good parallel for sleep. I invite the dental team to think about how they would consider a medical provider who was “interested in adding a periodontal soft-tissue program” to their clinic. What they would need to know in order to be an asset? As with this example, most would agree the method used for assessment of risk and identification of patients is first on the list.

In the dental office, what team members can be involved in risk assessment?

Answer: Everyone. Information pieces on sleep disturbances can be part of the information available for patients in the reception area. You could run information on

44 DSP | Fall 2017

a TV or use wall posters. This “early education” of your population allows your patients to know your interest and service. But of equal importance the front desk must know how to handle an inquiry. Snoring, weight, morning headaches, and tooth grinding can relate to sleep disordered breathing and can become part of your office initial questionnaire and as part of the update questions gathered at follow up visits. Next is the hygiene department. This is the engine that drives any great practice. This is where relationships are built. This is where time for questions and answers occurs, and this is where the doctor is directed as to what message is ready to be reinforced to the patient. In order to make this engine work, the hygienists have to be: interested, educated, knowledgeable, and supportive. Questions started in the hygiene chair must be supported and stratified for more earnest discussion. Assistants are also critically important in the process. Patient questions must be responded to and directed either in printed format or to the appropriate caregiver within the facility. As we know, the staff is critical to the overall success of all programs within dental practices. Dentists are now ready to provide this service, patients are interested in this service, and relationships already in place can be solidified.

Back to the periodontal example: What level of understanding would you expect of the doctor providing a periodontal soft-tissue program?


TEAMengagement 1. What disease types, states and levels would be appropriate to be addressed in a first or second line treatment facility? 2. What treatments are reasonable to offer and who within the facility offers the treatments? 3. What supporting information do you have to help educate the patient on their disease state and the importance of not only initiating treatment but ongoing care? 4. As with all special care, knowing who not to treat is very important.

Who within the office would you want to be able to receive information or have your questions answered?

This includes not only the care itself but information regarding insurance coverage, duration of care, cost of care, and number of treatment visits. I am concerned when the focus of most of the current educational programs is solely on the economic potential benefits of the addition of an alternative care strategy but fails to provide the doctor even the minimum amount of information or education on their particular role. It is hard to not be intoxicated by advertisements quoting dollar figures, things that “could transform your practice”, that by completing their course, the doctor does not have to settle for a trickle of business. For twenty years, I have personally been involved in the field, providing services to patients suffering with a disease state that progresses throughout their lifetime. The number of patients in need of these services truly is enormous and dentistry’s role and participation can be limitless. Practitioners interested in this field are generally interested in new challenges and opportunities to improve their patients, quality of life, which grows both their position in

their community as well as value to their business. At last check, little to no information or education is currently provided at the predoctoral level of most dental programs, dental hygiene programs or dental assisting programs. Therefore, the people who are interested in this field and adding it to their existing dental treatment model must recognize that unlike many other dental programs, which build upon their basic foundational understanding, dental sleep care requires a much greater level of commitment to foundational education for all of the office participants. Dentists are capable of providing a great service to the community with professionalism and respectability. The economic value gained by expanding services is rarely the driving force in a successful program. I caution any provider who is considering the treatment of sleep disordered breathing as a value added economic machine to an existing general dental practice to proceed cautiously. Most of the true hurdles encountered have nothing to do with providing care. Rather, they are the result of working within the medical model and require strong understanding of rules and pathways currently not part of the dental treatment community or algorithms. Persistence, setting goals with reasonable expectations for completion, and being educated at a level you would expect from a medical colleague interested in adding a dental procedure to their list of services will keep the process in context and prevent burnout and frustration that often comes from a revenue-only based model. Remember, although mandibular advancement devices attach to the teeth, placement of these devices is treating a medical breathing condition. Having a strong understanding and respect for where your service benefits these disorders and and where it may not will keep you and your staff on the high value side for years to come.

The number of patients in need of these services truly is enormous and dentistry’s role and participation can be limitless.

Dr. Bradley Eli received his post-doctorate training at UCLA School of Dentistry in Oral Biology (1992), focused on head, neck facial pain, chronic headache, temporomandibular joint orthopedics, and treatment of sleep disordered breathing. In addition to his private practice in Southern California, he is a peer educator in medical and dental societies and on the medical staff at local hospitals for consultation. Dr. Eli has obtained patents and trademarks in the fields of pain and sleep, is qualified as an expert witness in San Diego and San Bernardino counties superior courts, and is an Associate Clinical Professor, School of Respiratory Therapy, California College San Diego.

DentalSleepPractice.com

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PRACTICEdevelopment

The Importance of Website Lead Conversion Ian McNickle, MBA, discusses how your website can lead patients to your practice

W

hat would you say if I told you that by making some changes to your website design, content, and layout, you could generate over $100,000 in additional revenue in 12 months? You might think I’m crazy, but I encourage you to take 5 minutes to read this article. You might be very glad you did. To learn how, we need to first take a step back and discuss online marketing. When it comes to online marketing, there are two primary objectives: 1. Generate as much “relevant” traffic as possible. 2. Convert that traffic into as many new patient leads and appointments as possible. I frequently lecture at dental conferences and study clubs all over North America, and almost without exception, the clinicians and staff in attendance are not familiar with the performance metric of website lead conversion.

Website traffic

To better understand this metric, let’s start with generating traffic. There are many ways to generate traffic to a website such as high search rankings on Google, Bing, Yahoo, etc., which is achieved through effective Search Engine Optimization (SEO). Driving lots of pa-

tient reviews to review sites such as Google, Facebook, Healthgrades, and Yelp also have a very positive impact on your search rankings and traffic. Social media activity, engagement, boosted posts, and paid ads can all drive traffic to a website as well. Online directories can drive traffic, and the list goes on and on.

Lead conversion

Once you’ve implemented a robust program to generate traffic, it is equally important to understand how to convert all this traffic into new patient leads. As with traffic, there are many items that affect website lead conversion such as: • having a modern website design with proper layout • the location of the phone number • appointment request buttons or forms • clear calls to action • effective use of videos • compelling offers • online scheduling links • the use of actual photos instead of stock photos • great doctor bio and team pages • patient testimonials (video and written) • helpful and accurate content An experienced online marketing agency with expertise in the dental industry like WEO Media should be consulted for best practices in this area.

How is the lead conversion rate calculated?

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com

46 DSP | Fall 2017

The lead conversion rate is calculated by dividing the amount of conversion activities (phone calls, appointment requests, etc.) by your website traffic each month. By doing this, you’ll be able to develop a baseline range for how your website typically converts traffic. Consider this example: Let’s suppose your website generates 400 visits (traffic) in a month. You received 30 phone calls from the website and 10 appointment requests through the website. Your conversion rate would be 40 conversion activities divided into 400 visits for a conversion rate of 10%. If you monitor this


PRACTICEdevelopment rate over time, you’ll be able to understand how your website is actually performing as a marketing tool.

Maximize your Return on Investment (ROI)

Where this gets really interesting is when you can improve items on your website that improve your website conversion rate. Even a small improvement can result in tens of thousands or even hundreds of thousands of dollars per year in extra revenue. An average website may generate 500 visits per month with an average conversion rate of around 10%. If you can implement strategies to improve your conversion rate, and it improves to 12%, consider the impact. This slight 2% improvement equates to 10 additional new patients leads per month or 120 per year. If you can convert even 25% of these new patient leads, you’ve now generated an extra 30 patients per year. How much is that worth?

The good news is most of the items that improve the website conversion rate do not involve ongoing costs, but rather specific expertise and industry experience to properly design and construct the website.

Marketing consultation

If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or call 888-246-6906. For more information, you can visit online at www.weodental.com.

1-888-751-1121

What is HindexRV™ & How does it work? Visit us at www.physiologicaldentistry.com Learn the basics of our technology and see how you can implement it in your practice.

Physiological Monitoring for Dentistry and Medicine HindexRV™ is an FDA approved cutting-edge physiological monitoring system for collecting and transmitting multiple measurements. The HindexRV™ system monitors the autonomic nervous system using accurate recordings of multiple physiological parameters and statistical data which the clinician can use to make a clinical assessment of medical, dental, or peak performance interventions.

DentalSleepPractice.com

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NASALhealth

Chronic Rhinitis and the Sleep Dentist by Warren Schlott

E

very sleep dentist has patients who include chronic nasal congestion and/or post nasal drip on their list of complaints. More often than not, the patient suffers from chronic rhinitis. This condition can play a prominent role as a cause of snoring and sleep apnea. It is known that congestion can lead to an increase in intra pharyngeal pressure that leads to open mouth posture and posterior tongue base displacement. This posterior displacement can lead to a partial blockage of the airway resulting in snoring and/or a hypopnea. If the blockage is complete an apnea can occur. At best, an open posture can lead to dry mouth. Hence, rhinitis can cause havoc with CPAP and oral appliance use. An understanding of this condition can be pivotal with treatment of snoring and sleep apnea. Rhinitis means inflammation of the nose. Signs and symptoms of rhinitis include a blocked or congested nose, runny nose, sneezing, mucus (phlegm) in the throat known as postnasal drip, and cough. Other symptoms can include facial pain, headache, and loss of smell. The most common causes of rhinitis are the common cold and allergies causing hay fever. Chronic or persistent rhinitis doesnâ&#x20AC;&#x2122;t usually cause itchy nose, eyes or throat. The most common definition of chronic rhinitis is symptoms lasting for an hour or more on most days of the year. Chronic rhinitis causes can be divided in to two groups: those caused by allergies, and those caused by non-allergic reasons (idiopathic). The most common cause of chronic rhinitis is allergy. The most common allergen is the house dust mite. This tiny insect lives mostly in mattresses, pillows, and carpet. Their feces cause an allergic reaction in many people. House mites live all year long, but their numbers peak in the spring and fall. Another common allergen is pets. Flaking skin, urine,

48 DSP | Fall 2017

or saliva from dogs, cats, and rodents such as hamsters or guinea pigs can trigger allergic reactions. A small percentage of people are allergic to formaldehyde found in furniture, wood dust, latex, and other chemicals. Regardless of the allergen, histamine and other chemicals are released by the cells lining the nose causing swelling and other symptoms. Non-allergic rhinitis results when the blood vessels of the nose dilate, filling the nasal lining with blood and fluid. There are several possible reasons this can occur. Some people can have nerve endings that are hyper responsive to a stimulus, in a manner like the way the bronchia react in asthma. Such things as smoke, changes in temperature, humidity, strong odors such as perfumes, and even stress can trigger a reaction. Many drugs can cause rhinitis. These include aspirin, Ibuprofen, oral contraceptives, hormone replacement therapy, anti-anxiety medications (especially alprazolam), sedatives, antidepressants, Viagra and Cialis, and blood pressure medications including beta-blockers and vasodilators. Alcohol can also cause nasal congestion. Another cause of rhinitis is prolonged use of decongestant nasal drops and sprays such as Afrin or Dristan. Regardless of the cause of rhinitis, rhinitis can be a cause of snoring and obstructive sleep apnea, and it can create problems with treatment for snoring and obstructive sleep apnea. Like sleep apnea treatment, rhinitis is a condition that generally cannot be cured. The condition must be managed. If the cause of rhinitis is allergy, the simplest course of action is to avoid the cause of the allergy. For instance removing a pet from the home may lessen the problem. However, many times removing the cause is impractical. Thus, other steps can be taken. For mild cases of rhinitis, a nasal wash can be helpful. Neti pots have become pop-


NASALhealth

It is prudent to question all new patients, and existing patients with dry mouth from OAT, about nasal congestion.

ular. They can be purchased online and at most drug stores â&#x20AC;&#x201C; NeilMed provides a product for nearly every age and sinus problem. The nasal rinse kit includes a squeezable bottle and packages that contain a salt and baking soda mixture that when combined with water create a saline solution that can be used to rinse the nasal passages. The rinse can remove mucus from the nose and help improve coordination of the cilia (hair-like structures in the nose) to remove allergens. Antihistamines can be used for seasonal rhinitis. While, they can help with itchy eyes and runny noses, they are not very effective with nasal congestion. Usually, secondgeneration antihistamines such as Claritin, Zyttec, Allegra, and Xyzal are used because they have fewer side effects (sleepiness) than first generation antihistamines. Second generation antihistamines in a nasal spray may be more effective than the pill form for seasonal allergic rhinitis. However, they may cause sleepiness. Common prescription nasal antihistamine sprays include Astelin, Astepro, Dymista, and Pantanase. It should be noted that nasal antihistamine sprays are not as effective as nasal corticosteroids. Corticosteroid nasal sprays help prevent and treat inflammation associated with rhinitis, and are considered the most effective drugs for controlling rhinitis. They are often used in conjunction with second generation antihistamines. It takes several days and up to three weeks for a steroid nasal spray to reach maximum effectiveness. However, once symptoms disappear, dosage can be reduced. Commonly used sprays are Nasacort, Nasonex, Flonase, Rhinocort, Nasarel, and Alvesco. Some sprays such as Dymista combine a corticosteroid and an antihistamine. Whereas, oral corticosteroids can have severe side effects, nasal corticosteroids have few. Overt overuse of these sprays can lead to dryness of the nose and/ or headaches.

Warren J. Schlott has been a practicing dentist in Brea, California since 1978. Dr. Schlott developed a thriving restorative dental practice and then in the early 2000â&#x20AC;&#x2122;s developed a busy full time sleep practice. He has published numerous articles, and has helped other dentists establish sleep practices. Dr. Schlott is a member of the American Academy of Sleep medicine and is a Diplomate of the American Academy of Dental Sleep medicine. Dr. Schlott can be reached at wschlott@wschlott.com.

50 DSP | Fall 2017

Other possible treatments include sodium cromoglicate nasal spray. This drug is usually used if there is a problem with other treatments. The problem with this spray is that it must be taken 4-5 times per day as compared to once or twice for corticosteroid spray. Leukotriene antagonist drugs such as Accolate and Singulair can be used, but have been associated with mood and behavioral changes and other side effects. They are generally considered less effective than nasal corticosteroid sprays. Over the counter oral decongestants containing pseudoephedrine can be used for congestion but have side effects such as insomnia, irritability, nervousness, heart palpitations, and can raise blood pressure. Sudafed, Claritin-D, Allegra-D, and Zyrtec-D are common names of drugs with pseudoephedrine. Experimentally, the use of capsaicin, an ingredient that makes peppers hot, has been shown to reduce rhinitis for as long as 36 weeks. If medications fail, immunotherapy is an alternative. More commonly called allergy shots; this therapy hopes to reduce sensitivity to the allergen. The allergen must be first identified, then injected in increasing doses until desensitivity occurs. The injection is usually given twice a week, and then in increasing doses until a maintenance dose is achieved. It can take up to three years to reach a maintenance dose and then this dose may be continued for up to five years. However, symptom relief can begin within three to six months. Chronic nasal congestion is rampant. Hence, it is prudent to question all new patients about nasal congestion. If your existing patients complain of dry mouth with oral appliance therapy, you probably want to question the patient about nasal congestion. It is unlikely that they will know about chronic rhinitis. Your job is then to educate the patient about rhinitis. You can then suggest over the counter treatments or you may refer the patient to their primary care physician, ENT, or allergist for treatment. 1. 2. 3.

4. 5.

Massic and Metz: Three Parameters AADSM presentation Minneapolis 2014 Dykewicz MS, Hamilos DL. Rhinitis and Sinusitis J Allergy Clin Immunol. 2010 Feb; 125(2 Suppl 2): S103-15 Rabago D, Zgierska A. Saline Nasal Irrigation for Upper Respiratory Conditiions. Am Fam Physician. 2009 Nov 15; 80 (10): 1117-9 www.acaai.org American College of Allergy, Asthma and Immunology Sur DK, Scandale S. Treatment of allergic Rhinitis. Am Fam Physician. 2010 Jun 15; 81 (12): 1440-6


Only 15% of airway/ sleep disorders are diagnosed. Help address this major unrecognized public healthcare crisis

BECOME INVOLVED

by joining thought leaders, academies, organizations and corporations to bring a unified message of awareness to the public.

â&#x20AC;˘ Attend Foundation Events - White Flag Event II @ the AAPMD Conference September 13-17, 2017 in San Juan, Puerto Rico - Airway Summit @ The Greater New York Dental Meeting November 25, 2017 in New York, NY

â&#x20AC;˘ Complete the Foundation for Airway Health Pledge (below) and be listed as a resource for those seeking care for airway/sleep problems.

For more information, visit www.foundationforairwayhealth.org Foundation for Airway Health Pledge We want to fill our pledge rolls with practitioners of any modality that believe in the importance and priority of airway. Those interested can use this form or visit the Foundation website and find the pledge under the Healthcare Professionals tab. Thank for your support and partnership in our airway mission.

o

I am committed to championing the recognition, diagnosis and treatment of airway disorders through collaboration, awareness, research and education, and access to care. I pledge all patients seen in my office will be screened for airway/sleep problems and will be provided resources for diagnosis, treatment and referral.

o

I wish to be listed on the Foundation for Airway Health website as a referral resource for those seeking care for airway/sleep problems. Airway is a priority.

Name ____________________________________________________ Email ____________________________________________________________ Send to Foundation for Airway Health, 355 Lexington Ave., 5th Floor, New York, NY 10017 or pledges@airwayhealth.org


COMBINATIONtherapy

Physician and Dentist Co-Referrals Improve Patient Outcome by Mayoor Patel, DDS, MS

I

t’s clear that the availability of oral appliance therapy (OAT) is a successful form of treatment for patients with obstructive sleep apnea (OSA). The availability of OAT helps dental sleep medicine specialists treat patients suffering from mild to moderate sleep apnea. However, OAT isn’t always the best form of treatment for patients. If OAT doesn’t produce the results dental sleep medicine specialists are looking for in the treatment of sleep apnea, combination therapy might be an improved option for providing relief. Combination Therapy for Sleep Apnea Treatment Success

Combination therapy is the use of oral appliance therapy in tandem with another form of treatment for sleep apnea. One option I typically use is OAT with ventral only ablation therapy (VOAT). VOAT is a newer approach created by a local physician in Atlanta, GA, Dr. David Dillard. Together these treatment options can further help in improving the treatment of obstructive sleep apnea in qualified patients. It is important to note that if OAT doesn’t work, VOAT might and vice versa. In these cases, Dr. Dillard and I often collaborate to provide dual treatment for our patients. While you might not have the same option for treatment available in your community, there are other combination therapy options available.

Ventral Only Ablation Therapy (VOAT) and OAT

VOAT surgery is a new approach to radiofrequency ablation of the tongue that has improved success rates over similar treatments. Previous radiofrequency ablation (RFA) procedures approached the tongue from a dorsal (top surface) aspect of the tongue. However, the VOAT procedure approach is from the bottom surface for a less painful and better outcome. With this procedure, patients have an 80% chance of improvement. As a result, many patients don’t require a CPAP machine to improve their sleeping patterns. The VOAT procedure is quick and re-

52 DSP | Fall 2017

quires minimal sedation and treatment sometimes takes only 30 seconds. Through the availability of combination therapy, OAT and VOAT give patients the benefits of both individual treatments. Many patients are CPAP non-compliant, and the combination of VOAT and OAT helps patients experience improved results.

Utilizing CPAP and OAT

Another combination therapy approach is through continuous positive airway pressure (CPAP) therapy. CPAP therapy is highly effective in treating obstructive sleep apnea, but it is limited by poor adherence to therapy. The combination of a nasal CPAP and OAT can provide another option for CPAP-intolerant patients with incomplete response to OAT. In a 2011 study, ten patients with residual apnea/hypopnea events on mandibular advancement devices (MADs) who were intolerant to CPAP therapy were examined. The combination of MAD and nasal CPAP was well tolerated by all participants. Compared to utilizing CPAP therapy alone, the optimal pressure required to eliminate all obstructive events on the combination therapy was reduced from 9.4 to 7.3 cm. The combination therapy was also effective in reducing daytime sleepiness.1

Drug-Induced Sleep Endoscopy (DISE)

The mandatory diagnostic workup for OSA is through polysomnography (PSG). An up and coming adjunct diagnostic procedure is drug-induced sleep endoscopy (DISE), which is a dynamic, safe, easy-to-perform technique that visualizes the anatomic sites of snoring or apneas. DISE looks at the airway with a scope to see at which level obstructions are taking place. DISE guides the making of a tailor-made treatment plan in individualized cases. A study of 100 patients who were eligible for sleep surgery or mandibular repositioning appliance (MRA) underwent PSG and DISE. As a result of this study, multilevel collapse, complete collapse, and a tongue-based col-


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COMBINATIONtherapy lapse were statistically associated with higher apnea-hypopnea index values. The result of this study helps healthcare professionals to understand the pathogenesis of OSA and the associations between PSG outcomes and DISE results while assisting in the creation of patient-specific treatment options.2 Another study further displayed DISE’s influence on the location of treatment. As a result, the change in success rates of non-CPAP therapy in OSA and snoring might be possible.3 DISE also plays a role in determining if implanted upper airway stimulation (UAS), which consists of a respiration sensor, a programmable implanted pulse generator, and stimulating electrodes, is an effective tool in the treatment of OSA. A study of 21 OSA patients who underwent DISE before implantation of a UAS system revealed a significantly better outcome for these patients. The absence of palatal collapsibility during DISE may help to predict therapeutic success with UAS therapy.4

Body Position and OSA

Patients can experience improvement through their body position. A study of 30 male patients examined time spent on their side versus time on their back while sleeping. For 24 of the subjects, the apnea index was found to be twice as high during time spent sleeping on their backs than when they slept in the side position. This difference is reliable and inversely related to obesity. Five patients meeting diagnostic criteria for obstructive sleep apnea on an all-night basis fell within normal limits while in the side position, which suggests sleep position adjustment may be a viable treatment for patients who are not obese.5 Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP, serves as a board member with the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain (ABCP), American Academy of Craniofacial Pain and the British Society of DSM. He also has taken the role as examination chair for the ABCP. Having a limited practice to Craniofacial Pain and DSM, Dr. Patel utilizes his experience and expertise to help dentists across the country excel within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops up-to-date curriculum for their sleep apnea and craniofacial pain programs. To register for a seminar, contact Nierman Practice Management through Contactus@dentalwriter.com or 800-879-6468.

54 DSP | Fall 2017

Weight Loss and OSA

Therapeutic effects of weight loss was evaluated in 15 patients suffering from moderately severe OSA. As these patients decreased their body weight, the frequency of apnea fell significantly in non-rapid-eye-movement sleep. Weight loss also led to a decline in the mean oxyhemoglobin saturation during the remaining episodes of sleep apnea. Patients also experienced improved sleep patterns with a reduction in stage I sleep and a rise in stage II sleep. Of the nine patients with the most marked fall in apnea frequency, daytime hypersomnolence decreased. In patients who didn’t lose weight, there were no significant changes in sleep patterns. The results from this study showed that moderate weight loss alone could alleviate sleep apnea, improve sleep architecture, and decrease daytime hypersomnolence.6 Combination therapy can involve CPAP, OAT, a change in sleep position, DISE as a guide to determining treatment, or even weight loss. It can also be any other upper airway surgical procedure in combination with OAT. The key is to identify the level at which treatment is failing. Once we visualize where the failure is, with or without OAT, a better-targeted approach can be created to improve treatment outcomes. The newer procedures listed above are not the gold standard of care for sleep apnea, but they are upcoming treatments that may be promising. Remaining open and committed to finding the right treatment for patients, including combination therapy, has provided common ground to work with physicians and co-referrals. Communicating with physicians is the key to a successful dental sleep medicine practice, and combination therapy allows dentists to keep that line of communication open. 1.

2.

3.

4.

5. 6.

El-Solh, Ali A., et al. “Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study.” Sleep and Breathing 15.2 (2011): 203-208. Ravesloot, Madeline JL, and Nico de Vries. “One hundred consecutive patients undergoing drug-induced sleep endoscopy: Results and evaluation.” The Laryngoscope 121.12 (2011): 2710-2716. Eichler, Corlette, et al. “Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea?.” Sleep and Breathing (2013): 1-6. Vanderveken, Olivier M., et al. “Evaluation of drug-induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea.” Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 9.5 (2013): 433. Cartwright, Rosalind Dymond. “Effect of sleep position on sleep apnea severity.” Sleep 7.2 (1984): 110-114. Smith, Philip L., et al. “Weight loss in mildly to moderately obese patients with obstructive sleep apnea.” Ann Intern Med 103.6 Pt 1 (1985): 850-5.


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CASEreport

Successful Treatment of a Patient Diagnosed with Severe OSA with an Oral Appliance in a Pre-Doctoral Student Clinic by Paul D. Levine, DDS

S

leep Disordered Breathing (SDB) has become a chronic disease affecting more than 50% of US adults, according to the Foundation for Airway Health (FAH). Today, only 15% of patients with SDB are diagnosed. Untreated, it can lead to an increased risk of cardiovascular disease, stroke, and numerous other co-morbidities. It has become a goal of the FAH to dramatically increase the awareness, education, and treatment of sleep breathing disorders. To facilitate this end, they have called on the medical and dental community to come together and increase the education process both at the undergraduate and graduate levels. This includes the collaboration of both dentists and physicians to work in consort, with their patients who present with symptoms of SDB. The author, as an assistant professor, recognized that there was a sparsity of education at the pre-doctoral student level in most dental schools around the country. Therefore, it was set as a goal to increase the education in SDB here at the University of Texas at Houston School of Dentistry. The following case represents a step in the right direction to reach that end.

Figure 1: Protrusive bite record with George Gauge

56 DSP | Fall 2017

The following patient was referred to the pre-doctoral student clinic at the University of Texas Health Science Center at Houston School of Dentistry. She is a 71 year old female, 5â&#x20AC;&#x2122;5â&#x20AC;? tall, weighing 172 lb. Her BMI is 21. Her medical history was significant for hypertension that is uncontrolled by current medication. She also reported a history of gastric reflux and seasonal allergies. The patient is taking hydrochlorothiazide, valsartan, solifenacin succinate, rantidine, estradiol, and fluticasone. Her chief complaint included a history of loud snoring, witnessed apnea, daytime hypersomnolence, and bruxism. The reason she sought a consultation with a sleep physician was due to an avoidable complication she had while undergoing IV sedation for out-patient surgery in mid-2014. She suspected for years that she might have a sleep


CASEreport disorder, due to her nighttime snoring and witnessed pauses in breathing. She neglected to report this to her surgeon and anesthesiologist prior to having IV sedation for an outpatient procedure. She stopped breathing during the procedure and had to be resuscitated. The patient considered this episode a wake-up call and pursued the consultation with a sleep physician. She had an overnight Polysomnogram at Medical Clinic of Houston, Sleep Disorders Center on 02/11/2015, upon which she was diagnosed with severe obstructive sleep apnea: AHI was 72.0, RDI 84.0, and Oxygen nadir of 87%. She spent 0% of the sleep test in REM and 0% in slow wave sleep, with 70% of the sleep test in N1 sleep, suggesting very poor-quality sleep. She was subsequently put on CPAP but could not tolerate any kind of mask on her face. Since she was already a patient of record at UTSD, Dr. Levine was asked to evaluate her for oral appliance therapy (OAT) as an alternative treatment. When evaluating a patient for OAT who has been diagnosed with severe OSA, it is incumbent on the novice dentist to recognize individual patient phenotypes that would have an effect on treatment success. This can only be accomplished with a thorough clinical exam. Predicting success with OAT should be a part of the evaluation process for each patient that is screened for sleep disordered breathing. Every patient should be made aware that the general efficacy of OAT with a diagnosis of mild to moderate is 51- 80%. This decreases if the diagnosis is severe OSA. Therefore, the dentist and patient will not enter into treatment with false expectations. As part of the initial process before proceeding with a thorough clinic exam, a copy of the PSG was requested along with a prescription from the sleep physician to proceed with OAT. It is important for the overall success of OAT to collaborate with the referring sleep physician. The Texas State Dental Board requires collaboration with a licensed physician. The treating dentist can obtain valuable information from the sleep study to help predict successful outcomes with OAT, including sleep architecture, time spent below 90% oxygen saturation, amount of time spent in REM and N-3, and sleep position. Studies have shown that a patient with positional OSA has a better chance of successful treatment with OAT than a patient without

Figure 2

it. This information can only be obtained by looking at the sleep study. I would encourage all dentists to ask for a copy of the sleep study and learn how to interpret the findings. She was screened in the student clinic on 11/09/16. At that time, she was found to be a good candidate for OAT. She had a healthy dentition except for moderate wear from a life long history of bruxism, a healthy periodontium, and good range of motion. Her arch width was narrow, in both mandible and maxilla, with a high palatal vault, retrognathic chin, and very large mandibular tori taking up much of her tongue space. A complete muscle, TMJ, and range of motion examination was documented prior to initiating Figure 3: AM aligner treatment to record baseline data. She signed an informed consent specifically for OAT and was given the opportunity to ask questions. It was stressed that she will need to return to her sleep physician for a post titration sleep test after subjective symptoms are alleviated with the oral appliance. Full arch impressions were taken with Identium (Ketttenbach USA) and a protrusive Paul Levine, DDS, is a Clinical Assistant Professor in the Department of General Practice and Dental Public Health at the University of Texas Health Science Center at Houston (UTHealth) School of Dentistry, where he also serves as course director for pre-doctoral studies in dental sleep medicine. He earned his DDS from UTHealth School of Dentistry in 1982. He is a member of the American Academy of Dental Sleep Medicine and is a Diplomate with the American Board of Dental Sleep Medicine. Dr. Levine maintains a private practice with a focus on the dental management of sleep-disordered breathing. Dr. Levine volunteers his time to speak at study club groups and other organizations to help facilitate awareness of sleep breathing disorders.

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CASEreport bite record at 60% of maximum was recorded with a George Gauge. A Narval (ResMed) appliance was chosen to match patient details. It is structurally smaller than some of the others, as this patient has a very small mouth with narrow arches and large mandibular tori. The protrusive adjustments are on the side, and does not interfere with her limited tongue space. It is also a sturdy and robust appliance that will resist the forces of bruxism. It uses replaceable side straps that are calibrated to be .5mm difference in length. The appliance was delivered on 01/18/17. Upon insertion, it was noted that there was not enough retention on the lower arch. I used a flameless torch to heat the lingual flange to obtain more retention.

Figure 4

Figure 5: Note: lack of tongue space

58 DSP | Fall 2017

The device came with a 27mm strap in place and I advanced her mandible using the 24.0 mm strap. This seemed to be a comfortable amount of protrusion to begin. The patient noted that she is a mouth breather and has trouble keeping her mouth closed at night. She could very easily open wide enough to dislodge the appliance from her lower arch. I first placed a lower tension rubber band on both sides of the appliance and she still reported that it dislodged with ease. So, I replaced the rubber bands with one that had more tension, 8oz., and this seemed to work well. I constructed a morning aligner using a preformed horseshoe shape of Thermacryl (AM Aligner, Airway Lab). The patient was informed of the proper use and maintenance of both the appliance and aligner. She was told that the aligner will help prevent permanent protrusion of her mandible, but she will likely have long term craniofacial changes that include changes in overbite and overjet and minor teeth movement. It was recommended she use Retainer Brite (Dentsply) to clean her appliance. The patient was told to return for a follow up in 2-3 weeks for a follow up appointment. She left very satisfied and excited to start treatment. This delivery re-emphasized to me the importance of examining the teeth to determine the proper appliance. The Narval requires more retention on the posterior teeth than other appliances do. The contours of this patientâ&#x20AC;&#x2122;s posterior teeth only had moderate retentive contours, so I had to increase the retention by heating the flanges and reshaping them. This is not as easily accomplished with this appliance as it is with others. In addition, the patient had much trouble keeping her mouth closed at night while sleeping. She required rubber bands with an increased amount of tension to help keep her mouth closed. Fortunately, being at the dental school, I had access to a variety of rubber bands. The patient returned for her first follow up on 02/22/2017. She reported that she was extremely happy with alleviation of her subjective symptoms. She only reported mild snoring on 2-3 occasions and no longer was suffering from daytime fatigue. She found the rubber bands to be very useful and wanted to continue using them. She is compliant with her morning aligner and her bite was stable. She had no masticatory muscle soreness nor any TMD issues. Due to residual light snoring,


CASEreport I protruded her mandible 1.5 mm using the 22.5 strap. The patient left happy and shared with me that her husband was most satisfied at her greatly reduced amount of snoring. I told her we will follow up in another 2-3 weeks, and if she is doing well, I will recommend she go back to her sleep physician for a post titration sleep test to confirm efficacy of her oral appliance. The patient was not able to make an appointment for another follow up, but we spoke on the phone and she said that she was continuing to do very well with her appliance. So, I decided to leave her appliance at the current amount of protrusion and send her back to her sleep physician for a sleep test. She subsequently got very busy and was not able to schedule a sleep test until 06/27/2017. I received the results of the PSG on 07/11/2017. This post titration PSG showed an AHI of 3.2, an RDI of 4.6, and O2 Nadir of 86% and T90 was less than 1%. The hypnogram revealed two brief dips to 86% oxygen saturation, remaining above 90% the rest of the night. Mild snoring was reported during this sleep study and it was suggested by her sleep physician to try and sleep in a non-supine position. She spent 76.3 % of her PSG in a supine position. Part of dental sleep medicine is to council our patients on other aspects of sleep disordered breathing such as sleep position. Positional therapy is an important component in the overall success of treating a patient with OSA. The patient will be scheduled for another follow up in approximately 6 months, to monitor structural integrity of her appliance and morning aligner, any return of subjective symptoms, side effects, and changes in occlusion. After that, yearly follow ups will be recommended. This was a patient who was diagnosed with severe OSA and subsequently failed CPAP therapy. She was screened in the pre-doctoral student clinic at the University of Texas at Houston School of Dentistry. She was subsequently deemed to be a candidate for oral appliance therapy and impressions and a bite record were taken. The appliance was delivered and follow ups with appropriate titrations were performed. After titration was complete, the patient returned for a post titration PSG. The results showed successful treatment with an oral appliance according to AASM and AADSM parameters of care. This included alleviation of subjective symptoms and a reduction of AHI below 5. The patient

was very happy and felt a vast improvement in her quality of life. Oral appliance therapy is a recommended treatment for patients who fail CPAP after being diagnosed with severe OSA. Studies have shown that CPAP is superior to OAT for lowering AHI and raising blood oxygen levels. However, compliance with CPAP has always been an issue that must be addressed. This case demonstrated the effectiveness of OAT for severe OSA. This does not insinuate that all cases of severe OSA can be successfully treated with OAT, but it should be considered as a viable alternative in cases of non-compliance of CPAP. It is important for clinicians to recognize the clinical factors that will lead to a successful outcome with OAT. This can only come with proper education and an understanding of the principles of airway management. This represents the first case of OAT performed in the pre-doctoral student clinic at the University of Texas at Houston School of Dentistry. It involved a senior dental student after successfully completing 16 hours of additional education in sleep disordered breathing as an elective course at this school. This author recognizes that the education of all dentists in the field of sleep disordered breathing must start at the pre-doctoral student level. It should be incumbent on all dental schools throughout the country to teach courses in dental sleep medicine. This institution is at the forefront of this education process both at the pre-doctoral and post graduate level. I hope to expand our program here to heighten the awareness of the importance of recognizing sleep disordered breathing in every patient. To date, it is said that only 15% of patients with SDB will be referred to a sleep physician for consultation. Untreated OSA represents a significant risk for cardiovascular events, along with a host of additional co-morbidities. We are doing our part at this institution to help rectify this. It is estimated that over 40 million Americans may suffer from sleep disordered breathing. The future of our profession should see a significant increase in the awareness, education, and treatment of SDB. This is a challenge that I embrace and look forward to.

The patient left happy and shared with me that her husband was most satisfied at her greatly reduced amount of snoring.

Acknowledgement: Appreciation is given to the University of Texas at Houston School of Dentistry, Department of General Dentistry and Dental Public Health, chaired by Gary Frey DDS. Recognition is given to Tom Guu, senior dental student and Debra Stewart DDS, group practice director, UTSD.

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LEGALledger

MEDICARE DME/ TELEMEDICINE

FRIEND OR FOE? Part 3

by Ken Berley, DDS, JD, DABDSM

I

just returned from the AADSM meeting in Boston. I was truly honored to be asked to speak at this year’s AADSM meeting and I want to take this opportunity to thank everyone for your encouragement and positive feedback. The one thing that caught me by surprise at the AADSM was the number of commercial organizations who are now focused on providing telehealth services for dentists to coordinate the care of their patients with a Sleep Physician via a telemedicine portal. In Dental Sleep Medicine, we have a number of IDTF (Independent Diagnostic Testing Facilities) companies popping up that offer a number of services that seem appealing. For example: they will provide HST’s for your patients to use; they will score the results of your HSTs; their companies’ sleep physician will provide a diagnosis of OSA based on the HST results; their sleep physician will provide a face-to-face patient consultation for your patients via a telemedicine portal and the IDTF sleep physician will recommend an oral appliance and write a prescription for you to fabricate an oral appliance based on the face to face consultation. I was asked on several occasions at the AADSM meeting if telemedicine was legal for dentists practicing DSM. When faced with this question I always returned the question by asking, “Why do you want to do telemedicine?

60 DSP | Fall 2017

Are there no Sleep Physicians in your area?” Invariably, I was informed that the dentist involved did not like the local sleep physicians and did not want to lose control of their patients. You should know that if you are wanting to practice telemedicine to get around establishing relationships with your local sleep physicians, in my opinion you’re making a serious mistake. We need local sleep physicians on our team to share liability with us. However, to bring clarity to a difficult subject, in this article I will look at the pertinent legal issues associated with telehealth.

Question #1

Is it legal for a dentist (DME POS) Medicare provider to participate in Telehealth Services? Medicare has published guidelines on virtually every subject imaginable. You should know that telehealth services are paid under Part B of Medicare. Therefore, for a dentist to participate in Telehealth Services, he should be enrolled as a Medicare Part B provider. It can be argued that under Medicare Part B, dentists should be treated as a physician. If treated as a physician, it is possible that a dentist practicing DSM could qualify as an originating site for telehealth services. The reason this is so important is that telemedicine under Medicare is limited to Distant Site Practitioners with qualified Originating Sites.


LEGALledger Department of Health and Human Services Centers for Medicare and Medicaid Services Telehealth Services The relevant part follows: Rural Health Series An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in: • A county outside of a Metropolitan Statistical Area (MSA) • A rural Health Professional Shortage Area (HPSA) located in a rural census tract The Health Recourses and Services Administration (HRSA) determines HPSA’s and the Census Bureau determines MSA’s. You can access HRSA’s Medicare Telehealth Payment Eligibility Analyzer to determine a potential originating sites eligibility for Medicare telehealth payment. Each calendar year, the geographic eligibility of an originating site is established based on the status of the area as of December 31st of the prior calendar year. Such eligibility continues for the full calendar year. Originating Sites authorized by law are: • The offices of physicians or practitioners • Hospitals • Critical Access Hospitals (CAHs) • Rural Health Clinics • Federally Qualified Health Centers • Hospital-based or CAH-based Renal Dialysis Centers (including satellites) • Skilled Nursing Facilities (SNF’s) • Community Mental Health Centers (CMHCs) As a condition of payment, you must use interactive audio and video telecommunications systems that permits real-time communications between you (Sleep physician at the IDTF), at the distant site, and the beneficiary (Medicare Patient), at the originating site (Dental Office). Billing and Payment for Professional Services Furnished Via Telehealth Submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT). By coding and billing the GT modifier with a covered telehealth procedure code, you (Sleep Physician at the IDTF) are

certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth services. Billing and Payment for the Originating Site Facility Fee Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. Bill the MAC for the originating site facility fee, which is a separately billable Part B payment.

Discussion

To bring clarity to

Is Telemedicine face-to-face sleep physician examinations legal for dentists a difficult subject, let’s practicing Dental Sleep Medicine and look at the pertinent filing Medicare? Obviously, that is a difficult question to answer. However, if you legal issues associated are a Part B Medicare provider and you with telehealth. live in a rural area without a sleep physician, the answer is MAYBE! The primary issue is whether a dentist who is a Medicare Part B provider, living in a rural area can qualify as an originating site and whether the IDTF can provide the home sleep test in a manner that qualifies as a “Medicare” approved sleep test. Medicare has declared that dentists cannot participate in any aspect of sleep testing, which may be violated in a telehealth arrangement. Additionally, Medicare patients are supposed to be given choices of physicians where care can be obtained. If your Medicare patients are routinely directed to participate with the IDTF telehealth sleep physician, that could be a violation. My big concern is whether the Sleep Physicians working for the IDTFs are establishing themselves as the patient’s sleep physician of record. Is this physician having the patient fill out adequate medical histories and drug histories. Do they have access to the patient’s med-

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 ical records? In other words, are the telehealth sleep physicians truly participating as the patient’s physician. Are they prepared to write prescriptions for Oral Appliances and CPAP? Will they monitor the patient’s CPAP usage or appliance success? Problems do arise when we look at AADSM protocols. Who will perform the recall of your patients? Will the IDTF sleep physician perform yearly recalls for all your sleep patients and is that level of recall adequate to provide appropriate recommendations. In my opinion, it is unlikely that your patients will be recalled by the IDTF Sleep Physician. Are these sleep physicians prepared to defend their medical decisions and recommendations in a court of law? My worry is that these physicians who are providing telemedicine services do not consider themselves to be the physician of record for your OSA patients. If you are sued, will these sleep physicians be Do not expect tele- in a position to help defend you? That medicine providers to is unlikely! Remember, even if you do not parknow your state laws ticipate in Medicare and forgo accepting or bail you out if you Medicare benefits, Medicare rules still apply. The federal government assumes get in trouble. that if you are over the age of 65, you are incapable of making sound medical decisions. Therefore, to participate in telemedicine and fabricate a MAD, would require full disclosure of patient options, informing the patient of offices that would accept Medicare reimbursement and having the patient sign a Private Contract for the provision of services. Just because you aren’t filing the patient’s Medicare doesn’t mean they do not have applicable Medicare regulations.

Question #2

Is it legal for a dentist to participate in telehealth services and file private medical insurance? That question is still difficult to answer. However, twenty-four states have removed the rural area restriction and twenty-eight states have decided that the originating site can be somewhere other than a physician’s office. So, it is much more likely that a dental office could qualify as an originating site under private medical insurance. Additionally, United Healthcare has specifically stated that a dental office can qualify as an originating site. The Federation of State Medical Boards has published an overview of state telemed-

62 DSP | Fall 2017

icine regulations. You can access your state’s telemedicine regulations at: https://www.fsmb. org/Media/Default/PDF/FSMB/Advocacy/ GRPOL_Telemedicine_Licensure.pdf Federation of State Medical Boards: Overview of Telemedicine Policies Forty-eight (48) state boards, plus the medical boards of District of Columbia, Puerto Rico, and the Virgin Islands, require that physicians engaging in telemedicine are licensed in the state in which the patient is located. Fifteen (15) state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine. Four (4) state boards require physicians to register if they wish to practice across state lines. Twenty-eight (28) states, plus the District of Columbia, require both private insurance companies and Medicaid to cover telemedicine services to the same extent as face-to-face consultations. Eighteen (18) states currently require only Medicaid to cover telemedicine services. One (1) state requires only private insurance companies to reimburse for services provided through telemedicine.

Discussion

Medical insurance policies and some medical boards require medical practitioners to obtain full histories and physical examinations before diagnosing any condition or prescribing any therapy. Some states require an “in person” physical. The treatment is said to occur at the location of the patient, and most states require a medical license in the state where the patient presents for care. Each practitioner must be very aware of the telemedicine regulations in each state where he is treating patients as these regulations seem to change rapidly. In order to practice telemedicine, you must enter into an agreement where you will be referring telemedicine patients for examination, HST, diagnosis and prescription for Oral Appliance Therapy. The IDTF/Sleep Physician will receive payment for these services, and the referring dentist will benefit from a diagnosed patient and prescription for OAT. My worry is that this arrangement could be considered a violation of Federal Stark Laws or Federal Anti-Kickback Statutes. You should know, these laws are still in full effect when providing telemedicine and it could be devastating if it were determined that your arrangement was a violation.


LEGALledger I cannot help but worry about the logistics of appointing a patient for telehealth services. If you have a significant number of patients each day needing telehealth services, it could present a logistical nightmare. At the first appointment, they would need health history, sleep history, physical examination and an HST ordered. During the second appointment, the sleep physician would need to go over the results and recommend an oral appliance or CPAP. If the IDTF sleep physician is the physician of record, he should write the RX for CPAP if indicated and follow the patientâ&#x20AC;&#x2122;s CPAP results and compliance. If all of these appointments are originating from a dental office, it could become a real logistical nightmare. A dental office filing Medicare or private medical insurance as an originating site, will eventually be questioned. Medicare or the private insurance will eventually evaluate whether you (a Dental Office) are a qualified originating site. Sadly, this may be after you have received benefit payments for some time. If an audit/case review determines that you are not an appropriate originating site you could be forced to reimburse all moneys paid.

make sure that your patients receive a full physical from a local physician. Your telemedicine physician cannot perform a physical. As we all know OSA is a serious medical condition with many comorbid diseases. You do not want to be responsible for your patientâ&#x20AC;&#x2122;s physical health. Since your sleep physician is in a remote location, you need to make sure that your patientâ&#x20AC;&#x2122;s health is monitored on a yearly basis by a local PCP. Telemedicine could be a great addition to your practice if you have a dental office in a remote area of this country. However, there are many limitations that apply. For any dentist contemplating telemedicine, make sure you know the rules and regulations that apply for your particular practice location. In my opinion you should not use telemedicine to avoid referring your patients to a local sleep physician. If you are ever sued, that decision could be a costly mistake.

Conclusion

If you find yourself in a rural area with no sleep physicians within reasonable driving distance, telemedicine may provide an opportunity to have a sleep physician participate in the care of your patients. However, I would not file for compensation as an originating site until Medicare determines that a Part B (Dentist) in a rural area qualifies as an appropriate originating site. You should make sure that the telemedicine sleep physician has a license in your state and is willing to accept your patients and be the sleep physician of record. He should follow your patients whether they are utilizing oral appliances or CPAP. He should be seeing your patients on yearly recall and be responsible for writing any prescription for CPAP. If you intend to file private medical insurance and utilize telemedicine, I would contact a local healthcare attorney and have him/her evaluate whether you are likely to qualify under your state laws. I would much rather pay for a legal opinion than find out later that you are violating the law. Do not expect telemedicine providers to know your state laws or bail you out if you get in trouble. If you decide to use telemedicine for diagnosis and face-to-face examination, please DentalSleepPractice.com

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Dental Sleep Practice - Fall 2017