Page 1

Extending

Value of CBCT the

Applications of

CBCT Technology

in Dentistry by Gayle Tieszen Reardon, DDS, MS

Analyzing the Airway with SICAT Air

PLUS

Dramatic Improvement

SPRING 2016

in OSA severity when oral appliance and positional therapies are combined by David P. Barr, DDS

FIT IT with Ez Sleep + Apnea Guard Supporting Dentists Through PRACTICAL Sleep Apnea Education

Take the Guesswork Out of Oral Appliance Therapy


INTRODUCTION

Let’s look a little deeper, shall we?

H

ow many mysteries do our patients present us with as we seek to resolve their symptoms? We talk, we listen, we interpret, and we use diagnostic tools to help us prescribe a course of treatment that we hope will result in the preferred outcome. Such is the nature of medicine. To aid us in our pursuit of better odds, there is constant improvement in diagnostic aids. One set of such tools involves imaging – developing a rendering of our patient’s anatomy so we can predict what might happen to those body parts and allow us to make a connection between those events and the symptoms. We want something concrete to pin the diagnosis to. We want something to blame. A dragon to fight. Too bad for us that the oropharynx lends itself poorly to observation. Especially when our patient is asleep. We know it differs in parts of sleep, in varying parts of the night. We can measure with great skill and reliability the response of the body to narrowing or closure of the airway, but actually observing the apneas and hypopneas is pretty much impossible in normal sleep. Certainly not in the patient’s natural state, unsullied by observer effect. We are, of course, dealing with a fairly simple mechanical problem. We can use physics to describe the challenge, with terms like Bernoulli, Starling, and Poiseuille. Without looking back to your high-school physics class, think of the mandible and the tongue falling into the airway, the palate flopping over the nasopharynx, and you can build a 3-D picture in your mind about what goes on during a disordered-breathing event. What would we all like? To show that 3-D image on a screen so that we can understand it ourselves, manipulate the virtual tissue to effect a desired change, and enable our patient to ‘own the problem’ as they see themselves on our monitors. Recently I enjoyed a pinch-me, careerhighlight event having dinner with the engineer whose group developed CBCT for the head and neck. He’s (my guess) younger than me and working very hard to give his medical

colleagues more and better tools to help us treat patients. There is no such thing as ‘mature technology’ in medical imaging. The innovations he shared, both real today and just at the edge of imagining, are nothing short of awe-inspiring. OK, maybe I’m a little geeky, but who will say that moving a virtual jaw exactly like the actual person that stood there in the scanner isn’t pretty cool? There is also technology that’s not Steve Carstensen, DDS changed much in a long time that Diplomate, American Board of also shows airway anatomy well. Dr. Dental Sleep Medicine Dan Taché, one of the most respected teachers in sleep, leaped at the invitation to share how he uses a pharyngometer to help his patients. His commitment to the best outcome includes using every tool he has to inform his treatment strategies. There are dots still to be connected. We cannot know with precision, no matter what imaging system we use, what happens to the soft tissue during sleep. Stay tuned. Very smart people are working day and night to help us clinicians with this mystery. This issue showcases what we know about imaging today. I present it to you knowing that by the time you read this, we will know more, be able to do more, and move closer to our wish to predict, exactly, how we can help. Many fear moving into this exciting world of imaging technology because of what’s around the corner. How long do we wait, guessing about anatomy, hoping our clinical judgement alone is enough? Do you like what you are reading in DSP? Do you have ideas you want to share about what works in your practice? I would be happy to consider essays from any reader! Don’t be shy – we’ll help polish your ideas and spread the wisdom of Practical Sleep Education. Contact me at SteveC@MedMarkAZ.com.

DentalSleepPractice.com

1


CONTENTS

10

Cover Story

Extending the Value of CBCT Analyzing the Airway with SICAT Air An interview with Dr. Scott Pope How many ways can you put this new investment to work?

18

Specialist’s View

Applications of CBCT Technology in Dentistry by Gayle Tieszen Reardon, DDS, MS Board Certified Oral and Maxillofacial Radiologist weighs in on what she sees in imaging.

40

Case Report

26

Product Spotlight

FIT-IT with Ez Sleep + Apnea Guard Take the Guesswork Out of Oral Appliance Therapy Treat your patient now – why make them wait?

2 DSP | Spring 2016

Dramatic Improvement in OSA severity when oral appliance and positional therapies are combined by David P. Barr, DDS Positional therapy is not just about back pillows. A happy patient story.


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CONTENTS

6

Inside the Lab

The value of intraoral scanning for your sleep appliances

by Janice Gruber Our labs work hard to keep up with their doctors.

8 Cash Balance Plans Financial Focus

by Tony Robbins and Tom Zgainer An option to accelerate retirement savings and lower tax liability.

14

Practice Management

An Overview of Electronic Solutions for Practice Management of Dental Sleep Medicine by Glennine Varga, AAS, RDA, CTA Managing data improves your team efficiency. How do you choose?

28

Clinical Focus

Employing Acoustic Pharyngometry to Improve Efficacy of Oral Airway Therapy Device When Mandibular Advancement is Ineffective

43

Technology Update

Cone-beam Computed Tomography Imaging for Temporomandibular Joint Disorders and Dental Sleep by Mayoor Patel, DDS, MS, RPSGT Comparing different ways of imaging the airway and the TMJ.

46

Problem Solving

Narval CC & D-SAD Strap Failures by John Viviano, DDS, DABDSM There’s a weak point by design in every system.

50

New Imaging in the office, what does this mean for team? by Glennine Varga, AAS, RDA, CTA Everyone on your team must support technology for your patients to believe in it, too.

36

52

Get Paid for Imaging – 3 Tips for DSM by Rose Nierman Helping our teams set expectations for our patients’ financial details.

38

Education Spotlight

What do you see? by Mark T. Murphy, DDS There’s a generational shift happening in oral appliances.

4 DSP | Spring 2016

Legal Ledger

Insurance Fraud, Part III by Ken Berley, DDS, JD, DABDSM The final word on keeping your office systems safe.

56

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

Team Focus

by Dan Taché, DMD Thinking about what else can we use to guide our therapy. Practice Management

Spring 2016

Sleep Humor

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

$79* $189*

*plus shipping

©MedMark, LLC 2016. 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.


INSIDEtheLAB

The value of intraoral scanning for your sleep appliances What you should know... by Janice Gruber Laboratory Customer Service Manager, Great Lakes Orthodontics, Ltd.

“A

re intraoral scans right for my practice – Why not?” This technology is moving so fast what seemed unbelievable 2-3 years ago is standard practice in many offices and labs today. Why should you consider intraoral scans if you haven’t yet? It’s not the future – it’s the present!

Why should I change?

• Customers tell us, “The appliance fit from my digital order submissions is superior to impressions”. • The time to scan versus taking impression is about the same • Long teeth and open contacts are no longer a concern with dental scans • Reduces your inventory of consumable materials & alginate and eliminates the mess and cleanup required • Patient comfort and no re-takes as opposed to impressions = Priceless With the proper software you can also use these scans for: • Treatment planning • Tooth width analysis • Model set comparisons • Virtual set ups; move or extract teeth • Model storage

It’s hard to change, but you’re not alone – our lab had to relearn what we knew, too!

Segmental model

6 DSP | Spring 2016

Digital order requests from clinicians were coming in fast. As one of the bigger labs, Great Lakes learned quickly what we

needed to do to keep up and fulfill these orders. To say we felt overwhelmed in the beginning is an understatement. There was so much to learn; all the procedures we used had to be modified. In your office you will need to make modifications, too, but the benefits will be worth the effort.

Take your time and research the scanner options to find what fits your needs

• Make a list of the positives and negatives of each scanner you are comparing • Ask what the annual fees are • Does the scanner integrate with your patient management software • Compare price versus value. Price is important but sometimes you get what you pay for. In the lab we need to receive files in an open file format referred to as .stl files. ‘Per Wikipedia, .stl is defined as STereoLithography – a file format native to the stereolithography CAD software created by 3D Systems. STL is also known as Standard Tessellation Language’.


INSIDEtheLAB

6mm beyond gingival margin

Some scanners use a cloud-based file sending system. Your lab needs to be connected to these vendors in order to receive your orders directly from the scanner, which saves you time. Some scanners allow you to access your .stl files and you can upload them where ever you like. At Great Lakes, we provide a digital portal where you can upload and monitor all your orders 24/7 https://upload.greatlakesortho.com. Your files are safe, password protected; it’s fast and as simple as sending an email with attachments. From these scans the lab will print the appropriate size model for the appliance you are ordering. We select from segmental, 6mm (horseshoe), palate and lingual anatomy, and also offer Low Profile or Full Study model bases if requested. Keep in mind if you needed to capture an area in an impression, you still need to capture that area in the scan. For your bite registration you can scan the patient in C/O, C/R or protrusive and provide the proper VDO. We will print the bite position to use to mount your models! Physical model storage, bubbles, shifted or broken bites, model

voids, and distortions are a thing of the past! Digital model files are now at your fingertips and easily managed on an external hard drive. Take your time to choose your scanner, but adding this digital technology to your practice will be a decision you will not regret!

About Great Lakes Orthodontics Great Lakes Orthodontics, Ltd., is an employee-owned company, serves sleep specialists, orthodontists, prosthodontists, oral surgeons, the restorative and general dental profession worldwide. We offer over 2,500 products and operate one of the largest orthodontic laboratories in the United States. We also conduct classes on the latest appliance fabrication techniques at our on-site training center. Our employee team of 250+ members serves customers from our headquarters in Tonawanda, New York, a suburb of Buffalo. We sell, install and service intraoral scanners, desktop scanners, software, printers and a wide variety of lab services.

Palate and lingual anatomy

Low profile model

DentalSleepPractice.com

7


FINANCIALfocus

Cash balance plans by Tony Robbins and Tom Zgainer

E

ach year around this time, we can all see the inevitable not too far in the distance. Our tax liability — and how we manage it — is generally not as festive as the recently past holiday season. However, your retirement planning and the type of plan you establish can offer a reduction of tax liability and accelerated contributions to help produce additional income when you’ll need it most — at retirement after active work. There are two general types of pension plans — defined-benefit plans and defined-contribution plans. In general, defined-benefit plans provide a specific benefit at retirement for each eligible employee, while defined-contribution plans specify the amount of contributions to be made by the employer toward an employee’s retirement account. In a defined-contribution plan, the actual amount of retirement benefits provided to employees depends on the amount of their contributions,

2016 Contribution Limits 401(k) PROFIT-SHARING AND CASH BALANCE PLANS Age

401(k) with Profit Sharing*

Cash Balance

Total

Tax Savings**

$59,000

$237,000+

$296,000+

$133,200

65

$59,000

$237,000

$296,000

$133,200

64

$59,000

$243,000

$302,000

$135,900

63

$59,000

$248,000

$307,000

$138,150

62

$59,000

$254,000

$313,000

$140,850 $135,000

Above 65

61

$59,000

$241,000

$300,000

60

$59,000

$228,000

$287,000

$129,150

59

$59,000

$216,000

$275,000

$123,750

58

$59,000

$205,000

$264,000

$118,800

57

$59,000

$194,000

$253,000

$113,850

56

$59,000

$184,000

$243,000

$109,350

55

$59,000

$175,000

$234,000

$105,300

54

$59,000

$165,000

$224,000

$100,800

53

$59,000

$157,000

$216,000

$97,200

52

$59,000

$149,000

$208,000

$93,600

51

$59,000

$141,000

$200,000

$90,000

50

$59,000

$133,000

$192,000

$86,400

49

$53,000

$126,000

$179,000

$80,550

48

$53,000

$120,000

$173,000

$77,850

47

$53,000

$114,000

$167,000

$75,150

46

$53,000

$108,000

$161,000

$72,450

45

$53,000

$102,000

$155,000

$69,750

44

$53,000

$97,000

$150,000

$67,500

43

$53,000

$92,000

$145,000

$65,250

42

$53,000

$87,000

$140,000

$63,000

41

$53,000

$82,000

$135,000

$60,750

40

$53,000

$78,000

$131,000

$58,950

39

$53,000

$74,000

$127,000

$57,150

38

$53,000

$70,000

$123,000

$55,350

37

$53,000

$66,000

$119,000

$53,550

36

$53,000

$63,000

$116,000

$52,200

35 Under 35

$53,000

$59,000

$53,000

Up to $56,000

*401(k): $18,000; $6,000 catch-up; $35,000 profit sharing

8 DSP | Spring 2016

$112,000 Up to $109,000

$50,400 Up to $49,050

** Assuming 45% tax, varies by state. Taxes are deferred

AMERICA’S BEST 401k

along with employer contributions such as Safe Harbor or profit-sharing contributions, as well as the gains or losses of the account over time. Many of our dentist clients take advantage of this combination by “maxing” out the total allowable contributions, currently $53,000 if under age 50 or $59,000 if over age 50, while giving a needed ratio of contributions to eligible staff as well. However, we often are asked, “What else can I do aside from after tax investing? What other types of retirement plans are available?” Enter the cash balance plan, a type of defined-benefit plan that when paired with a 401k/profit-sharing plan provides an opportunity to essentially squeeze 20 years of saving into 10, while at the same time significantly reducing your tax liability along the way. As the chart accompanying this article shows, the benefits of the cash balance plan really start to accelerate as the business owner gets beyond age 45-50. While employer matching and profitsharing contributions are discretionary, cash balance plans require more of a commitment to fund the plan by the employer. Most plans are set up with a 3-5 year funding period, so they work well in environments where the business owner will have predictable income over that time frame. Different from a 401k plan where participants generally choose their investment options, the assets of a cash balance plan are managed by the employer or an investment manager. In a typical cash balance plan, a participant’s account is credited each year with a “pay credit” (such as 5% of compensation from the employer) and an “interest credit” (either a fixed rate or a variable rate that is linked to an index such as the 1-year Treasury Bill rate). To determine if a cash balance plan is right for you, enlist an actuary who is an expert in retirement plan design to analyze your practice demographics with a current census of full-time employees. If this plan design can meet your individual and corporate objectives, you have a far greater pool of income available when the time comes to hang up the white coat.


Dentists have trusted

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Scan code to view all of our sleep appliances and products


COVERstory

Extending the Value of Introducing the first 3D Solution for the Analysis and Treatment

D

ental Sleep Practice recently sat down with Dr. Scott Pope, an expert in the field of using Cone Beam technology to assist his patient care, to talk about the value his GALILEOS brings to his practice.

DSP: Scott, like many dentists, you have been treating sleep patients for a while in your dental practice. What’s special about CBCT for you?

SP: People care about their own problems. If you can get them to feel what you’ve discovered is an important problem for them, they’re more likely to seek treatment. Is snoring a big deal? We know it can be. Snoring is, for many, the most observable sign of sleep apnea, and it’s becoming an important discussion topic in the dental office. The health risks associated with obstructive sleep apnea are ever-increasing and as health care providers, we have an obligation to increase our patient’s awareness of this health problem. We can help them reduce the risk of high blood pressure, heart attack, stroke, obesity, diabetes, arrhythmias, and atrial fibrillation.

DSP: Walk us through the patient flow in your practice.

Airway volume before

Airway volume after

10 DSP | Spring 2016

SP: I have been treating sleep apnea with oral appliance therapy for about 10 years and have used the Epworth Sleepiness Scale and the STOP-BANG Sleep Apnea Questionnaire to help patients accept a referral for further evaluation for sleep apnea. I originally purchased the Sirona’s GALILEOS for implant treatment planning and implant placement, unaware of its greater potential. When I added SICAT Air software, I discovered by highlighting the airway and showing our patients that their own airway has critical restrictions, they became much more interested in seeking solutions. The color coded airway images have dramatically increased the awareness and conversations we have with patients regarding sleep apnea. It is like having an endoscope of the airway with the ability to actually measure airway volume and identify possible obstructive sleep apnea sufferers. SICAT Air has a BuiltIn Communication that I use to communicate with my specialists and with the patient. Patients are then sent to


COVERstory

CBCT of OSA

DentalSleepPractice.com

11


COVERstory DSP: You say the appliance can be made where the airway is open on the scan? So do you have to take a lot of scans? How do you know when it’s really effective?

their PCP or sleep MD with more information, motivation, and understanding of why they need to complete the medical diagnostic process.

DSP: When you get a prescription for oral appliance therapy, how does the system help you then?

SP: Once the diagnosis of sleep apnea has been made, the treatment workflow to fabricate an oral appliance is streamlined by incorporating GALILEOS, SICAT Air and CEREC together. With SICAT Air, I have the ability to compare initial pre-treatment airway volume with the volume of a forward-posture position – we position the patient with a George Gauge and compare the scans. This allows me to setup the appliance predicting that the airway will be improved. With the GALILEOS scan and SICAT AIR, we can check the condyle fossa relation in a treatment position before we treat the patient, which dramatically reduces the possibility for TMD problems later. We scan the teeth with CEREC, which is combined with the GALILEOS 3D Imaging to plan the appliance to fit the teeth, jaws, and airway for our patients. I am able to digitally send the case for fabrication and be confident that the OPTSLEEP appliance will have a perfect fit and perfect occlusion. When this appliance gets final FDA clearance, I’m sure you’ll be hearing more about it. Meanwhile, several labs are accepting scans to make other appliances, too. I find the workflow to be very efficient and easy to use as this process applies the same principles I use to have a SICAT OPTIGUIDE fabricated for guided implant surgery with the GALILEOS CEREC Integration and the digital data transfer for appliance fabrication.

Narrow airway separately

SP: Most of our patients get a GALILEOS scan and bitewing images for their complete series – it’s actually less radiation than a conventional digital full periapical series, and it gives us so much more. My partner and I have taken extra training to be able to see what structures are normal vs. abnormal in the scan, and we use a radiologist when we suspect something is unusual. This GALILEOS scan, that had already been taken during prior evaluation or treatment, is now again utilized during the initial communication and education about the possibilty of existent constrictions within the upper airway. If we suspect sleep apnea, we use that image to open a conversation and often take a low dose, low resolution scan in a protruded jaw position to see the effect on the airway. With the SICAT Air software, we can look at the airway in the protruded position and visualize the patients’ advancement we have created in his upper airway and more importantly we have data to analyze the improvements as well. Every OPTISLEEP Appliance will be delivered with 10 individual and interchangeable rots. The rots have different lenghts which allow us

OPTISLEEP

Dr. Scott Pope is a graduate from Northwestern University and has over 20 years of private practice experience in Walnut Creek, CA. He is an advanced CEREC cad/cam and Cone Beam CT trainer and a beta tester with Sirona. Dr. Pope is also a co-founder of CAD3D Academy, educating dentists on advanced CEREC dentistry, CBCT imaging and implant guided surgery in the dental practice. Dr. Pope has achieved Fellowship status with the Academy of General Dentistry and the International Congress of Oral Implantologists. Dr. Pope was the team dentist for the Saint Mary’s Gaels for almost 10 years until 2013 and was involved with the 2013 America’s Cup in San Francisco as the team dentist for Artemis Racing from Sweden.

12 DSP | Spring 2016


COVERstory

Airway before

to increase or even decrease the degree of protrusion to justify the perfect mandible advancement. The amazing benefits of having a digital practice is that everything integrates. I can open my scans I have taken two years ago and use this information as a platform to start the dialog on sleep apnea with the patient and for my communication with sleep MD’s. So far, we’ve found the patients needed very few adjustments to the MAD – the airway tests ‘open’ most of the time. Patients get to the treatment position faster with less help from our office. That’s more efficient.

DSP: Advanced software solutions can sometimes be so complicated that they’re hard to use. What you’re describing is certainly on the cutting edge. Say more about how it integrated into your practice.

SP: We had a digital pan for a few years, then moved up to GALILEOS for implant planning about four years ago. Each step, Sirona has been great about training, and, really, we’ve found the combination of the im-

Airway after

aging devices and the software to be no more challenging than any top-level program – it’s all pretty intuitive. The SICAT Air software is an addition to the SIDEXIS 4 software, and it all combines with the GALILEOS and the CEREC to give us a full suite of solutions. We get to focus on the patient – it’s fun to be able to show them the clear images, especially when we know it’s really serving to help us care for them best.

DSP: So many dentists are thinking about adding Cone Beam technology to their practice – your enthusiasm for how much you feel it’s improved your patient care is clear, Dr. Pope. I’m sure you’ve inspired others to look into it for their practices.

The amazing benefits of having a digital practice is that everything integrates.

SP: Thank you for letting me share my passion!

SICAT Air screenshot

DentalSleepPractice.com

13


PRACTICEmanagement

An Overview of

Electronic Solutions

for Practice Management of Dental Sleep Medicine by Glennine Varga, AAS, RDA, CTA

A

s a dental sleep medicine (DSM) consultant I have been asked by several dentists what system, software and medical billing company I recommend. My reply… That’s a great question! It depends on several factors and what’s best for you.

Before I break down my logic of analyzing which e-solution is best for my dentist friends I want to list some of the e-options available to dentists today. Dental practice management software, DSM designed practice management software/systems, DSM designed analytics and patient tracking, Electronic Medical Records (EMR), Electronic Health Records (EHR), medical clearing houses for electronic submission of medical claim forms, physician portals, cloud technology solutions, signature pads, secure and encrypted email, HIPPA complaint patient intake transfer, patient education/contact solutions, and soon telemedicine are just a few that come to mind. If you are like most dentists you may be scratching your head at this list and only identifying with dental practice management software. This is because just like DSM, e-solutions for DSM are in their infancy stage. Evaluating options for e-solutions for DSM and determining what’s best for each dentist takes some research. First, I feel it’s important to know what is required for efficacious DSM. Second it’s best to analyze if oral appliance therapy will be added into an existing dental practice as additional therapy to general dentistry or is the practice planning to become DSM exclusive? Last, will the dental office be billing medical insurance for the patient and or participate with the patient’s medical insurance policies? Once these three factors are established the options are easier to evaluate. What is required for efficacious DSM? In order to answer this we need to define the term. Efficacious is “successful in producing a desired or intended result.” This is a broad state-

14 DSP | Spring 2016

ment when it comes to DSM. What is deemed success- a patient accepting therapy, improving a patient’s overall health, physician interpreted before and after treatment sleep study results with at least a 50% improvement in breathing, receiving a check from a medical insurance company, or working with community physicians in a multi-disiplinary approach to therapy? Dentists will have different answers to these questions and most will say yes to all of the above. Most dentists I’ve encountered get involved in DSM to help patients breathe better during sleep and improve overall health then become aware of medical billing and clinical practice guidelines, which add a layer of actions and the need for electronic solutions. I interviewed several of my professional colleagues, educators and dentists regarding this topic and it became very apparent that dentists offering patients oral appliance therapy are using 1 of 3 e-solutions for practice management: Dental software with an integration of DSM, Electronic Health Records (EHR) revised for DSM or practice management systems specifically designed for DSM. The majority of dentists I have encountered are looking to add DSM to an existing general dental practice. They already have dental software such as Dentrix, Eaglesoft or Carestream to complete the fundamental tasks and functions including a scheduler, ledger, medical history, encounter notes and patient recall tracking. These systems also allow importing documents such as sleep study reports and written prescriptions. However, in my opinion they fall short as an e-solution for medical billing, DSM patient tracking


PRACTICEmanagement and physician outreach. The need to add an ancillary software/system will manifest. Let’s evaluate an overview of e-solutions for DSM. Most dental software can be customized to accommodate DSM management but only to a certain extent. For example, custom codes can be entered for scheduling and posting completed appointments. Dental medical histories can be revised to ask questions like; Do you snore? Have you ever had your sleep evaluated? Have you ever been prescribed to use Positive Airway Pressure (PAP or CPAP) therapy? Template notes can be created for DSM appointments and patients can be filtered into a recall system for sleep, like hygiene schedules are tracked. Documentation such as sleep study reports and written prescriptions can be scanned into document storage. However, all of these tasks take work. Most dental practice management software companies have not fully caught onto DSM and have no pre-designed templates within their systems to accommodate it. Since this is the case the more customizable your dental software, the better. MacPractice has built-in DSM capabilities courtesy of pioneering DSM dentists who use it - you need to request it, since it is not automatically installed. As DSM becomes more main stream we will see dental software systems possibly accommodate for it. A dentist also can consider a practice management system specifically designed for DSM. The three predominate DSM systems today include DentalWriter, Dental Sleep Solutions (DS3) and SleepConnect. All three can be used in conjunction with dental software. DentalWriter and DS3 are complete practice management systems including a scheduler and ledger for those dentists who want to keep DSM patient transactions separate from dental. Although SleepCon-

Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain. She has been employed in dental education for over 19 years. Glennine is certified in radiology, electrodiagnostics, expanded duties dental assistant in the treatment of temporomandibular disorders. She has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and has tried the use of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp. She has trained and assisted hundreds of dental offices on practice management, TMD/Sleep Apnea concepts, medical billing and team training. For more information visit www.dsmbootcamp.com or email g@dsmbootcamp.com.

DentalSleepPractice.com

15


PRACTICEmanagement nect does not have a scheduler the color coded patient management feature gives a visual overview of patient tracking. All three systems are built on the fundamental strategy of proper documentation to support medical billing, physician outreach and DSM support. Each are unique with special features and functions. DentalWriter has been on the market for 25 years helping dentists navigate medical billing for all medically necessary procedures such as TMD, oral surgery and accident cases. In the past 10 years DentalWriter has focused on DSM and added a medical billing service option and a marketing campaign through Snoring Isn’t Sexy. DS3 has been developed by dentists working exclusively in DSM and have expanded to offer a wide range services including online study clubs, community education outreach and marketing materials. SleepConnect is amazing for patient tracking and analytic reporting along with secure physician portal to view mutual patient records.

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What is the difference between an EMR and an EHR? An electronic medical record (EMR) is a digital version of a chart with patient information stored in a computer. An electronic health record (EHR) is a digital records of health information that can be shared instantly with authorized providers across practices and health organizations. There are several of both EMR and EHR systems available on the market designed for physicians. Most are customizable to accommodate DSM. For example PracticeFusion, AdvancedMD or CureMD are the top 3 I encounter among DSM dentists. These systems are nice because they are designed for medical intake and evaluation. The downfall is currently the same as it is with dental software these EMR and EHR systems are not automatically ready for use with DSM patients and they do need customization to accommodate DSM. A medical clearing house is used to submit medical claims electronically. This is something I have all my clients consider. Dentists are not required today to file a claim form electronically to medical insurance, although electronic submission makes the process easier and the claims processing time is much shorter. DentalWriter, DS3, SleepConnect, MacPractice and all EMR/EHR systems work with medical clearing houses to submit claims electronically. Some will also allow the printing of a claim if necessary. A dentist can register directly with medical clearing houses for electronic claims submission. If hiring a medical billing entity is your goal, chances are they are using medical clearing houses to submit your claims and will set that up for you. However, discussing options for electronic documentation transfer is a must because without that there will be a lot of faxing documentation back and forth unless a HIPPA compliant secure email system can be used between parties. Physicians are slow to adopt even secure email systems. Like any big decision when adding something new a dental office it is imperative to do your homework. Research options by reaching out and scheduling demos or trial period to evaluate what works best for your goals with DSM and what you are comfortable using. Evaluate pricing structures as they are all different depending on the level of capabilities you strive for. Maybe even survey the physicians you work with closely and see if what they use can connect with what you are considering. E-solutions are our future! Embrace them and find what works best for you!


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SPECIALIST’S view

Applications of CBCT Technology in Dentistry by Gayle Tieszen Reardon, DDS, MS Board Certified in Oral and Maxillofacial Radiology

A

dvanced cross-sectional imaging techniques such as CT are used in dentomaxillofacial imaging to solve complex diagnostic and treatment-planning problems, such as those encountered in craniofacial fractures, endosseous dental-implant planning, and orthodontics, among others. With the advent of CBCT technology, cross-sectional imaging that had previously been outsourced to medical CT scanners has begun to take place in dental offices. Early dedicated CBCT scanners for dental use were characterized by Mozzo et al and Arai et al in the late 1990s. Since then, more commercial models have become available, inciting research in many fields of dentistry and oral and maxillofacial surgery. To date, multiple ex vivo studies have attempted to establish the ability of CBCT images to accurately reproduce the geometric dimensions of the maxillodental structures and the mandible. A relatively low patient dose for dedicated dentomaxillofacial scans is a potentially attractive feature of CBCT imaging. An effective dose in the broad range of 13–498 Sv can be expected, with most scans falling between 30 and 80 Sv, depending on exposure parameters and the selected FOV size. In comparison, standard panoramic radiography delivers 13.3 Sv and multi-detector CT with a similar FOV delivers 860 Sv. Image quality can vary considerably with dose; images acquired with higher radiation exposure often produce superior image quality. The discussion below reviews potential CBCT applications in the dentomaxillofacial regions. Most of this research remains preliminary; further prospective and outcomes-based research is required to make informed recommendations on the appropriate use of CBCT in dentomaxillofacial imaging.

18 DSP | Spring 2016

Dr. Reardon evaluating CBCT images

Airway Analysis Obstructive sleep apnea (OSA) is characterized by the episodic cessation of breathing during sleep and is frequently unidentified and undiagnosed. Conventionally, the most common tool for diagnosis of OSA is in-laboratory polysomnography; however, this technique is expensive, requires specialized resources, and is time-consuming for patients (Pack 2004; Flemons, Douglas, Kuna et al 2004). Although imaging is not generally used for OSA diagnosis, it can help identify airways at risk for obstruction and also patients whose airway anatomies may contribute to OSA (Hatcher 2010). Cephalometric radiographs are advantageous to clinicians as an adjunctive diagnostic tool for OSA patients. CBCT presents an opportunity with three-dimensional images of the airway to serially examine individuals, acquire airway patency information, and improve the evaluation of sites of airway obstruction.


SPECIALIST’S view

Axial region above posterior nasal spine

Implantology

Cross-sectional imaging techniques can be an invaluable tool during preoperative planning for complicated endosseous dental implantation procedures. Conventional linear tomography and CT have traditionally been used in pre-surgical imaging, though the former has overlain ghosting artifacts and the latter has a higher high radiation exposure and cost. Practitioners have begun using office-based CBCT scanners in preoperative imaging for implant procedures, capitalizing on availability and low dosing requirements. A review by Guerrero et al outlines the clinical and technical aspects of CBCT, which have popularized this new technique. Preliminary evidence addresses the ability of CBCT images to characterize mandibular and alveolar bone morphology, as well as to visualize the maxillary sinuses, incisive canal, mandibular canal, and mental foramina, all structures particularly important in surgical planning for dental implantology. Several studies have described the 3D geometric accuracy of CBCT imaging in the maxillodental and mandibular regions as well.

Orthodontics

Cross-sectional imaging affords overlayfree visualization of structural and anatomic relationships important for addressing

Airway sagittal view

many radiologic questions in orthodontics. The current standard of care for overlay-free imaging in orthodontics is conventional CT. Low-cost office-based CBCT imaging has recently been explored for orthodontic applications, including assessment of palatal

Dr. Gayle Tieszen Reardon obtained a B.A. degree in 1974 from Augustana College in Sioux Falls, South Dakota. In 1978, she graduated from the University of Minnesota School of Dentistry and joined the dental practice of her father in May 1979. After thirty years of full time practice, Dr. Gayle elected to pursue a specialty in the area of Oral and Maxillofacial Radiology at the University of Iowa. In 2011, she completed her three-year program and her board certification. Her specialty training is of particular application in Oral and Maxillofacial Diagnostics and Dental Implantology and her training has been of great diagnostic and treatment planning assistance in her restorative dental practice. Dr. Gayle and her husband, Tom, have two daughters, Katherine and Kimberly. Katie graduated from the University of Denver in 2006 and from Creighton University’s School of Dentistry in 2010. Katie has maintained a practice in South Dakota since that time. Daughter Kimberly was a 2008 graduate of the University of Colorado and works in the travel business planning African safaris. When Dr. Gayle is not in her office located in South Dakota, she enjoys doing bronze sculpture and trekking with her beloved Cavalier King Charles Spaniel dogs.

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19


SPECIALIST’S view

Airway summary

Coronal view

bone thickness, skeletal growth patterns, dental age estimation, upper airway evaluation, and visualization of impacted teeth. Although preliminary results are encouraging, established cross-sectional techniques such as conventional CT provide superior image quality of dental and surrounding structures for advanced orthodontic treatment planning. Low dosing requirements appear to remain a benefit of CBCT when compared with conventional CT, with a routine orthodontic CBCT study delivering an effective dose of 61.1Sv compared with 429.7 Sv for multi-section CT. Lateral cephalograms deliver 10.4 Sv in comparison, though without the benefit of 3D structural visualization.

Temporomandibular Joint

Morphologic changes of the temporomandibular joint (TMJ) as depicted with conventional MR imaging, CT, and radiographic imaging are often useful in diagnosing pathologic processes such as degenerative changes and ankylosis, joint remodeling after diskectomy, malocclusion, and congenital and developmental malformations. CBCT is a technique that has recently inspired research in TMJ imaging, though preliminary

20 DSP | Spring 2016

experiments have yet to translate into clinical studies. Several cadaver studies have explored the use of TMJ CBCT to assess peri-articular bony defects, flattenings, osteophytes, and sclerotic changes. Preliminary studies have also directly compared CBCT with radiography, multidetector row CT (MDCT), and linear tomography for detection of osseous abnormalities of the TMJ. A recent systematic review by Hussain et al suggests that axially corrected sagittal tomography is still the method of choice in the detection of periarticular erosions and osteophytes.

Endodontics

CBCT has been explored for applications in endodontics, including peri-radicular surgical planning, assessment of periapical pathology, and dentoalveolar trauma evaluation. The diagnostic properties of CBCT at the root apices and peri-radicular region have been reported in several studies. In retrospective cohorts and case reports, CBCT has been suggested as superior to periapical radiographs in the characterization of periapical lucent lesions, reliably demonstrating lesion proximity to the maxillary sinus, sinus membrane involvement, and lesion location rela-


SPECIALIST’S view tive to the mandibular canal. There may also eventually be a role for CBCT in early detection of periapical disease, which could lead to better endodontic treatment outcomes. Promising results have been demonstrated in studies characterizing CBCT images for endodontic surgical planning purposes as well.

Periodontics

The first reported applications of CBCT in periodontology were for diagnostic and treatment-outcome evaluations of periodontitis. Ex vivo studies later characterthe ability of CBCT to accurately To optimize the ized reconstruct periodontal intrabony and diagnostic value of fenestration defects, dehiscences, and furcation involvements in comparthe CBCT, the dentist root ison with radiography, MDCT, and hismust have mastery of tologic measurements. CBCT 3D geoaccuracy has been suggested to human anatomy as seen metric be equal to radiography and MDCT but in the axial, sagittal, with better observer-rated image qualithan MDCT as well as superior periand coronal views radi- ty odontal-defect detection than radiograologically, as well as phy. Although periodontal bony defects well visualized with CBCT, conventhree-dimensionally. are tional radiography still affords higher quality bony contrast and delineation of the lamina dura. CBCT ex vivo visualization of the periodontal ligament and periodontal ligament space has been evaluated in comparison with radiography with mixed results, a more recent study suggesting that CBCT visualization is still inferior to that of radiography.

Head and Neck

As CBCT imaging systems have become more widely available, interest in the intraoperative and diagnostic CBCT applications in the extracranial head and neck regions has intensified. The reported high isotropic spatial resolution and relatively low dose requirements of CBCT are characteristics that have made it particularly attractive. In the head and neck region, a premium is placed on discriminating fine anatomic detail in territories where the vascular and bony structural anatomy is particularly complex. Potential applications in sinus, temporal bone, and skull base imaging have been explored. Head and neck CBCT studies visualizing the paranasal sinuses; temporal bones; maxillary sinus floor and alveolar process of the maxilla; and orbital floors respectively.

22 DSP | Spring 2016

Sinus Imaging/Frontal Recess

Comparatively low dosing requirements, high-quality bony definition, and the compact design afforded by CBCT scanners have made them attractive for office-based and intraoperative scanning of the paranasal sinuses. To date, there have been few studies comparing image quality in paranasal sinus CBCT scans with that in MDCT. Alspaugh et al did directly compare the spatial resolution obtained with CBCT scans of the paranasal sinuses with that of 16- and 64-section MDCT scanners. They concluded that 12 line pairs per centimeter (lp/cm) isotropic spatial resolution could be obtained with an effective dose of 0.17 mSv compared with a dose requirement of 0.87 mSv for 11-lp/cm spatial resolution in a 64-section MDCT scanner. To a large degree, evidence supporting sinus CBCT imaging has emerged from exploration of intraoperative CBCT applications in endoscopic sinus surgery (ESS). Both spatial and soft-tissue contrast was sufficient to aid surgical navigation in the frontal recess. More recent clinical studies have also provided qualitative evidence that intraoperative CBCT provides high-quality definition of bony anatomy, which can lead to refinement of surgical strategy. In a series of twenty-five patients undergoing ESS, Batra et al found that residual bony partitions and stent locations could be visualized with intraoperative CBCT scans, leading to surgical revision. CBCT has also been used recently to evaluate contrast delivery during sinus irrigation after ESS. Preliminary evidence suggests that CBCT may be suited for specific imaging tasks in the context of intraoperative and perioperative bony structural evaluations, enabling low-dose assessment of individualized paranasal sinus anatomy, surgical outcomes, and stent placements. To our knowledge, there is no current evidence, however, supporting CBCT use in general diagnostic sinus imaging owing to lack of soft-tissue contrast resolution. Furthermore, significant complications of ESS, including encephalocele, subarachnoid hemorrhage, and meningitis are unlikely to be evaluated adequately with current CBCT image quality.

Temporal Bone/Lateral Skull Base

The temporal bone was one of the earliest targets for head and neck CBCT imaging. Specific applications have been explored,


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SPECIALIST’S view including post-procedural middle and inner ear implant evaluation, visualization of the reuniting duct in the inner ear, and intraoperative temporal bone surgical guidance.

Visions for future development

Further technical improvements to CBCT devices can be anticipated in the future. Advances in FP CBCT relate to detector design (Kalender and Kyriakou 2007, Gupta et al. 2008) and will consequently expand the applicability of FP CBCT. FP CSI detectors have a slower response than the proprietary ceramic detectors used in MDCT systems and the quantum efficiency of CSI detectors is also slightly slower. These two characteristics limit the temporal resolution and dynamic range, respectively, of FPDs compared with standard MDCT detectors (Orth et al. 2008). Possible improvements are multiple FPs to increase the volumetric coverage, or dual-source CT to provide faster scanning times and double the amount of spectral information (Gupta et al. 2008). Reducing the detector read-out time would decrease scanning time. An increased dynamic range would allow higher dosages and thus better soft tissue contrast (Bartling et al. 2007). X-ray scatter in CBCT limits image quality significantly by reducing contrast and creating image artefacts (Siewerdsen et al. 2006). Physical modifications to the image acquisition equipment such as anti-scatter grids (Siewerdsen et al. 2004, Gupta et al.2006), scatter reduction algorithms (Ning et al. 2004, Gupta et al. 2006), beam filters (Gupta et al. 2006, Mail et al. 2009) and object-to-detector distance (i.e. air-gap), have been investigated as potential ways to minimize scatter in CBCT. Image reconstruction from cone-beam projections collected along a circle source trajectory is commonly done using the Feldkamp algorithm, which performs well only with a small cone angle. For that reason, variants of the Feldkamp algorithm have been developed for practical applications that involve large cone angles (Zhuang et al. 2008). Dental CBCT unit manufacturers have already introduced artefact reduction algorithms within the reconstruction process. For example, instead of the Feldkamp back projection, an iterative reconstruction called algebraic reconstruction technique (ART) has been used (Scanora 3D). It requires fewer projections to perform the reconstruction.

24 DSP | Spring 2016

These algorithms reduce image-, noise-, metal-, and motion-related artefacts (Scarfe and Farman 2008). The current literature on CT metal artefact reduction can be divided into iterative and projection modification methods (Zhang et al. 2007). The iterative method involves reconstruction of the CT image using only non-corrupted projections while discarding those projections affected by metal objects. In the projection modification method the metal shadows in the raw projection data are first segmented and then replaced using some estimated values. This latter method has been increasingly favored because of its simplicity and has also been used in CBCT applications. Devices which allow variation of FOV and resolution, thus making possible task-specific protocols, are indicated in dental and maxillofacial imaging (Scarfe and Farman 2008). The so-called region of interest (ROI) imaging technique reduces radiation exposure to the patient, causes less scattering to the detector, and has the potential to increase the spatial resolution of the reconstructed images (Wiegert et al. 2005, Cho et al. 2007). Standards for image quality and dose for the various diagnostic tasks should be developed. Furthermore, multimodal imaging devices, including conventional panoramic and cephalometric options in addition to CBCT, will most probably be a future trend (Scarfe and Farman 2008).

Conclusions

The applications of CBCT technology in dentistry are seemingly endless. Using CBCT, subjective identification of anatomy and pathology relevant in dental practice can be readily achieved. To optimize the diagnostic value of the CBCT, the dentist must have mastery of human anatomy as seen in the axial, sagittal, and coronal views radiologically, as well as three-dimensionally. While dentists are traditionally accustomed to interpreting imaging made in their offices, the complexity of the multi-planar CBCT datasets exceed that of the two-dimensional flat film. It is likely that the standard of care for image interpretation may shift with the availability of CBCT technology in dental offices. Because dentists are legally responsible for the content of an entire image, and not just the teeth, dentists are relying upon the expertise of specialists in the area of oral and maxillofacial radiology for interpretation assistance.


PRODUCTspotlight

FIT IT with Ez Sleep + Apnea Guard

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ecognizing a patient at risk for obstructive sleep apnea is something practices should and are doing nationwide. It has become a regular part of what it means to offer the highest quality of care to patients and sets practices apart from those who are just getting by. The trainers at Ez Sleep have been teaching practices how to quickly and effectively screen patients for risks of OSA for years now. This had led to practitioners treating hundreds of patients using oral appliance therapy. Screening patients for dangerous sleep breathing disorders is the first step towards treating the various other conditions that are associated with obstructive sleep apnea. FIT-IT is the easy-to-remember way to quickly get your patient the care the patient needs. Once the patient has been screened by you and tested at home with an Ez Sleep At-Home sleep test that renders a diagnosis it is time to pull out the FIT-IT Quick Start Guide and get him into a trial appliance TONIGHT. No waiting for impressions and lab fabrications only to find out that the patient isn’t a responder to the therapy. Your patient can take this FDA approved trial appliance home the very same night the test results are known. Ez Sleep can test your patient with the appliance as soon as possible, show-

26 DSP | Spring 2016

ing response and improvement that drives home the point and need for your patient to undergo custom oral appliance therapy successfully. “F” is for FIND. Finding the patient’s Apnea Guard® tray size is a matter of a quick look in the patient’s mouth to establish tongue size. Then in Finding the patient’s neutral bite position. The neutral bite is important when deciding how enough protrusion is available to open the airway. The great news is the Apnea Guard® instructions make this very clear and very precise. There are simple rules, leaving no confusion on how to go about finding this very important measurement. “I” for IMPRESSIONS comes next. Upper and lower impressions are taken using the specialized putty developed for use with the Apnea Guard® trays. Again, using the FITIT process and Ez Sleep’s instructions, the Apnea Guard® trays are available in three distinct sizes, each accounting for vertical space. Women typically are fitted using a low sized tray while men will use a medium. A step up in tray size is added for a large or scalloped tongue. “T” is for TITRATE. The newly impressed Apnea Guard® trial appliance is ready for immediate use to take the guesswork out


PRODUCTspotlight of oral appliance therapy. Ez Sleep + Apnea Guard® makes titration as effortless as it could possibly be. A patient will advance his or her own jaw, giving the practitioner feedback to determine the position that opens the airway as much as possible. Not the most advanced jaw, but the one that will best treat the patient without causing any needless advancement. “I” for IDENTIFY is intended to identify the patient’s 70% protrusive measurement. Here we see how FIT-IT with Ez Sleep + Apnea Guard® has taken the guesswork out of oral appliance therapy. What is 70% of your patient’s maximum protrusive? Apnea Guard® was developed with a sure fire algorithm to make finding this number easy too. Using the chart provided all the practitioner need do is identify the measurements to achieve the correct fit. “T” represents. TRIAL and TEST, the final steps of Apnea Guard® FIT-IT program. This means immediate treatment that your patients used to have to wait weeks or months to begin. But Ez Sleep’s FIT-IT with Apnea Guard®, your patient will begin actual therapy tonight, the very same night the patient hears of their diagnosis. Unfortunately, the CPAP has long been the only means of treating diagnosed patients. The guesswork involved in treating patients with an oral appliance has been a hurdle many doctors are not prepared to overcome. It makes sense too. How does one know if a patient will respond to oral appliance therapy? Isn’t there a risk of him not being able to wear an oral appliance? How about making any specific adjustments to the appliance once the patient is given instructions on wearing it? For far too long patients have undergone an at-home sleep test only to find that oral appliance therapy is still weeks away. Time goes by and they nervously sit down for a consultation to discuss the findings and diagnosis by a board certified sleep physician only to be told that there will be no treatment given for this newly discovered life threatening condition tonight. This can be very disconcerting for the patient. Can you imagine finding out you have a sleep breathing condition and then having to wait weeks before you can expect to be treated? To add insult to injury the therapy is rarely efficacy-tested to prove the benefit or results of the oral appliance. Ez Sleep’s at-home efficacy studies are

FIT-IT with Apnea Guard

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the Apnea Guard® tray size your patient needs and find their neutral bite

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of the Apnea Guard® and Testing of your patient’s response to oral appliance therapy

the quick and easy answer to this dilemma. Efficacy studies show how well the treatment works under the best possible conditions. It also proves benefits to the practitioner and the patient resulting in higher compliance due to the fact that the patient can now see the results of the efficacy study. Finally, there is a smooth, step-by-step process available to ensure patients will receive the care they expect and the care you are determined to provide. And just like Ez Sleep, it’s so simple. With FIT-IT and Ez Sleep + Apnea Guard®, you and your patients will achieve the highest level of care and treatment available. With FIT-IT, Ez Sleep + Apnea Guard®, and the process of immediate trial appliance therapy, your patients will know that you put their health and care as your utmost priority. Is Ez Sleep’s FIT-IT process and Apnea Guard® in your practice’s future? More training on how you can use Ez Sleep’s screening methods, their easy and convenient in-home testing and the Apnea Guard® immediate trial appliance are available with purchase of the Starter Kit. For more information contact ApneaGuard@ ezsleeptest.com or by calling Ez Sleep’s National Sales Manager Ryan Javanbakht at (949) 467-4510. DentalSleepPractice.com

27


CLINICALfocus

Employing Acoustic Pharyngometry to Improve Efficacy Of Oral Airway Therapy Device When Mandibular Advancement Is Ineffective: Essential Technology for Any Dental Sleep Medicine Practice? You Decide! by Dan Taché, DMD

I

nterest in Sleep Medicine (SM) and Dental Sleep Medicine (DSM) has grown considerably over the past decade; between 2002 and 2013 the number of articles published about SM/DSM grew from approximately 500 articles to more than 1500 and the trend continues. DSM’s growth has mirrored that of sleep medicine – there is abundant evidence demonstrating high efficacy of oral airway therapy devices (OAT) as an alternative to CPAP therapy for patients who have been diagnosed with mild-moderate Obstructive Sleep Apnea (OSA).

In 2006, the AADSM produced the first systematic DSM literature review and clinical practice parameters but the exponential growth of the field of Dental Sleep Medicine (DSM) demanded an update of the document. In February of 2013 the AADSM brought together a representative cross-section of notable leaders in the field of DSM to more correctly define what constitutes an effective oral appliance for the treatment of sleep disordered breathing based on then-current research and experience. This consensus committee produced a new definition, approved by the Board of Directors of the AADSM in March 2013. (Ramar, 2014) (Scherr, 2014)

Conclusions of the AADSM Report: “Definition of an Effective Oral Appliance” Subsection 5.1 entitled “Purpose of an Effective Oral Appliance” defines comparative efficacy of OAT vs. CPAP as the percentage of patients treated where AHI was reduced to <5 events/hour. Results for mild-moderate OSA: efficacy of CPAP=76% vs. OAT=62%; moderate-severe – CPAP=71% vs. OAT=51%. If we take a half full look at efficacy of CPAP vs. OAT, the inescapable conclusion is that for all levels of disease, OAT is relatively quite effective (Weaver, 2008) (Chan,

28 DSP | Spring 2016

2007). If, however, we allow ourselves to see outcomes from a half empty perspective of treatment failures regardless of method of treatment we are leaving roughly 30-50% of our patients with disease for all levels of disease severity!

Mandibular Advancement vs. Vertical Titration

Subsection 5.2.3 entitled “Protrusion Mechanism” notes that advancement of the mandible is a “key” feature of success with OAT. Surprisingly, the committee also reported that “...no recommendations regarding increased Vertical Dimension of Occlusion (VDO) adjustment were included in the definition”. While the committee failed to deal with the issue of VDO, there is published evidence and a multitude of case reports showing that in select cases, additional VDO may have a stabilizing effect upon the airway thereby increasing OAT efficacy. (Kryger MH, 1989) (George, 2001) In contrast, other studies suggest that increased VDO reduced patient acceptance. (Pitsis AJ, 2002) An oft-cited study argued that only mandibular advancement “increases cross-sectional area of several segments of the upper airway” whereas increased VDO had a destabilizing effect upon them. (Isono, 1995)


CLINICALfocus These conflicting outcomes likely identify this as a case-specific issue. In this author’s experience, increasing VDO is often effective especially when the specific risk factors such as obesity, male gender, or a diagnosis of polycystic ovarian syndrome are present in the patient who is refractory to advancement of the mandible.

Currently Available Technology to Assess Oropharyngeal Compliance

If a patient is not responding to treatment with (mandibular) advancement, short of abandoning treatment is there technology available to help improve outcomes? There have been a number of technological advances to help us visualize the airway to better determine site of oropharyngeal compliance leading to OSA. Compliance is roughly equivalent with collapsibility of the airway. Some of the currently available technologies are: 1. Drug induced sleep endoscopy (DISE) 2. Magnetic Resonance imaging (MRI) 3. Computerized Tomography (CT)/Cone Beam C.T. (CBCT) 4. Cephalometric radiographs, 5. Acoustic Pharyngometry As with any medical technology, there are certain practical considerations which must be applied to determine whether the specific technology is appropriate for the disease condition & patient being evaluated. The criteria often applied are (Faber, 2003): 1. Ease of implementation 2. Accuracy and reproducibility 3. Cost-effectiveness 4. Availability in a clinical setting

Drug Induced Sleep Endoscopy (DISE)

Airway obstruction in obstructive sleep apnea (OSA) can occur at many levels. The principal regions most susceptible to collapse are the palate, hypopharynx, and the retrolingual area; all readily visualized with Drug-Induced Sleep Endoscopy (DISE) and provide useful information about upper airway stability. Although DISE has demonstrated substantial diagnostic validity and reliability, it has associated costs and risks that must be balanced against the potential benefits of the procedure vis-à-vis alternative diagnostic assessment with less cost and risk for harm. (Kezirian EJ, 2010)

Magnetic Resonance Imaging (MRI)

Upper airway MRI images can be useful in identifying soft tissue shapes which may affect airway size and compliance, notably tongue volume (Faber, 2003). MRI is noninvasive and does not expose the patient to ionizing radiation, however, this technique is time-intensive, costly, and not easily convenient for the DSM practitioner. MRI is also not always available for obese patients or those with pacemakers.

Computerized Tomography (CT) and Cone Beam Computerized Tomography (CBCT)

CT is a 2D image which can reveal anatomic risk factors for OSA. Evidence shows that there are significant craniofacial differences between OSA and non-OSA individuals such as size and position of the mandible, size of the posterior airway space, tongue size and length of the soft palate The most clinically useful measurements of the upper airway to discern morphological risk factors for OSA are: minimum cross-sectional area of the oropharyngeal region and antero-posterior dimension of the smallest dimension of the airway. While 2D imaging is valuable, the complex shape of the airway is better revealed by 3D images from CBCT which also allows software manipulation of the data volume for sophisticated analysis. CT & CBCT imaging, although sufficient for establishing if there is risk for airway instability, do not provide insight to a dynamic airway, i.e. are not real-time images so have Daniel E. Taché, DMD is a graduate of Tufts University School of Dental Medicine and completed an advanced General Dentistry Residency program with the Veterans Administration in Houston, TX, where he first practiced TMD/Pain therapy before relocating to Wisconsin. Dr. Taché attended an 18-month training program for the diagnosis and treatment of Myofascial Pain Dysfunction (MPD). Between 20082010 he conducted research on the relationship between Fibromyalgia and sleep disorders. He is a staff member of the TMJ & Orofacial Pain Treatment Centers, based in Milwaukee, and his practice of dentistry in Wisconsin is limited to TMD/Orofacial and Dental Sleep Medicine. In 2009, Dr. Taché was elected for a 3-year term as President of the Wisconsin Sleep Society. He currently serves on the Board of Directors. Dr. Taché is married to Kathy, his wife of 30 years, and has four children.

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CLINICALfocus limited usefulness. Such images require substantial exposure to ionizing radiation, which is particularly problematic with children or when repeat images are needed. The major disadvantages of Cone Beam CT (CBCT) are perhaps, fourfold: 1) availability; due to the significant cost to acquire this technology, not every clinician will have this readily available when needed and the information (images) are static, not dynamic, so to speak which limits application to an every-day clinical setting, 2) high cost and radiation exposure 3) radiation exposure can be significant because multiple exposures may be needed if we are using it to predict airway response with repositioning, and 4) efficacy of CBCT to predict elevated risk for oropharyngeal instability with CBCT has been done evaluating both the A-P cross sectional diameter and/or air volume at the most compliant point of an airway of the patient with the teeth together. There is no data, currently to assess changes in airway stability with changes in vertical displacement of the mandible. This too degrades the practical application of CBCT in a dynamic clinical setting.

Cephalometric Radiography (CR)

An advantage of CR is that it is very quick, easy and the equipment is quite affordable for most all general and specialty dental offices. CR has been used to assess mandibular deficiency, soft palate length, position of the hyoid bone and posterior airway space. Mandibular body length alone demonstrated

The velo-, oro- and hypopharynx (blue) can all be assessed from the results of the MMM and moreover, it can be done quickly by support staff, is non-invasive, painless, easily repeatable within seconds and is dynamic or real-time study meaning that in a single visit, an infinite number of mandibular repositionings (vis-à-vis advancement) can be performed quite readily during a routine clinical visit

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a clinically significant association with risk for OSA. (Riley, 1983) (Scherr, 2014)

Acoustic Pharyngometry (AP)

Evidence has shown that sound waves generated and directed towards either a rigid tube like a water pipe or a flexible tube such as an air vent or the muscular walled oropharyngeal airway, will be reflected by changes in impedance caused by changes in the cross-sectional area of that tube. By comparing the incident sound wave with the reflected waves changes in the cross-sectional area, can be accurately calculated. With the emergence of more compact, portable sound-generating units and the development of a proper mouthpiece to deliver the generated sound waves into the oropharynx, AP was now able to be applied to airway analysis and ultimately found application in DSM. AP also provides useful information when assessing patients at risk for OSA. AP, because of the relative ease of use, reproducibility, availability, and cost-effectiveness, is slowly gaining importance in the clinical setting of the DSM practice to evaluate airway stability of the oropharyngeal cavity using reflected acoustic signals (Gelardi, 2007). AP efficacy: studies have established a near 100% accuracy in the identification of which level(s) are most susceptible to collapse along the entire length of the airway. There is excellent agreement between data obtained with DISE when contrasted with data obtained from AP. The “data” obtained with AP which provides insight into the location and degree of volume changes of the airway is the Residual Volume (RV) (Terris, 2000). A recent, and very elegant, study evaluating the predictive value OSA by AP appeared in the Journal of Clinical Sleep Medicine (DeYoung, 2013). It compared the gold-standard of polysomnography (PSG) to the reliability of AP as a viable method to triage patients at risk for OSA. It was concluded that AP “...when analyzed alongside other variables such as gender, age, and neck circumference...provides an objective and simple test with strong independent predictive value for the presence of moderate-to-severe OSA.” Numerous studies have concluded that AP has sufficient sensitivity and specificity to be clinically useful for airway measurement and assessment. Bradley T. et al maintained that acoustic pharyngometry demonstrates


CLINICALfocus both reproducibility of results and excellent agreement in assessing airway cross-sectional diameter as compared to computerized tomography of the velopharynx (Bradley, 1986)

Concluding Remarks

AP is gaining respect in DSM practices because it provides real-time dynamic data about the potential responsiveness of the oroand hypopharynx to mandibular repositioning device therapy for the treatment of sleep related breathing disorders. AP accurately and with good reproducibility, estimates cross-sectional diameter of the pharyngeal airway (Brooks LJ, 1989). AP is not limited because it reveals broader pathways for treatment by enabling the clinician to exploit both x- and y-axes with repositioning. AP is very simple to utilize, non-invasive, and carries no risks for the patient. (Okun, 2010) It is applicable in both the identification of patients at risk for SRBD who not have been diagnosed but also enhances the treatment of patients diagnosed with OSA who are utilizing a mandibular repositioning device to control their disease. More simply put, assists in “finding an airway” when the traditional approach of minimal opening and advancement alone are insufficiently stabilizing the oropharyngeal airway. An attempt has been made to objectively review a number of currently available technologies which have been shown to have value in the analysis of airway compliance relative to the treatment of sleep-related breathing disorders with OAT devices. The analysis was done from the perspective of the criteria for practical application in a clinical setting, namely: 1) Ease of implementation, 2) Accuracy and reproducibility, 3) Cost-effectiveness and 4) Availability in a clinical setting (Faber, 2003). A strong argument can be made that AP, given the modest cost to acquire, ease of use requiring just a few minutes from start to stop in most cases, coupled with the fact that it is non-invasive and virtually harmless, and easily delegated to support staff, should be high on the list of essential technology for the Dental Sleep Medicine practitioner. There are few opportunities in any other area of Dentistry where the demands for such service are so desperately high and failure can mean the untimely demise of a patient.

If a single failing Mandibular Advancement Device case can be rendered more effective from the real-time information AP does provide, why would it not seem “essential”? There are notable disadvantages of AP method: a) the generated sounds waves cannot access any of the airway area above the level or posterior to, the soft palate; that area, however, can be evaluated utilizing a different wave tube, namely the acoustic Rhinometer and has shown applicability in pediatric patients, b) another disadvantage of the AP is that the surrounding soft tissues are not visualized, and c) AP is usually performed with the subject erect during Wakefulness. This “disadvantage” has largely been overcome consequent to the work done by Kamal who showed that employing the Mueller Maneuver when acoustically analyzing the airway of the erect awake patient revealed both level(s) and degree of compliance airway compliance. (Kamal, 2004) I will attempt to illustrate the practical application of AP in a clinical setting utilizing a clinical case report showing a patient who was refractory to mandibular advancement alone. Through application of information gleaned from AP analysis of the airway, we were able to substantially enhance efficacy of the oral device by increasing the VDO with minimal clinical time and virtually no outside laboratory expense. Although a case reports are considered to be relatively weak scientific evidence, this sort of report can provide a great deal of information and could stimulate future research and hopefully help improve the effectiveness of our treatment for patients who are not responding sufficiently to mandibular advancement alone (Greenhalgh, 2002).

Case Study: Employing Technology in Managing the Mandibular Advancement Device Therapy Patient Who is Not Responding to Advancement

JT is a Dental Sleep Medicine patient whom I have been treating for about 8 years. He is professor at a local community college, hunter and loves being a father to his 3 children...just a wonderful and grateful patient and person. He has had OSA since he was a young man and we have been able to control it well mandibular repositioning devices (OAT). He is now on his 2nd appliance, which we just had made for him, a Respire Blue dorsal appliance.

AP specifically reveals both the site of obstruction which provides precise discrimination and degree of compliance (red arrows) of location(s) of obstruction contributing to the genesis of SRBD (D’Urzo, 1988) (Rivlin, 1984).

Meet JT • Diagnosed with moderate Obstructive Sleep Apnea (OSA) approximately 10 years ago and has been under my care for nearly 8 years. • We have successfully managed his OSA with Mandibular Repositioning Devices (OAT); he has been well controlled with minimal adverse effects. • Annual Home Sleep Tests (HST) have shown good control of OSA • Last HST was performed in 2013 and showed good results.

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CLINICALfocus

2013-present: • This is a close-up of JT’s OAT in place, showing the A-P position of the mandible relative to the maxilla. • A HST (below) demonstrated very adequate efficacy of this appliance.

The Respire Blue Series dorsal-type appliance. OAT currently utilized by JT.

JT has always done as I have asked and returns regularly for DSM follow-up visits and each time he returns, we provide a HST monitor to check efficacy of his appliance. Each time, with little effort, we have kept respiratory indices well under control until this most recent annual DSM recall. The last time he returned for his annual progress evaluation, I noted that he looked tired, pleasant as always, not complaining but his countenance was one of someone who appeared not be sleeping well. Below, is a step-by-step account of why, what, and how we improved his response to mandibular repositioning device therapy.

2013: Apnea Link HST summary report • This is the Apnea Link HST test performed 2 years ago showing normal AHI & oxygen saturation

2015: Apnea Link HST summary report • Here is the most recent Apnea Link HST report • Both AHI (3/hr.) & mean oxygen saturation (93%) are normalized however JT, states that he is often more tired now and his wife does admit that he is making more noise while sleeping.

2013: Apnea Link HST - A closer look • Looking back at our HST from 2013, comparing details between the most current HST (2015) and that of 2013 • Major difference seen is the NOT the AHI but the total amount of time that JT is sleeping and has significant oxidative stress i.e. (%age of TST <90% saturation)! • Normal value should be less than 1% of total sleep time (TST) • Result recorded in 2013 = 1%

2015: Apnea Link HST - A closer look • Another very useful metric to assess OAT efficacy is the percentage of Total Sleep Time (TST) that the patient has less than 90% saturation. • This value should be < 1% of TST. • This value is greatly elevated since 2013 - in 2013 value: 1% - now value : 8% • This might explain JT’s excessive daytime sleepiness

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CLINICALfocus Looking for an Airway: Acoustic Pharyngometry (AP) • JT can advance very little • Using AR, we will assess effect of adding VDO to help • Goal: airway x-sec. diameter of 2.0 cm2 (+ or - 0.2 cm2)

Pharyngogram with OAT in place • Airway caliper provided by the OAT (after modified Mueller Maneuver) as it was set in 2013 is only 1.33 cm2 (YELLOW ARROW) • This is insufficient for controlling airway stability during sleep • Minimal x-sec. diameter is appx. 2.0 cm2 (Malhotra A. et al., 2013)

Will adding VERTICAL improve airway stability? • Using Airway Metrics Vertical Titration Key VDO • Pharyngometry may assist us in determining how much, if any, additional VDO will help • It appears +5mm VDO might help (www.airwaymetrics.com)

Q: Is Advancing more going to help? \A benefit of AR is that it is a real-time test. • This Pharyngogram reflects JT’s maximum effort to protrude (100% of protrusion) • Even with maximum advancement, airway stability actually DECLINES from 1.33 cm2 to 1.31 cm2 • This phenomenon of a decline in airway stability has been well documented (Hoekema, 2007)

Pharyngogram suggests that additional VDO looks promising • The x-sec. diameter is vastly improved from 1.33cm2 - 1.85 cm2 • OAT will be modified by adding +5 mm additional acrylic

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CLINICALfocus

Recording the modified bite • VTK separates upper & lower trays by +5mm • Bite registration paste is introduced to record the changes in VDO height (graphic illustration from different case)

Increased VDO added to Respire Blue OAT (red arrows) • JT’s OAT was modified (mockup) by adding 5mm acrylic • Many OAT appliances can be modified in this manner

HST following modification of OAT. Success!

Bibliography 1. 2. 3. 4. 5.

6. 7. 8. 9. 10. 11.

12. 13. 14. 15.

A. D. D’Urzo, I. R. (1988). Comparison Of Glottic Areas Measured By Acoustic Reflections Vs. Computerized Tomography. Journal of Applied Physiology, 64 (1), 367-370. Bradley, T. D. (1986). Pharyngeal size in snorers, nonsnorers, and patients with obstructive sleep apnea. New England Journal of Medicine, 315 (21), 1327-1331. Brooks LJ, B. P. (1989). Reproducibility of measurements of upper airway area by acoustic reflection. J Appl Physiol, 66, 2901–2905. Chan, A. S. (2007). Dental appliance treatment for obstructive sleep apnea. Chest Journal, 132 (2), 693-699. DeYoung, P. N.-A. (2013). Acoustic pharyngometry measurement of minimal cross-sectional airway area is a significant independent predictor of moderate-to-severe obstructive sleep apnea. Journal of clinical sleep medicine, 9 ((11)), 1161–1164. D’Urzo, A. D. (1988). Comparison of glottic areas measured by acoustic reflections vs. computerized tomography. Journal of Applied Physiology, 64 ((1)), 367-370. Faber, C. E. (2003). “Available techniques for objective assessment of upper airway narrowing in snoring and sleep apnea.” Sleep and Breathing, 7 (2), 77-86. Gelardi, M. A. (2007). Acoustic pharyngometry: clinical and instrumental correlations in sleep disorders. Brazilian Journal of Otorhinolaryngology, 73 (2), 257-265. George, P. T. (2001). Selecting sleep-disordered–breathing appliances: Biomechanical considerations. The Journal of the American Dental Association, 132 (3), 339-347. Greenhalgh, T. a. (2002). How to read a paper. London (3rd ed.). (M. Banks, Ed.) Blackwell Publishing Group. Hoekema, A. (2007). Oral-appliance therapy obstructive sleep apnea-hypopnea syndrome: a clinical study on therapeutic outcome. (U. o. Groningen, Ed.) Groningen, Netherlands. Isono, S. H. (1995). Advancement of the mandible improves velopharyngeal airway patency. Journal of Applied Physiology, 79 (6), 2132-2138. Ivanhoe, J. R. (2003). The teaching and treatment of upper airway sleep disorders in North American dental schools. The Journal of prosthetic dentistry, 89 (3), 292-296. Kamal, I. (2004). est-retest validity of acoustic pharyngometry measurements. T Otolaryngology--Head and Neck Surgery, 2, 223-228. Kezirian EJ, W. D. (2010). Interrater Reliability of Drug-Induced Sleep Endoscopy. Arch Otolaryngol Head Neck Surg, 136 (4), 393-397.

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16. Kryger MH, R. T. (1989). Principles and Practice of Sleep Medicine. Saunders. 17. Kwok, K. L. (2008). Cardiovascular changes in children with snoring and obstructive sleep apnoea. (Vol. 37). (A. A. Singapore, Ed.) 18. Li, A. M. (2009). Blood pressure is elevated in children with primary snoring (Vol. 155). (T. J. pediatrics, Ed.) 19. Mindell, J. A. (2011). Sleep education in medical school curriculum: a glimpse across countries. Sleep Medicine, 12 (9), 928-931. 20. Ogawa, T. E. (2007). Evaluation of cross-section airway configuration of obstructive sleep apnea. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 103 (1), 102-108. 21. Okun, M. N. (2010). Acoustic rhinometry in pediatric sleep apnea. Sleep and Breathing. 14 (1), 43-49. 22. Pitsis AJ, D. M. (2002). Effect of Vertical Dimension on Efficacy of Oral Appliance Therapy in Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 166 (6), 860-864. 23. Punjabi, N. M. (2009). Sleep-disordered breathing and mortality: a prospective cohort study. 6, 873. 24. Ramar, K. L. (2014). Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. Journal of clinical sleep medicine, 11 (7), 773-827. 25. Riley, R. C. (1983). Cephalometric analyses and flow-volume loops in obstructive sleep apnea patients. Sleep: Journal of Sleep Research & Sleep Medicine. 26. Rivlin, J. H. (1984). Upper Airway Morphology in Patients with Idiopathic Obstructive Sleep Apnea. American Review of Respiratory Disease, 129 ((3)), 355-360. 27. Rosen, R. C. (1993). Physician education in sleep and sleep disorders: a national survey of US medical schools. Sleep, 16 (3), 249. 28. Scherr, S. C. (2014). Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. Journal of Dental Sleep Medicine, 1 (1), 39-50. 29. Terris, D. J. (2000). “Reliability of the Muller Maneuver and Its Association With Sleep-Disordered Breathing.”. The Laryngoscope, 110 (11), 1819-1823. 30. Weaver, T. E. (2008). Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proceedings of the American Thoracic Society. Annals of the American Thoracic Society, 5 (2), 173-178.


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PRACTICEmanagement

Get Paid for Imaging – 3 Tips for DSM by Rose Nierman

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etting paid for imaging for medically necessary exams and imaging is commonplace in many dental practices. An exam, airway screening and panorex are routinely reimbursed. The good news is that panorex x-rays do not require preauthorization. A cephalometric view may also be covered, subject to a prepayment or post payment review. Cone Beam Computerized Tomography (CBCT) reimbursement through medical insurance often requires preauthorization. Payment is dependent on many factors. It’s important for the cross-coding dental office to keep up with insurance guidelines, typically posted on their websites. It’s also recommended that you register for insurer newsletters. Our research into CT scans and cone beam has uncovered 3 guidelines to help pave the way to payments: 1. Document! Be diligent about recording your history-taking and exam findings including “Review of Systems” and “Exam Elements” when billing medical for imaging and the associated exam. For instance, a detailed encounter for a current patient is billed as an evaluation and management (E/M) code, such as CPT 99213. Note: Insurers will reimburse for a New Patient E/M (i.e. 99203) only if the patient has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. The September 2015 issue of DSP outlines E/M guidelines: http://www.dentalsleeppractice.com/ Rose Nierman has been at the forefront of educating dental practices on medical billing in dentistry, cross-coding and the expansion of patient services for over 26 years. She is the creator of DentalWriter™ Software and a CE provider for CrossCoding; Unlocking the Code to Medical Billing in Dentistry™. Contact Nierman Practice Management at 1-800-879-6468 or www.NiermanPM.com.

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cover-stories/what-documentation-doesa-physician-want-from-a-dentist/. 2. Preauthorize CT scans. Most CT scans involve a preauthorization process. The majority of medical insurers contract with outside organizations to administrate advanced imaging. One such contractor is National Imaging Associates (NIA). There are similar contractors working with various insurers. As far as the preauthorization process goes, some of the contractors yield same day decisions on the phone. One contractor is known to send a FAX asking for clinical information. Once you send in your SOAP notes, it may take 3-4 days for a written decision. Newer imaging technology, such as the i-CAT, is often reimbursed using CPT 70486, CT Scan, Maxillofacial. Although this is the proper code for CT scans, some insurers started differentiating cone beam technology by listing other codes for CBCT. For example, a BCBS carrier stipulates: There are no specific codes that address the conebeam technique even for medical claims. Please submit claims with the following unlisted CPT, 76497. 3. Look into CBCT Accreditation. Dental offices billing for advanced imaging will want to take a moment to review current medical policies. Many policies specify that for a physician (dentist) to receive reimbursement for CT, they must be accredited as a CT Imaging Accredited facility. Several resources have recently popped up to fill this need. For more information on accreditation, contact us through www.Dentalwriter.com. Increased access to care through medical insurance benefits will help many OSA sufferers find an alternative to CPAP and receive needed treatment with oral appliances. Anything covered in a medical policy must meet the insurer’s criteria for...you guessed it…medical necessity. Diligent documentation and excellent records will help to bring peace of mind to your practice when billing medical insurance.


EDUCATIONspotlight

What do you see?

The FUTUREISNOWHERE

The FUTURE IS NOWHERE

The FUTURE IS NOW HERE

by Mark T. Murphy, DDS

W

hen teaching at the Pankey Institute in the early 90â&#x20AC;&#x2122;s, I was fortunate to be influenced by some great minds in TMD, Chronic Pain and Sleep Medicine. Drs. Parker Mahan, Henry Gremillion, Keith Thornton, William Dement and others, all, unknowingly, had a hand in directing my journey; Mahan and Gremillion taught me about chronic pain and fibromyalgia, Stanfordâ&#x20AC;&#x2122;s Dement and his books helped me be confused at a higher level about sleep and Thornton encouraged me to make my first Crude OSA appliance an early TAP. Without titration or pre or post Polysomnograms, it looked more like an impression tray on the maxilla with a flat area on the lower anterior that patients would have to protrude past to close...hence opening the airway. Or so we hoped. The second generation or Static Twin Block Appliances were far more attractive and comfortable to wear but really offered little else than cosmetics as an improvement. The science began to evolve and pre and post testing began to showcase the efficacy of this new way of treating OSA.

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Generation 3 or the Titratable appliance designs, saw a vast improvement in both the science and the function of OAT. Hooks, tubes, screws, straps and bars were all used to measure and hold the mandible in a protruded position to open the airway. PSGs and HSTs provided data that demonstrated we were in a new era of treating OSA. The dentist had an advantaged solution over pressurized air that patients found far more comfortable to wear. Dr. Steve Carstensen recently told me that the most impactful thing about the fourth generation of CAD CAM optimized appliances is how they serve the patient. The reduction in chair time, patient education and maintenance regarding use were all worthwhile, but the fact that this generation makes it easier for the end user was the point he


EDUCATIONspotlight made. He said, “CAD CAM appliances make it easier for the patient to fit, wear, acclimate to and depend on my appliance. Many of my patients feel like they couldn’t live without it!”. He continues, “the intricacies and complexities we saw in the Gen 3 devices were things we could understand and adjust, but patients struggled with them. The engineers who designed the MicrO2 and Narval CAD CAM solutions clearly used the technology to not only improve the product, they improved the patient experience as well”. The milled MicrO2 has distinct advantages over the earlier generations of appliances. The denser acrylic puck used in the milling is stronger and leaches less monomer than other PMMA forms. Removing the lower lingual acrylic allows the patient to feel their teeth and leaves 11% more tongue space. This type of MAD can be made thinner and with significantly less overall bulk and volume. The CAD CAM digital process allows for accuracies that we have not seen before. With a retainer like fit, teeth do not more and the initial delivery adjustments disappear. Patients rave about how much more comfortable the MicrO2 is to wear and have chosen it over other appliances when give a choice. There is no doubt a dental sleep medicine provider can leverage the new generation of materials and processes into a patient experience that sets them apart. For most dentists, the era of wanting infinite adjustment settings has also passed. The

ability to design the appliance and prescribe 0.5 or 1.0 mm titration increments and control them accurately and easily is the new norm. Patients do better, call less and it saves valuable chair time. There will always be less expensive appliances, but if they “cost” more time, they are not cheaper at all. Incorporating dental sleep medicine into your practice has never been easier, more fulfilling or profitable. Today, a full arch of teeth can be scanned along with a protruded, open bite and sent digitally to MicroDental, where, without a model, a CAD CAM OSA appliance can be milled and finished with fit and function like never before. Dentistry has moved a giant step towards a digital future resulting in better patient health and outcomes, a more fulfilling and less stressful practice and a patient experience that has been optimized. This spring, April 21-24, 2016, several of North America’s most prestigious leaders in Dental Sleep Medicine will gather in Austin, Texas for the “Sleep Matters” MicrO2 Users conference. For more information and to step into digital sleep dentistry, visit http://www. microdental.com/micro2conference/ Mark T. Murphy, DDS, is the Principal of funktionaltracker.com, Lead Faculty at Microdental Laboratories, Guest Faculty at the University of Detroit Mercy and is a Regular Presenter on Business Development, Practice Management and Leadership at the Pankey Institute.

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CASEreport

Dramatic improvement in OSA severity when oral appliance and positional therapies are combined â&#x20AC;&#x201C; a case study by David P. Barr, DDS

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T

reating obstructive sleep apnea with oral appliance therapy is a rewarding and challenging undertaking. Every doctor/clinician has patients who do not completely respond to oral appliance therapy (OAT.) Once this is known, decisions need to be made to modify treatment for the best possible outcome. In the case study below I will describe how an innovative device was combined with an oral appliance to manage a patient with severe obstructive sleep apnea (OSA).


CASEreport An 85 year old CPAP intolerant male (neck circumference = 18 inches, BMI = 26) was referred for treatment of severe obstructive sleep apnea. His initial apnea-hypopnea index (AHI) was 46 and his supine-AHI was 51. A Herbst appliance was selected and over a six week period the appliance was advanced to a maximum comfortable protrusion. During this time, he experienced some improvement of symptoms, but was still snoring enough to disturb his wife. An efficacy home sleep study was administered and revealed OAT reduced the overall AHI by 49%, but a residual AHI of 24, with a supine-AHI of 53, and a snore index of 10.9 remained. At this point, I was left with a clinical decision point of abandoning OAT in favor of PAP therapy, surgical intervention, increasing vertical dimension, and/or adding positional therapy. After speaking with the patient, he wished to exhaust all treatment options before returning to PAP therapy or considering any type of surgery. This left altering vertical dimension of his oral appliance and positional therapy as choices for what to do next. This patient clearly was an appropriate candidate for positional therapy based on the Cartwright definition: supine-AHI at least twice the non-supine-AHI1. I have always been a strong advocate of positional therapy, but have found compliance with the tennis ball or positioning pillow approach to be poor due to the reliance on punitive techniques to restrict supine sleep. Recently I had read about a new approach for positional therapy devices that are worn around the chest or on the back of the neck and combine body position awareness with increasing levels of vibrations. These devices provide behavioral feedback so supine sleeping is avoided while also monitoring both efficacy and compliance. One article showed that vibro-tactile therapy significantly reduced the overall AHI, percent time SpO2<90%, snoring, and improved the sleep architecture (reduced stage N1 and increased stage N2 sleep) and sleep continuity (significantly reduced arousal index)2. The other article showed that an oral appliance combined with vibro-tactile therapy was far superior than either therapy used separately3. I obtained a vibro-tactile positional therapy device (Night Shiftâ&#x201E;˘, Advanced Brain Monitoring, Carlsbad, CA) (Figure 1) for my

practice and offered it to the patient on a trial basis for use in combination with his oral appliance. He agreed to use it for two weeks and return for a follow-up home sleep test. I was impressed with the results. The two therapies, in combination, reduced his overall AHI by 87%, from 46 to 6, with positional therapy contributing to the additional 40% reduction in the overall AHI from OAT alone, a finding consistent with the Dieltjens study3. The HST reported that his snoring index was reduced from 10.9% to 1.8%, and that he slept less than 3% of the night in the supine position (total of 14 minutes) with a supine AHI of 4 (likely explained by the fact that the Night Shift does not initiate feedback for the first 15 minutes of recording time to allow the user to fall asleep). As a result of the trial, the patient purchased a Night Shift device and states he has been sleeping much better with much less daytime sleepiness since the two therapies were combined. His wife is very happy since she no longer is disturbed by his snoring. Figure 2 provides an example of the Night Shift report that I used to evaluate the efficacy of the combination therapy. Results showed that this patient had a strong drive to sleep on his back, as he attempted to sleep supine nine times over the course of the night (the red lines identify when these occurred, the thickness indicates how long it took to respond to the feedback). Most patients, on average, attempt to sleep supine five times per night4. He was somewhat of a heavy sleeper in that it typically took him 22 vibrations (or 44 seconds) before he responded to the feedback. Most importantly, his percent time snoring above 50 dB was less than 10%, and his sleep efficiency was greater than 80%, both strong indicators that the combination therapy was effective.

Figure 1: photo of Night Shift

Dr. David P. Barr has been practicing general dentistry in Kronenwetter, WI for the past 28 years. His interest in treating obstructive sleep apnea stems from his own diagnosis in 2006. Dr. Barr opened a separate office in Wausau, WI dedicated to the treatment of snoring and OSA in 2014 where he provides oral appliance therapy and PAP therapy for his patients. Dr. Barr is a diplomat with the American Sleep and Breathing Academy and is a member of the American Association of Dental Sleep Medicine.

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CASEreport

吀栀甀爀猀搀愀礀Ⰰ 匀攀瀀琀攀洀戀攀爀 ㈀㐀Ⰰ ㈀ ㄀㔀

Figure 2: sample Night Shift report

Since as many as 70% of patients diagnosed with obstructive sleep apnea are position dependent2, the potential for vibro-tactile devices in combination with OAT appears to show great promise. The use of positional therapy could reduce the amount of protrusion needed from OAT,

since airway patency is easier to maintain in the non-supine position. The potential benefits include greater comfort, reduced side effects, lowered barriers to compliance, and improved efficacy across a wider range of patients. With CPAP intolerant patients, maximizing OAT is imperative. Combining positive airway pressure with OAT may not be an option, so effectively reducing supine AHI (and therefore total AHI) by adding a device like the Night Shift could mean better outcomes for this group of patients. It is gratifying to effectively manage a patient’s obstructive sleep apnea with oral appliance therapy, and frustrating when we encounter a patient whose problem does not completely resolve. My experience with the patient in this case study will change the way that I look at patients who are not responding completely to oral appliance therapy. In the future, I will be considering combination therapy earlier in the course of treatment, maybe even starting patients on it if there is a strong pre-treatment positional component. I believe that vibro-tactile devices will become an integral part in the treatment of OSA in my practice. It is exciting when an innovative therapy comes along that can be combined with oral appliance therapy to improve patient outcomes. 1. 2.

3.

4.

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Cartwright RD. Effect of sleep position on sleep apnea severity. Sleep,1984; 7(2): 110-114. Levendowski D, Seagraves, S, Popovic D, et al. Assessment of neck-based treatment and monitoring device for positional obstructive sleep apnea. J Clin Sleep Med, 2014; 10(8):863-871. Dieltjens M, Vroegop AV, Verbuggen AE et al. A promising concept of combination therapy for positional obstructive sleep apnea. Sleep Breath, 2015; 19(2): 637-644. Levendowski D, Cunnington D, Swieca J et a. User compliance and behavioral adaption with supine avoidance therapy. Behav Sleep Med, 2015; accepted.


TECHNOLOGYupdate

Cone-beam Computed Tomography (CBCT) Imaging for Temporomandibular Joint (TMJ) Disorders and Dental Sleep by Mayoor Patel, DDS, MS, RPSGT

T

he use of the Cone-beam Computed Tomography (CBCT) of the maxillofacial region has quickly created a revolution in all fields of dentistry. It has expanded the role of imaging from diagnosis to image guidance for many procedures and has eliminated some of the inherent limitations of 2D images such as magnification, distortion, superimposition and misrepresentations.

Image Selection

The American Academy of Oral and Maxillofacial Radiology (AAOMR) has established the groundwork and guidelines for image selection in diagnosis, treatment planning and follow up of a patient with conditions affecting the TMJ. Conventional radiographic TMJ projections like transpharyngeal, transcranial, panoramic radiograph, and tomographic sections of TMJ may be adequate in a number of clinical situations.

However, there are bony alterations that occur in these disorders like erosions, osteophytes, and pneumatisation of the articular eminence that are difficult to detect in conventional radiographs due to overlapping of the anatomic structures. Because of this, the use of advanced imaging modalities like Magnetic Resonance Imaging (MRI), arthrography, conventional Computed Tomography (CT) and CBCT are warranted. Letâ&#x20AC;&#x2122;s take a look at a few of the advanced imaging modalities and their use in diagnosis and treatment: MRI: Imaging of the TMJ should be performed on a case by case basis depending upon clinical signs and symptoms. An MRI is the diagnostic study of choice for evaluation of disk position and internal derangement of the joint because it provides high resolution and great tissue contrast. DentalSleepPractice.com

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TECHNOLOGYupdate The ADA Council on Scientific Affairs also suggests CBCT use should be based on professional judgment.

and volumetric measurements that include assessing the morphometry of the airway.

Guidelines Arthrography: Today, arthrography is rarely used because an MRI can be used to evaluate the TMJ without being invasive, exposing the patient to a possibility of allergic reaction from the contrast, the possibility of infection, or using radiation. CT Scan: The use of a CT scan for evaluation of TMJ is indicated if bony involvement is suspected. This choice should be judiciously considered because of radiation exposure. CBCT Imaging: By utilizing CBCT imaging, clinicians receive sub-millimeter spatial resolution images of high diagnostic quality with relatively short scanning times (10–70 seconds) and a reported radiation dose equivalent to that needed for 4 to 15 periapical radiographs. CBCT imaging is ideal for the evaluation of fractures, degenerative changes, erosions, infection, airway volume, sinus, nasal passages as well as congenital anomalies. Evaluation of the airway has become an important diagnostic test in several subspecialties of dentistry. Multiple orthodontic researchers have developed techniques to use full-head x-rays to determine airway obstruction, and the potential impact of high-resistance airways leading to abnormally developed increases in the vertical facial dimensions in young patients. CBCT imaging has opened up the opportunity to evaluate the cross-sectional area of the airway as well as the volumetric 3-dimensional (3D) depiction of the entire airway using a lower-radiation method than a medical CT. The CBCT system provides a low-radiation, rapid- scan capability to assess patients’ airway using a highly correlative linear, cross-sectional area,

Dr. Mayoor Patel has taken well over 1400 hours of postgraduate education courses in the area of Sleep Medicine, Craniofacial Pain, Sleep disorders and Orthodontics. Since 2003, he has limited his practice to the treatment of TMJ Disorders, Headaches, Facial Pain, Sleep Apnea and Snoring.

44 DSP | Spring 2016

Clinicians must abide by the ALARA (As Low As Reasonably Achievable) principle when ordering an imaging modality for a patient. Exposing the patient to the radiation must provide an image whose diagnostic value is greater than the detriment the radiation exposure may cause. Not every patient requires a CBCT because it does expose the patient to radiation and results in increased cost. The ADA Council on Scientific Affairs also suggests that CBCT use should be based on professional judgment and clinicians must optimize technical factors such as using the smallest field of view (FOV) necessary for diagnostic purposes and using appropriate personal protective shielding. Imaging for TMD and sleep has risen to a new level for TMD treatment, airway analysis and dental implants. Many of the scans are considered medically necessary in my practice which is limited to TMD treatment and Dental Sleep Medicine and are billed through medical insurance. For more related education, dentists may visit my office in Atlanta, GA as part of our “Shadow a TMD and OSA Dentist Program” through Nierman Practice Management CE or attend a seminar related to TMD and dental sleep medicine. For more information, contact Jon Nierman at 800-879-6468 or visit www.NiermanPM.com.

Bibliography 1. Scarfe W, Farman A, What is Cone-Beam CT and How does it work? Dent Clin N AM, 52, 707-730, 2008 2. Tyndall D et al, Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography, Oral Surg Oral Med Oral Pathol Oral Radiol, 113, 817-826, 2012 3. The American Dental Association council on scientific affairs, The use of cone-beam computed tomography in dentistry, JADA, 143(8), 899-902, 2012 4. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone: Beam computed tomography in dental practice. J Can Dent Assoc. 2006;72:75–80.  5. Vig PS, Kowalski CJ. Interrelations between respiratory mode, nasal resistance, flowrate and cross-sectional area. J Dent Res 1991;72:342. 6. Aboudara CA, Nielsen IL, Huang JC, Maki K, Miller AJ, Hatcher D. Comparison of airway space with conventional lateral headfilms and 3-dimensional reconstruction from cone-beam computed tomography. Am J Orthod Dentofac Orthop 2009;135: 268-79. 7. Shi H, Scarfe WC, Farman AG. Upper airway segmentation and dimensions estimation from cone-beam CT image datasets. Int J CARS 2006;1:177-86.


PROBLEMsolving

Narval CC & D-SAD Strap Failures: Where would you place the Fuse? by John Viviano, DDS, DABDSM

A

lthough 3D printed nylon appliances such as the Narval CC by ResMed and D-Sad by Panthera have demonstrated themselves to be extremely robust, it turns out that they do have an “Achilles Heel”: the advancement strap. Even though this only applies to those patients that adequately challenge their appliance through extreme bruxism, it would be prudent to have a plan in place to manage this issue.

Figure 1: Narval CC

Figure 2: D-SAD

46 DSP | Spring 2016

Let’s start by understanding the “raison d’etre”. The easiest way to explain this is by comparing the advancement strap to an electrical fuse. Patented in 1880 by Thomas Edison, a fuse guards against catastrophic surges of electricity. By placing a ‘Fuse” between the electrical source and the electronic circuitry, the integrity of the circuitry is preserved in the event of an electrical surge, protecting from catastrophic events such as damage to Hard Drives, Mother Boards, Circuit Boards etc. In the oral cavity, “extreme bruxism events” can be likened to these “electrical surges”. According to the Oxford Handbook of Applied Dental Sciences (2002), maximum biting forces generate around 110 to

160 lbs/sf. Typically, for bruxers that sufficiently challenge their appliances, catastrophic events such as appliance breakage is common. In 3D printed nylon appliances, the advancement straps actually act as a “Fuse”. When these straps stretch or fail, they protect from more serious “Catastrophic” events such as breakage of the appliance body, restorative work or teeth, and straining of the periodontium, musculature or Temporomandibular Joint. When the D-SAD first arrived, it came with a much beefier strap than the Narval CC. Which at first appeared to be an enhancement, until they demonstrated to be problematic with heavy bruxers; the attachment nubs (Figure 3) simply distorted,


PROBLEMsolving

which allowed the advancement strap to pull through the engagement hole. At this point the strap required replacement. The solution was simple. Panthera created a “b” version of their straps that had beefier nubs, meant to stand up to the forces anticipated in these heavy bruxing situations. When I inquired as to why all the straps were not made beefier I was told that making the straps beefier reduces comfort, so it is better to use the beefier nub only when indicated. This made sense to me and all was fine until the same patient had the same problem with his new “b” strap. That is when I was told that for very extreme bruxers they have an even beefier

strap referred to as a “B” strap. Interestingly, to date, the patients I have transitioned to either a “b” or “B” strap have not reported any reduction in comfort at all. The original Narval CC advancement strap had a few shortcomings; the numbers were too small for most to read without a visual aide, no 0.5 mm increment and they stretched over time when challenged by a heavy bruxer. So, a beefier strap, with larger numbers available in 0.5 mm increments was introduced. Everyone was happy, until the first time a nub responsible for holding the advancement strap in place distorted, allowing the strap to dis-engage in the mouth,

Figure 3: Damaged and normal D-SAD straps

Figure 4: D-SAD strap 25, 25b, 25B

John Viviano, DDS, D ABDSM, obtained his credentials from the University of Toronto in 1983. His clinic is accredited by the American Academy of Dental Sleep Medicine and is limited to providing conservative therapy for Sleep Disordered Breathing and Sleep Bruxism. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally, conducted original research and authored articles on the management of Sleep-Disordered Breathing and the use of Acoustic Reflection to evaluate the upper airway.

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PROBLEMsolving

Figure 5: Damaged D-SAD and Narval CC straps

Figure 6: Original and new Narval CC straps

48 DSP | Spring 2016

similar to what happens with the beefier D-SAD straps. So, it appears that by making the strap beefier, the role of the “Fuse” was transferred from the strap, to the engagement nubs. ResMed may need to revisit their strap design, perhaps going the Panthera route providing different “Brux” versions of their advancement straps for those bruxing patients that sufficiently challenge their structural integrity. In the meantime we need a way to manage this issue for that subset of patients. Before we get into the solution I would like to clarify a few things. When patients are first becoming accustomed to mandibular advancement they challenge their appliance much more. So, for some patients that tear through the new straps in a short time, this issue may subside with time. In addition, we now better understand that reducing AHI often leads to a reduction in Sleep Bruxism so this could also reduce breakage with time. I found this to be the case in the very early days when I made a lot of Silencer appliances. The Silencer’s “Fuse” is the titanium pin holding the upper and lower component together. I found that in a subset of patients, breakage went from the category “Often” to “Never” with simply the passage of time. Some very heavy bruxers that continued to experience pin breakage even after being jumped to the alternative hinge that sported a much beefier pin, simply stopped breaking their pin with passage of time! This of course dates back to the ‘90’s demonstrating that this is not a new issue. Finally, if advancement has caused the patient’s jaw to be swayed to either the left or right of where it wants to be, the stress imposed on the straps from the jaws efforts to be in its happy place may be sufficient to fracture a strap and cause it to disengage. So, it is always indicated to check for this issue and if it exists, simply balance jaw alignment by using a different strap number on one side, shorter or longer as required. What you have to ask yourself is this: for your appliance of choice, where is the “Fuse” located? They all have one, even if it is the main body of the appliance itself, or the teeth or the musculature or the TMJ! I find that when appliances break, there is usually a common theme for that particular appliance, for example, Dorsal Style appliances have their advancement mechanism sheer off, Silencer appliances have their titanium pin break, Klearway appliances have a wire

dis-engage from the acrylic, Herbst appliances experience breakage at the metal-acrylic interface, and EMA appliances stretch out their weaker elastic straps prematurely or sheer off the strap attachment nub when using their stiffest strap (indicating that the stiffer strap transfers the “Fuse” to the attachment nub). Maybe thinking about this “Fuse” concept will help you better understand some of the breakage issues you have experienced with your appliance of choice. So, how does one deal with the beefier Narval CC advancement straps breaking? Simply go back to the original version of the strap for that patient. Thankfully, I did not throw them away! I would rather have a strap that I monitor for stretching and replace as needed than deal with a disgruntled patient coming into the office with what he perceives to be a “Broken” appliance! The good news is that I have only experienced the original version of the strap breaking into two pieces once. Indicating to me that this is a very rare occurrence and stretching of the strap is the most likely problem you will deal with. Let’s collectively give RESMED and Panthera our feedback so they can go back to their computers and continue making these already exceptional appliances even better. These types of modification are relatively easy to accomplish due to the CAD-CAM process. It really is a New World and these appliances continue to differentiate themselves as New World appliances. For those of you that are having a problem with this “fuse concept”, think about the breakage issues you have experienced with your appliance of choice and try to determine where the “Fuse” for that particular appliance is; if you do this sincerely, you may not be too pleased with the answer. Finally, the electronics people figured this out a long time ago; if I were designing a Sleep Apnea appliance, I would place the “Fuse” in the most easily and in-expensively replaced part of the appliance that caused no harm when it failed. Where would you place the Fuse?


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TEAMfocus

New Imaging in the office, what does this mean for team? by Glennine Varga, AAS, RDA, CTA

I

t’s an exciting day for dentists to say YES to new imaging in the practice. A new imaging system can open up multiple opportunities to evaluate, educate and treatment plan patients. What does this mean for team members? New training, imaging execution and patient communication are just a few new topics that come to mind. Team members also get excited about new technology in the practice. Most may worry about getting trained, doing something new and how to charge the patients for new imaging. These are all valid concerns and rest assured most imaging technology companies have solutions. Any new venture will take time to implement and once the decision is made to move forward typically there is no turning back. As a dental team member anything new to the practice can be overwhelming especially something that impacts every patient and procedure. It’s easy for a dental team member to take a quick PA x-ray, angle the film and x-ray cone just right, instruct the patient when to bite down, and quick press the button! Done. When or if patients ask about cost, no worries – the cost is minimal or covered by dental insurance. Life is good. Now we have new imaging! A new way to position the patient, new software to learn and what happens with the fee? Is it covered

50 DSP | Spring 2016

by dental or medical what is the patient’s responsibility? The good news is once your systems are in place, it will be difficult to comprehend working without it! Like anything in life it’s all about attitude. If getting new imaging is seen as challenging and impossible to implement, then guess what? It will be challenging and impossible to implement! If getting new imaging is exciting and increases your level of ability, then guess what? You have something new to promote in the office and it won’t be long before you master it, like every other procedure you have learned. Turns out new imaging is very exciting and most patients are intrigued to visually experience what is being evaluated. A picture is truly worth a thousand words. Do you remember when intra-oral cameras were introduced in patient treatment rooms and patients could see fractures and broken down fillings for the first time? The images educate patients that dentistry is needed.


TEAMfocus Now we have 3D technology! The ability to show and educate patients with 3D imaging is remarkable! The use of this technology for diagnosis, treatment planning and precision of treatment, as with implants, is unparalleled. And it comes with even less radiation than a few years ago. Enhancing the ability to educate patients, particularly with regards to airway analysis, should produce increasing patient acceptance. Of course it is always important to keep in mind that imaging of the airway in an upright awake position cannot be a diagnosis for a sleep breathing disorder. This can only be done with a diagnosed sleep test. Showing the airway volume increase in a before and after 3D image is very impressive! The initial shock of doing something different will lessen with experience and time. Focus on taking advantage of learning something new and expand your abilities. Donâ&#x20AC;&#x2122;t shy away from new technology, embrace it! 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 canâ&#x20AC;&#x2122;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 is certified in radiology, electrodiagnostics, expanded duties dental assistant in the treatment of temporomandibular disorders. She has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and has tried the use of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp. She has trained and assisted hundreds of dental offices on practice management, TMD/Sleep Apnea concepts, medical billing and team training. For more information visit www.dsmbootcamp.com or email g@dsmbootcamp.com.

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LEGALledger

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Part III by Ken Berley, DDS, JD, DABDSM 52 DSP | Spring 2016

know! By now you are tired of hearing about insurance fraud. Three articles on insurance fraud is a lot. For those who have not read the other two articles, the first contained definitions of insurance fraud and insurance abuse with examples. The second article in our last edition, gave instructions for the dental practitioner if an auditor were to show up at your front door. This article is to explain the consequences of insurance fraud. I certainly want you to appreciate how serious fraud is. So why the overkill on insurance fraud given that no audits have been conducted to date? In a lecture last year, I heard the owner of a medical billing company explain that a patientâ&#x20AC;&#x2122;s $ 5,000.00 deductible could be routinely written off by using the financial hardship exception. The lecturer explained that overcoming a large deductible was easy, just charge at least $10,000.00 for Oral Appliance Therapy and then write off the $5,000.00 deductible and state this was done due to the patientâ&#x20AC;&#x2122;s financial hardship and inability to pay. Those attending this lecture obviously considered this individual to be an expert. It is reasonable to assume that an owner of a Medical Insurance Billing Company should know the law and would not recommend practices that could result in a charge of insurance fraud. But sadly, that may not be the case. Insurance billing companies can get you in trouble! If a medical biller is filing your claims for you, he is acting as your agent and you are legally responsible for his actions. If the biller working for you commits fraud, you will be charged. In my professional legal opinion, if your biller is overcharging for OAT and you are writing off your patientsâ&#x20AC;&#x2122; deductibles and copayments, this practice constitutes insurance fraud and you could go to JAIL! If this practice is so bad, why no audits yet? Two immediate answers come to mind. First, it is possible the insurance companies might not know that financial hardship clauses are being abused. However, this is unlikely. Insurance companies have an unbelievable ability to determine when fraud is occurring. The more plausible explanation is that the


LEGALledger numbers of cases involved have not reached critical mass. Auditors generally work on a percentage of dollars recovered. Most auditors do not work for the insurance company, they are independent contractors and they work on the biggest cases first where they can make the most money. Therefore, for

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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an audit to occur the dentist has to have an adequate total dollar amount of suspicious claims. When an office reaches critical mass, the auditor appears for his percentage. If you are found guilty of insurance fraud, what can happen? A multitude of state and federal laws have been enacted to prevent fraud and punish those found guilty. There are civil, as well as, criminal statutes which apply, so a dentist convicted of fraud can face fines, as well as jail time. Obviously, state laws vary and you will need to research your particular state’s statutes to determine what punishment could be imposed if you were to be accused. Many states have simply enacted a state version of the existing federal statutes. Some states have enacted additional statutes covering fraud.

Penalties and Sentences in Texas

The penalties for a conviction on charges of insurance fraud vary depending on the amount or value of the claim. For example, a claim of less than $50 is a “Class C” misdemeanor, which only carries a $500 fine as a penalty. The severity of the penalty imposed increases with the increased value of the fraudulent claim. For example, the most severe penalty for insurance fraud is in the case that the value of the fraudulent claim is $200,000 or more. This will be a first degree felony, which carries a sentence of five to ninety-nine years in a state prison and/or a fine of up to $10,000. For the falsification of information on an application for insurance, the defendant will be charged with a state jail felony. This imposes a penalty of 180 days to two years in a state prison and/or a fine of no more than $10,000.

Federal Criminal Statutes

For more information call 888-462-4841 x218

54 DSP | Spring 2016

www.braebon.com @braebon

False Claims Act, 18 U.S.C. § 287. Under this statute, any health care provider who presents a false or fictitious claim or demand to the government seeking reimbursement for medical goods or services can be liable. The prosecutor need only prove that the provider intentionally submitted the claim knowing that it was false, fictitious or fraudulent. This can be shown by showing that the claim was for goods or services that were not provided, were not provided as stated, or were provided but not medically necessary.


LEGALledger The punishment for a conviction under the False Claims Act is up to five years imprisonment and a fine of $250,000.00 for an individual and $500,000.00 for a corporation for a felony conviction; or $100,000.00 for an individual and $200,000.00 for a misdemeanor conviction. It should be noted that this penalty is per occurrence. Thus, liability for numerous false claims is very heavy. In light of the new specific provisions concerning false statements in connection with health care fraud found in the recently enacted Health Insurance Portability Act, it is questionable whether this section is applicable to actions that would be covered by the new legislation. False Statements Act, 18 U.S.C. §1001 This act imposes liability on a health care provider that in a communication submitted to the government, makes false or fraudulent statements or representations, false writings or documents, or that falsifies or covers up a material fact. Like the false claims act, the health care provider need not necessarily have made the statement directly to the federal government; it is enough that the false statement was made to a state agency or insurance company and submitted to the government. See United States v. Huber, 603 F.2d 387 (2nd Cir. 1987) (hospital supply company violated act where it marked up supplies to hospitals, who then submitted the marked up costs to the insurance companies acting as fiscal intermediaries for the Medicare and Medicaid programs.) In order to show a violation of this act, the government must prove that the health care provider willfully submitted the false statement or representation to the government, knowing it to be false, and that the statement was material i.e. that the statement was of the type that has the natural tendency to influence the agency’s action. See United States V. Greber, 760 F.2d 68, 72-73 (3rd Cir. 1985). The penalty for a conviction under the False Statement Act is a fine of not more than $10,000.00 or imprisonment of more than 5 years, or both. As with the False Claims Act, this penalty can be assessed for every violation. This is only an example of the many federal statutes that can apply of Medicare and

Medicaid fraud, which many states have adopted as applicable in their state.

Conclusion

How to avoid an audit and a finding The prosecutor need of fraud: 1. Don’t be greedy. Excessive fees only prove that the invite audits. provider intentionally 2. Do NOT waive patient deductsubmitted the claim ibles or co-payments 3. Make sure that you have all your knowing that it was documentation before you file false, fictitious or the claim a. Make sure you do not charge fraudulent. for an evaluation and management code that you cannot justify. Avoid using 99205, as this E & M code likely requires a full body exam which we are not qualified to perform. Insurance fraud is completely avoidable. No practitioner should ever be convicted of fraud. As E.T. says: “Beeeee Gooooood.”

DentalSleepPractice.com

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Dental Sleep Practice: Spring 2016  
Dental Sleep Practice: Spring 2016