in a Dental Sleep Practice by Dr. Shouresh Charkhandeh
Sleep Matters ProSomnus Sleep Technologies Dream Team Â®
SPRING 2017 PLUS
Industry Partner Interview Richard Bonato, PhD, RPSGT
Understanding Overlooked Sleep Disordered Breathing Symptoms Supporting Dentists Through PRACTICAL Sleep Apnea Education
by Mayoor Patel, DDS, MS, RPSGT
Think small When we developed the first CAD/CAM oral appliance for the treatment of obstructive sleep apnea, we packed our biggest ideas into our smallest device. Today, Narval CC continues to revolutionize oral appliance therapy with its advanced technology, its proven track record of compliance and efficacy, and its compact, lightweight design. As the experts in sleep, we couldnâ€™t be prouder to offer the very best in dental sleep.
Contact us at email@example.com.
The Most Important Testing System in Dental Sleep Medicine
f you are rewarding your patients and yourself by providing therapy for sleep breathing disorders, you are probably seeing patients at risk everywhere you go. It’s like when you are fixated on buying a new car – don’t you see examples of it on every street? As dentists, we can’t not see flaws (and beauty!) in smiles, constantly. Ah, but if it were only so simple to identify sleep disorders in people. Alas, the body phenotype that correctly labels our population has yet to be discovered, so we must rely on measurements to separate the folks who need treatment from the healthy ones. Running smack into ‘Observer Effect,’ a principle with origins in physics, we find that there are no completely non-invasive tests. Patient after patient complains of the nature of their PSG, their HST, their fitness monitor, their phone app. They tell us they are never sleepy, yet the objective scoring says they have moderate OSA. “I don’t snore – but my wife says I do” may be the most commonly uttered phrase in sleep medicine. OK. We have trouble identifying patients. Retreating behind that barrier moves not the needle of addressing the sleep breathing epidemic. Accepting it requires working with the patient’s beliefs, the medical team’s acceptance, and, of course, the documentation requirements and local laws that constrain us from unmanaged solving of important medical problems. Tools that every medical provider can use include questionnaires – are you employing these powerful conversation starters with every patient in your practice? If not, why not? Many dentists wonder how they can implement sleep medicine in their busy dental practice. Maybe they are just making it too complicated. Use a screener like STOP-BANG and be prepared to answer the questions and direct the at-risk patient into diagnosis somewhere. You’ve opened a door to health. How should you incorporate testing in your patient population? Your state may prohibit dentists from using sleep testing; Medi-
care does so nationwide. Innovators in our market are looking for easier and cheaper ways to find sleepy patients and measure the results of the interventions we provide. Why not take advantage of these surrogate markers for sleep breathing and check an at-risk patient with something further up the objectiveness scale? Could there be any harm in helping a person own the disease and possibly find motivation to fully diagnose and treat? Yes, in fact, there is – the false negative. Pay attention to sensitivity and specificity and hone your verbal skills, lest you validate those patients who are reluctant to admit a medical problem. What’s the big question you always get? Is this thing going to work? Is it worth it? We all must be able to look the patient (or the sleep doc!) in the eye and have an answer that builds confidence. Identify. Test. Treat. Test Again. Success in sleep medicine comes down to being able to help patients and providers through that path. The devices are tools – what matters is how you can help the patient find the motivation, your team to show confidence, and yourself to channel the passion for improving the health of your population. Words, emotions, and values are what makes us effective. Our patients trust us based on how we use those human skills. Passing the trust-test is the key to success.
Steve Carstensen, DDS Diplomate, American Board of Dental Sleep Medicine
Beginning with this issue, subscribers will be able to earn up to 2 hours of AGD PACE CE in each issue by completing questions about an article (see page 14) and submitting to our website. Sponsored by Medmark and Seattle Sleep Education.
Sleep Matters by Mark T. Murphy, DDS, FAGD Be ready to meet the demand!
Precision Medicine in a Dental Sleep Practice: Importance of better screening, more efficient clinical workflow and patient selection in dental sleep medicine ProSomnus Sleep Technologies Dream Team: (standing back row left to right) Brian Kiser, Senior Account Manager; Jerry Vogel, VP Sales; Mark T. Murphy, DDS, VP Marketing; David Kuhns, PhD, VP Technology; (seated middle row) Sung Kim, VP Engineering & Operations; Len Liptak, CEO; Robert Starr, Chief Administrative Officer; (seated front row) Kimberly Martin, Technical Services Manager; and Heather Whalen, Senior Director of Marketing & Education.
by Dr. Shouresh Charkhandeh DSP’s first CDE article.
2 CE CREDITS
Industry Partner Interview
Richard Bonato, PhD, RPSGT Supporting our entire industry.
Focus on Diagnosis
Patient Selection: Understanding Overlooked Sleep Disordered Breathing Symptoms
by Mayoor Patel, DDS, MS, RPSGT Clues you can use.
2 DSP | Spring 2017
IDTF Sleep Centers and Guidelines
by Dr. Warren Schlott It’s important who you work with.
ProSomnus Sleep Technologies has
MOVED LOCATIONS NEW ADDRESS: 5860 West Las Positas Blvd., Ste. 25 Pleasanton, CA 94588
Introducing a new generation of oral appliance therapy. 2.5x
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Unique metal free titration with 3.6x less monomers2
Titration requires fewer steps and appointments2
COMFORTABLE 30% less overall volume2
MicrO2® Sleep and Snore Device by ProSomnus™ Sleep Technologies, a new way to help OSA patients wake up refreshed and energized. Join the growing number of dentists and patients who are benefiting from MicrO2. Visit ProSomnus.com or call 844 537 5337 for a free starter kit. PRO_DSM_Ad_Jan2017
844 537 5337 ProSomnus.com Micro2sleepdevice.com 1 Data on File. 2Based on a comparison of a meta-analysis, “Is Selecting the Appropriate Sleep Device for You and Your Patient Important?” by Dr. David Carlton III, and New Oral Appliance Titration Protocol using MicrO2 and Mandibular Positioning Home Sleep Test. Presented at AADSM on June 10, 2016 by Dr. Remmers and Dr. Vranjes during poster and oral presentations. University of Calgary in Alberta Canada, Zephyr Sleep Technologies, Calgary, Alberta, Canada, The Snore Center, Calgary, Alberta, Canada.
CONTENTS Financial Focus
Five Things Your 401(k) Provider Does Not Want You to Know
Five Things Your 401(k) Provider Does Not Want You to Know
by Tom Zgainer Delve into possible pitfalls.
The Healthy Start System Begins with Educating Your Community
Sedation in OSA
ADA Updates Guidelines to Protect Patients Under Sedation by Geoffrey Archibald, DDS News about Capnography.
Grow airways, protect health.
Communications Insider’s Guide to Home Sleep Testing for the Dentist Compliance and Adherence: Dysfunctional Concepts in by Randy Clare Matching equipment to a purpose. Sleep Apnea Care
by Pat Mc Bride, BA, RDA, CCSH Therapy works when the patient does.
Objective Sleep Disorder Screening
by Glennine Varga, AAS, RDA, CTA Maximizing the value of testing.
TMDs: How Much Does a Sleep Dentist Need to Know?
by Ian McNickle, MBA How to stay face-to-face with patients using Facebook.
Denials are Not Written in Stone
by Rose Nierman Persistence is the key.
Medicare DMEPOS: Friend or Foe? Part 1
Sleep Test Bingo
by Ken Berley, DDS, JD, DABDSM, and Courtney Snow Best practices with the rulemaker.
4 DSP | Spring 2017
Important Facebook Developments
by Samuel J. Higdon, DDS Part two of the series.
Editor in Chief | Steve Carstensen, DDS firstname.lastname@example.org Managing Editor | Lou Shuman, DMD, CAGS email@example.com Editorial Advisors Steve Bender, DDS Ken Berley, DDS, JD Ofer Jacobowitz, MD Christina LaJoie Steve Lamberg, DDS, DABDSM Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA
The Critical Role of Team with Sleep Tests in the Practice
by Solveig Magnusdottir, MD, MBA Simplifying sleep quality measurement.
Publisher | Lisa Moler firstname.lastname@example.org
National Sales Director Kristin Sammarco | email@example.com National Account Manager Donna Aly | firstname.lastname@example.org Manager – Client Services/Sales Support Adrienne Good | email@example.com Creative Director/Production Manager Amanda Culver | firstname.lastname@example.org Website Manager Anne Watson-Barber | email@example.com E-media Project Coordinator Michelle Kang | firstname.lastname@example.org Front Office Manager Theresa Jones | email@example.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 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2017. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.
Dentists have trusted
Great Lakes for effective sleep appliances, diagnostic devices, and technical support for over 25 years. Whether you are new to dental sleep medicine or a veteran, we will partner with you to provide the best solutions for your patients with snoring and obstructive sleep apnea. The patent-pending Soft Telescopic Sleep Herbst®*
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6 DSP | Spring 2017
ProSomnus Sleep Technologies Dream Team: (standing back row left to right) Brian Kiser, Senior Account Manager; Jerry Vogel, VP Sales; Mark T. Murphy, DDS, VP Marketing; David Kuhns, PhD, VP Technology; (seated middle row) Sung Kim, VP Engineering & Operations; Len Liptak, CEO; Robert Starr, Chief Administrative Officer; (seated front row) Kimberly Martin, Technical Services Manager; and Heather Whalen, Senior Director of Marketing & Education.
n his book “The World is Flat” Thomas Friedman notes that “Analysts have always tended to measure a society (substitute “Dental Sleep Medicine Profession”) by classic economic and social statistics. Such statistics are important and revealing. Friedman prefers to ask a more telling question; “Does this society or profession have more memories or dreams?” If memories prevail and we speak of the ‘good old days,’ the profession or society is dying. If there are more dreams than memories, the future is bright. In the case of Dental Sleep Medicine, the future looks so bright you ought to wear shades. Digital technology, faster turnaround times, doctor preferences, designs, rapidly evolving physicians’ acceptance, insurance reimbursement drivers and broader patient awareness and education about OSA provide us a clean canvas we can paint our future on. DentalSleepPractice.com
The next generation appliances take advantage of digital design, storage and processes to help dentists treat more OSA patients with better efficiency and effectiveness.
Go Digital or Go Home!
Dental digital technological developments are improving the consistency, fit and efficacy of oral appliance therapy. The ProSomnus Sleep Technology CAD-CAM process provides several advantages that next generation appliances enjoy. Precision medicine allows a patient-centric approach rather than hoping the they can conform to what the lab can make. Physicians and other providers in this arena have found comfort in the reduction of side effects and complications as well. With in-lab times of seven days, we can get patients into treatment faster. The digital designs allow manufacturers to customize doctor preferences and deliver them consistently. Changes in fin angle, titration schedule, retention and more can be stored in a doctorâ€™s design file and replicated perfectly. Details can include: desired mm length of titration, verification of protrusive setting, 1mm, 0.5mm or less incremental adjustment, anterior opening, discluders and more. The bio-compatibility of milled and printed appliances is second to none. Just as traditional dental labs have created the digital highway for CAD CAM production, so too have select medical device manufacturers embraced this exciting pathway. Although the majority of impressions received today are analog, the ratio is changing rapidly as dentists adopt intraoral scanning. The accuracy, fit, storage and reproducibility translate to less tooth movement and a more stable dentition. Clinicians report that the lingualess design and thinner materials have resulted in less mandibular advancement to achieve clinical success. Bright future indeed.
The largest percentage of the population remains undiagnosed and untreated, providing a fertile health care field for dentists and physicians alike.
Patient Centric Treatment
The barriers are crumbling as study after study demonstrates the efficacy of OAT. The
8 DSP | Spring 2017
Infographic from sleepeducation.org
medical profession is realizing that patient comfort and compliance are important considerations in designing effective treatments. Insurance companies are starting to realize that OAT lowers short and long term expense. The cost to third parties to treat the massive comorbidities of OSA translates into lower reimbursements and higher premiums. 100% effectiveness, 40% of the time, the score for PAP therapy, is not an acceptable patient outcome. The large and growing percentage of the population that has OSA and remains undiagnosed and untreated, providing a fertile health care field for dentists and physicians alike. Some companies have chosen a direct care path developing treatment centers and eliminating the general dentist population. Others support both CPAP and OAT with their product offerings. ProSomnus Sleep Technologies is dedicated to helping more dentists get more patients into treatment faster and more efficiently. As a profession, we will need as many advantages as possible. The recent FDA approval and addition of compliance chip technology to our appliances allows pilots, truck
COVERstory drivers, servicemen and dozens of other sleep critical professions to confirm they are following guidelines and treatment recommendations. PAP devices work well when the patient wears them. Recent studies suggest that five nights a week and four hours per night do not have the intended outcomes. Evolving applications, new technologies and innovative designs will help more doctors treat the growing number of OSA patients. “Dental” achievements, such as a healthy periodontium, with excellent implant restorations and naturally esthetic porcelain, are trumped by improper airway management. We stand on the front lines as systemic health issues, dentistry and precision medicine come together. A long time ago, dentistry learned to quit extracting teeth and battled decay instead. We then grew to understand that losing well-restored teeth to bone loss was not productive. More recently, we have become adept at managing the forces of occlusion. Today, an airway centric approach is guiding the medical decisions of general practitioners, orthodontists and oral surgeons. As my good friend, Dr. Michael Gelb, says, “Airway trumps everything.” We can go 3 weeks without food, 3 days without water, but only 3 minutes without air. 24 hours without sleep has the same effect as being drunk. Multiple nights with poor sleep have physiologic consequences throughout the body. Sleep Matters!
The Dream Team
Having a great appliance, advancing the mandible predictably, patient comfort and fast turnaround are table stakes to get into the game of medical device manufacturing today. Digital platforms have a distinct advantage over analog today. We will see an increase in digital solutions, platforms, manufacturers and appliances. Dentistry has and will always be about the people: You, your team, the patients and the various vendors, lab and medical device manufacturers you partner with. At ProSomnus Sleep Technologies, we design devices that make it easier for dentists to optimize health outcomes for patients. It is more than just AHI. It is more than just being easy for the dentist to use. It is about making a device that patients will use. It is about ease of use. It is about convenience. Success in the patient’s hands and in your practice. A real partnership.
part-ner; noun. a person who takes part in an undertaking with another or others, especially in a business or company with shared risks and profits. Interesting definition indeed. Shared risks and profits is something that often doesn’t show up in every partnership. Vendor partners should be involved in helping you in many ways: Providing patient education materials and opportunities, Shortening treatment time, Team training about sleep, Customized appliance manufacturing, Shared financial success and Volume rebates. At ProSomnus Sleep Technologies we have assembled top drawer leaders in design, manufacturing and education in dental sleep medicine. With an Engineer, a Material Science PhD, a Dentist with over 25 years experience in sleep, a Marketing and Education Director who is second to none, a CEO with incredible leadership and passion, and several technical support, sales, manufacturing and fulfillment people, we indeed have the Dream Team. dream team; noun. a team or group whose members are among the most qualified or talented in their fields. At ProSomnus, we have a diverse group of highly skilled people, dedicated to your success and the fulfillment of this preferred future vision for dental sleep medicine. Every patient encounter, even routine dental care, should be examined with airway centric eyes and treatment plans. If you have been frustrated with a ‘one design fits all’ approach, delayed patient treatment or unresponsive device manufacturers, reach out to ProSomnus. The Future is Bright. Sleep Matters!
Dentistry has and will always be about the people: You, your team, the patients and the various vendors, lab and medical device manufacturers you partner with.
With no metal parts, less overall volume and a lingualess design, the MicrO2 raises the bar for patient comfort, safety and effectiveness in OAT.
Mark T. Murphy, DDS, FAGD, is Lead Faculty for Clinical Education at ProSomnus, serves on the Guest Faculty at the University of Detroit Mercy, is a Regular Presenter on Business Development, Practice Management and Leadership at the Pankey Institute and is the Principal of Funktional Consulting. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Practice Management, Communication, Case Acceptance, Planning, Occlusion, Sleep and TMD. He has a knack for presenting pertinent information in an entertaining manner.
Five Things Your 401(k) Provider Does Not Want You to Know by Tom Zgainer
magine giving up 50% or more of your future nest egg to excessive fees. This is precisely what is happening when you utilize a traditional 401(k) plan (which represents 95% of the plans in existence). Seemingly, small percentages have a massive impact when you look at how they impact your account growth over time. Just 1% in excessive annual fees can add up to hundreds of thousands, even millions, of lost retirement dollars.
Figure 1: Assumes both plans have a starting balance of $1 million, a 7% annual growth rate, and $100,000 in annual contributions
10 DSP | Spring 2017
1. Fees matter, and their impact can be devastating. Have you ever been told your plan is “free?” Many 401(k) providers will market their plans as essentially “free” because there are no explicit checks being cut for recordkeeping, administrative fees, etc. But we all know there is no “free lunch” in this world. If you encounter a “free” plan, ironically, you could be in an extremely expensive plan. The fees are simply being subtracted from your retirement savings, which can act like a hole in your boat! Make no mistake. Just because you may not be cutting a check for your plan, you still may be cutting into your future nest egg. Figure 1 is a real-life example of two identical plans with the same growth rate, same ongoing contributions, but with different fee structures (0.65% versus 1.68% annually). All things being equal, the additional fees erode more than a million dollars in potential retirement savings.
FINANCIALfocus 2. Layers upon layers of fees are hidden in plain sight.
The traditional providers have been pushing the same old 401(k) plan for 30 years, but in 2012, the law finally required fees to be fully disclosed. The good news is that the curtain was pulled back. The bad news is their layer cake of fees is hidden in 30-50 page fee disclosures that the average person has no chance of deciphering. This is evident by the fact that 71% of Americans think they pay NO 401(k) fees. Nothing could be further from the truth. Not only do providers make money by kickbacks from mutual funds, they are also happy to layer on additional, seemingly arbitrary fees that can double or even triple the cost of your plan. If that weren’t enough, many will also hit you with a one-time sales charge (aka commission) on every single dollar that goes into the plan. It’s an expensive and entirely unnecessary toll for the “privilege” of saving money. Here are the charges that should raise red flags. • Contract asset charge/Asset management charge — a layer of fees charged on the entire balance of your plan. This is over and above the cost of the investments. • Required revenue — an almost comical line item, this is a fee charged to smaller plans where the providers insist they aren’t making enough. • Sales charge — a one-time commission that subtracts 3% to 6% from every dollar you deposit. • Surrender charge — many insurance company providers have figured out a way to have your 401(k) held within a “group annuity.” This means they can penalize you with hefty surrender charges if you decide to switch plans to another provider.
— stuffing your plan’s fund menu with the funds that are most profitable for the provider. Worse yet are the providers that stuff the menu with their own more profitable namebrand funds. Odds are that your 401(k) plan is packed full of expensive “actively managed” mutual funds that are hoping to beat the market by being the best stock pickers. The problem is that although they may have a hot streak, the studies overwhelmingly show that in due time, they will often lag the market. So you are usually overpaying for underperformance. What’s the alternative? A great number of Nobel laureates and investment legends such as Jack Bogle and Warren Buffet would recommend that most investors use low-cost index funds. Index funds simply track a basket of leading stocks like the S&P 500, for example. David Sw-
The vast majority of 401(k) providers make huge sums of money from kickbacks from the mutual funds in the plans they sell.
3. The mutual funds in your plan menu are often chosen for all the wrong reasons. The vast majority of 401(k) providers make huge sums of money from kickbacks from the mutual funds in the plans they sell. This payment for “shelf space” is a legal but opaque process called revenue sharing. The net result is what we call “menu stuffing”
FINANCIALfocus ensen, the Chief Investment Officer responsible for growing Yale’s endowment from $1 billion to $24 billion, warns us, “When you look at the results on an after-fee, after-tax basis, over reasonably long periods of time, there’s almost no chance that you end up beating the index fund.” Most plans do not offer access to low-cost index funds because they can’t receive kickbacks (aka revenue sharing) from these ultra-low-cost funds. Many small or midsize plans will be told they don’t qualify for index funds because their 401(k) is not large enough. (Translation: “We wouldn’t make enough money off of you if we granted you access.”) Or worse, if they do offer them, they charge an outrageous markup. One plan we reviewed offered index funds with a 3,000% markup from its normal retail price. That’s like buying a $30,000 car for $900,000. All clients of America’s Best 401k have access to same low-cost index funds regardless of the size of the plan. No commissions, no kickbacks, and no markups.
4. Many of the biggest providers have been named in lawsuits for excessive fees and self-dealing.
There has been a flurry of recent lawsuits against 401(k) providers. The primary reason is for excessive fees and the use of proprietary products. Interestingly, it’s not just the customers who are suing, but many providers have been sued by their OWN employees for their own in-house plan. Providers were caught with their hand in the cookie jar by peddling their own, more expensive name-brand mutual funds and, thus, profiting from their employees’ retirement savings. Business owners beware! You have a legal obligation to make sure the fees in your plan are both fair and reasonable. As the plan sponsor, the Department of Labor states that the fiduciary obligation falls on you to make sure the plan is set up for the sole benefit of your employees. Nothing external can influence the decisions you Table 1: 401(k) with $1 million in total assets America’s Best 401k
Year 1 (start)
*These examples above are actual examples of specific plans where the fee disclosure was provided for both Transamerica and John Hancock. We have analyzed hundreds of plans from Transamerica and John Hancock where the fees are both higher and lower than the amounts listed above. Fees in plans vary drastically even from the same provider
Tom Zgainer is CEO and founder of America’s Best 401k and has helped thousands of companies repair or rescue their retirement plans over the past 15 years.
Take control, start here: americasbest401k.com/fee-checker-medmark
12 DSP | Spring 2017
make for your plan, including a relationship with the existing broker. More importantly, it’s your legal duty to periodically benchmark your plan, so a side-by-side comparison is a task that is in your best interest to perform. America’s Best 401k will provide a complimentary benchmark at your request.
5. The traditional model is being disrupted and rapidly becoming a dinosaur.
The 401(k) industry is ripe for disruption. Much like Uber has the transportation industry on its heels, our company is seeking to transform a decades-old industry that is riddled with conflicts of interest and often puts profits ahead of people. They have seemingly forgotten that it’s YOUR money, NOT theirs. America’s Best 401k is a next generation solution that eliminates brokers, levels the playing field with transparency, and provides a combination of high-tech and high-touch interaction for our clients.
Your next step: Get a complimentary side-by-side plan comparison
Most of our prospective clients are astonished when they see the results of their side-by-side plan comparison. In many cases, the immediate savings is more than $10,000 in the first year alone. But the real impact is what happens over 10, 20, or even 30 years. Below is a chart showing a 401(k) with $1 million in total assets. Here we show our average plan cost versus two other common providers. Note that although fees vary from plan to plan, we often see fees that are even higher from these two providers as well as other major insurance companies and national payroll companies. Assuming the plan is growing at 7% and has modest contributions of $60,000 per year, there are millions in potential savings being left on the table if a switch is not made immediately. These savings will go right back into the pockets of you and your employees and make sure your money will last as long as possible into retirement. By sending us your fee disclosure form (to info@americasbest401k. com), which we can help you locate, and by taking 15 minutes to review the results, we hope to show irrefutable evidence why a switch is in your best interest.
Precision Medicine in a Dental Sleep Practice Importance of better screening, more efficient clinical workflow and patient selection in dental sleep medicine
by Dr. Shouresh Charkhandeh
oday, according to the American Academy of Sleep Medicine, about 30 million patients suffer from Obstructive Sleep Apnea (OSA) in the US alone. And unfortunately, about 80% of these patients remain undiagnosed, despite all the efforts and advancements in raising awareness, screening, diagnostic technology and clinical guidelines. The cost associated with this group alone is around 150 billion dollars per year; if we add the cost of treatment it adds up to 162 billion dollars per year. As of today, common treatment options are Continuous Positive Airway Pressure (CPAP), Oral Appliance Therapy (OAT) and surgical interventions, in combination with lifestyle modifications. The most common prescribed treatment remains to be CPAP at 85%, despite its not so impressive longterm compliance rate. Per the same study, only 60% of patients on CPAP remain adherent to this therapy, while the other 40% choose to discontinue treatment for various reasons. While the compliance rate and patient acceptance with OAT seems to be higher, the utilization rate remains very low at 5-10%, despite its proven efficacy in 50-60% of all patients. Closer scrutiny of the numbers reveals that our current model is resulting in about 40% inefficiency; i.e. 40% of patients that are prescribed CPAP are not using it and about 40% of all OSA patients that are OAT responders do not receive the care they need. 14 DSP | Spring 2017
The health challenge of untreated obstructed breathing during sleep provides a virtually unlimited opportunity for physicians and dentists to work together. Some limitations in treatment options and unpredictable outcomes hinder the impact of some treatment choices, and the financial costs are huge. This article puts numbers to some of those obstacles and offers a novel pathway to address them.
Dental Sleep Practice subscribers can answer the CE questions on page 20 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Describe to colleagues the current state of sleep breathing treatment choices • Understand financial costs associated with successful and unsuccessful treatment • Present an alternate pathway for identifying responders to mandibular advancement devices • Develop a different relationship with medical colleagues aimed at increasing overall treatment success
CONTINUING education Keeping all the above in mind, we seem to have a big problem on our hands and our current models do not seem to be providing adequate solutions. A popular justification that has grown over the last few years is to rationalize the poor OAT efficacy in non-responders by higher compliance rate. Although in some patients this might be true, generalizing this to all patients and setting our protocols based on that could prove to be an inefficient approach long-term. In my opinion, that is to “set the bar low”, to pass, as opposed to “raising the bar” by better treatment protocols and approaches. It is like saying; “OAT may not be better than CPAP, but it’s not worse either” and use this justification to increase utilization!!! In this era, when the health industry is working more and more towards precision medicine, this approach seems to be a bit backwards and perpetuates a “trial and error” model. Looking up the definition of “Precision Medicine” online, it is described as a “medical model that proposes the customization of healthcare, with medical decisions, practices, and/or products being tailored to the individual patient. In this model, diagnostic testing is often employed for selecting appropriate and optimal therapies based on the context of a patient’s genetic content or other molecular or cellular analysis.” Also, “Precision Medicine” refers to the tailoring of medical treatment to the individual characteristics of each patient. It does not literally mean the creation of drugs or medical devices that are unique to a patient, but rather the ability to classify individuals into subpopulations that differ in their susceptibility to a disease, in the biology and/or prognosis of those diseases they may develop, or in their response to a specific treatment. Preventive or therapeutic interventions can then be concentrated on
those who will benefit, sparing expense and side effects for those who will not.” In his 2015 State of the Union address, U.S. President Barack Obama stated his intention to fund a United States national “precision medicine initiative”. The Mission Statement of the Precision Medicine Initiative reads: To enable a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward development of individualized treatments. This is a powerful statement of our mission in treating OSA; we need to reflect on how we can apply new technologies in order to achieve this goal of individualized treatments. Another approach would be to say that OAT should be prescribed in the 40% CPAP non-compliant population as an alternative. At first, this may look like a great idea. However, the reality is different and we cannot ignore
Dr. Shouresh Charkhandeh received his Doctor of Dental Surgery (DDS) Degree and Bachelor of Medical Sciences from the University of Alberta, Canada. Dr. Charkhandeh is a general dentist who maintains a group of private practices in Edmonton and Calgary with an interest in Dental Sleep Medicine and TMD. He is actively involved in clinical research in Dental Sleep Medicine and his research focuses on developing new technologies to improve treatment outcome predictability and patient selection in Oral Appliance Therapy for patients with OSA (i.e. Obstructive Sleep Apnea). He is the “Chief Dental Officer” at Zephyr Sleep Technologies, the developer of “MATRx TM ” Technology. He is the recipient of the “2012 & 2015 Clinical Research Award” and “2015 Clinical Excellence Award” from the American Academy of Dental Sleep Medicine (AADSM). He has lectured at numerous meetings such as American Academy of Sleep Medicine Annual Meeting, AADSM Annual Meeting, IAO (International Association for Orthodontics) Annual Meeting, iBedsma and many more Sleep meetings across North America and Europe. He is the founder and director of Alberta Dental Sleep Medicine Study Club and also a member of the “Sleep Disordered Breathing Committee” for Alberta Dental Association & College. He is also the “Clinical Director” at The Snore Centre in Calgary, Alberta.
It is estimated that the cost associated with diagnosis and treatment of OSA in the US alone was around ~4.7 billion dollars in 2015.
that only 50-60% of these patients will fully respond to OAT and in the other 40% the OSA will remain uncontrolled. This adds cost to the system both indirect associated with untreated disease and direct, associated with inefficient clinical models (e.g. the cost of OAT in a non-responder). It is estimated that the cost associated with diagnosis and treatment of OSA in the US alone was around ~4.7 billion dollars in 2015. Keeping that cost in mind, it would be easy to see how any small inefficiencies in the model could result in hundreds of millions of wasted dollars. According to a report published by Harvard School of Medicine, assuming 100% treatment effectiveness, increasing diagnosis would drive economic benefits. Even with 100% diagnosis, compliance will remain a critical limiting factor and insurers will likely demand higher compliance as the treated population grows, and perhaps push more towards “Precision Medicine” to improve efficiencies.
So, how can we move Dental Sleep Medicine in the same direction?
Per the Frost and Sullivan Report, the US market will grow from 180,000-200,000 patients fitted with a custom made oral appliance in 2013 to over 1,000,000 patients in 2023. Although this may sound very promising and a step in the right direction, it does not necessarily associate with better utilization of OAT as an alternative treatment for OSA patients. As seen in the figure below, the percentage of patients utilizing OAT will remain quite low at ~12% by 2020.
The Price of a Good Night’s Sleep: Insights into the US Oral Appliance Market Tara Shelton, Research Analyst, Frost and Sullivan 2015
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As well, we must consider the cost associated with the OAT non-responders in this small group. According to the AASM in 2016, the cost associated with undiagnosed/untreated OSA is around $6336 per patient. Using this number and the direct cost associated with OAT (Average: $2,000) and the estimated 1,000,000 patients treated with OAT, the total cost associated with OAT non-responders is easily estimated. Although the anecdotal clinical non-responder rate differs from one practitioner to another (e.g. depending on the level of expertise, tools and technologies utilized, treatment philosophy,…), I decided to use a conservative 20% non-responder rate. This will result in 200,000 ineffective OAT per year, which will in turn result in ~1.7 billion dollars per year of wasted money in Dental Sleep Medicine (200,000 x (Cost of untreated disease: $6336.00 + Cost of OAT: $2000). That is in fact the cost associated with a “trial & error” method as opposed to a precision medicine model. On a smaller scale and focusing on individual patients and dental sleep practices, some of the direct and indirect costs associated with treatment of OAT non-responders could be: Cost to the patient: • Monetary cost associated with the therapy • Cost of reparative therapy if OAT was abandoned due to physical complications • Adverse health consequences associated with untreated OSA • Potential loss of confidence in the system and alternative therapies Cost to the Dentist: • Cost associated with the lost chairtime (It is commonly believed that OAT non-responders require an average 4-6 additional appointments compared to OAT responders, due to difficulties/ challenges associated with their treatment process) • Indirect cost associated with patients’ loss of confidence in the dentist and perhaps leaving the clinic • Indirect cost associated with the referring healthcare professionals’ loss of confidence in OAT and the dentist, reducing referrals for OAT. • Indirect cost of loss of confidence within the dental team, reducing screening activities and growth of SDB treatments by the dental practice. Aside from the health economics of Dental Sleep Medicine, there are many other chal-
CONTINUING education lenges that we’re facing today, such as high number of undiagnosed patients. This is a challenge that is not specific to dentists, but to Sleep Medicine in general. Dentists can play a major role in helping with this area, as they can screen many patients that are currently in their practices. An average dentist has between 1500-2000 active patients which they see once or twice per year and have about an hour during their hygiene appointments to discuss various topics including OSA. However, today less than one third of dentists screen for OSA and even in those clinics the screening seems to be inconsistent. Over the years I’ve had the privilege of helping, meeting and training many dentists in Dental Sleep Medicine across the world and tried to keep in touch with most of them, if possible. Despite all the initial excitement, continued effort and commitment to implementing OAT in their clinics, the majority of the offices fail to keep up the sleep program over the years. When looked deeper into this loss of interest, the barriers seems to remain the same for most clinics, despite all their other differences. Aside from general challenges to implementation of any new program in a dental clinic (the need for proper training, team training, consistency and daily huddles, time and many other factors) there seem to be specific issues that are related to Dental Sleep Medicine: • Difficulty in referring patients to sleep physicians for proper testing and diagnosis, resulting in long waitlists, financial and time cost. Many patients lose interest and become lost to the system. • From the patients that make it to the diagnostic phase, only 5-10% are referred to the dentist for OAT and the rest are prescribed CPAP. Out of the 5-10% OAT referrals, many have already tried CPAP, for many reasons were either non-compliant or did not experience the immediate benefits, and become hesitant or lack confidence to start a new treatment. • From the ones are still interested in OAT, the consultation seems to be a bit of a challenge. When asked if the OAT will work for them and how, most dentist seem to have a problem with telling the patients that it may or may not work for them and the only way to know is to make an appliance and go through the subjective titration protocol and commit to the time and financials costs.
• The same issue also seems to pose a challenge for dentists that are trying to have a dialogue with sleep physicians and other healthcare professionals about OAT and raising awareness. They seem to hit a roadblock when asked the same question: “Is this going to work and how long before efficacious treatment is achieved?” Although research has shown many benefits of OAT and also novel ways of looking at treatment effectiveness (such as Mean Disease Alleviation) have given dentists tools to be better equipped for such discussions, the reality is most prescribers consider OAT a secondary treatment option in CPAP non-compliant patients, as opposed to an equal treatment alternative in the OAT responders. • In patient consultation, as dentists we are trained to provide the best evidence-based treatment for our patients with good to excellent prognosis. Every day, we’re using better diagnostic tools and material to improve the quality of general dental care and minimize the uncertainty. However, in Dental Sleep Medicine (DSM) we’re faced with a big challenge of accepting 60-80% rate of success (depending on clinician’s experience and how “liberal” they are with patient selection) and a “trial and error” method. Such uncertainties reflect on the dentist during the consultation appointment and does not convey the level of confidence that many patients require from their treating clinician and consequently their final decision on whether to go ahead with treatment. DentalSleepPractice.com
This will allow the patients to receive the therapy of their choice, with confidence in the therapeutic outcome.
Despite all the challenges above, some dentists remain motivated to help patients and will continue their efforts for a while. However, after a while, like any other added service in a dental practice, the financial realities of running a business will kick in. If only 5-10% of diagnosed patients are referred to a dentist for OAT, the ratio of number of patients screened to the number of patients that invest in OAT will remain very low, perhaps around 3-5%. That means for every 100 patients screened for OAT, the dentist may end up making 5-10 appliances in our current model. If we were to look at this solely from a “Return on Time Invested” point of view and time spent on screening and referrals for 100 patients to only get 5-10 appliances, the results won’t be very impressive long-term, especially when compared to other dental procedures in a clinic. To make things even more challenging, out of the 5-10 appliances fabricated, without objective patient selection, there will be a few non-responders that will cost the dentist excessive chairtime, loss of patients’ trust and referring physicians’ trust. These daunting challenges make many dentists think twice about providing such services in their clinics long-term, despite all the potential values and ethical obligations. Too many patients will be left undiagnosed or untreated. And as discussed earlier, to create any meaningful impact on this epidemic, the sleep field and patient population require as much help as possible. Losing dentists that are interested in providing OAT is doing the exact opposite.
So, what’s the solution and do we have the necessary tools?
As the medical model focuses more on “precision medicine”, dentistry has no choice other than to follow and we need to move away from segregation between the two professions and become more united. We require a new approach, new model, new clinical guidelines. A model in which the patient is offered their therapeutic choices and asked their preference, and before proceeding with such treatment, the efficacy of such potential treatment can be prospectively tested. This will allow the patients to receive the therapy of their choice, with confidence in the therapeutic outcome. Individualized care and patient selection will become key factors in such model. This could also result in an improved cost-to-benefit ratio in the system, by avoid-
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ing the costs associated with inefficiencies discussed earlier. This “Test, Select, Treat” model could perhaps be a novel, yet very effective approach in our battle against the epidemic. Although there have been many studies on utilizing different techniques and technologies for patient selection for OAT, such as Cephalometric Characteristics, 3D/CBCT Imaging, acoustic imaging, CPAP pressure, Mallampati score & BMI, as of today the actual role of such techniques remains unclear in the clinical practice due to low Positive Predictive Value (PPV) or Negative Predictive Value (NPV). However, there are promising approaches such as RCMP (Remotely Controlled Mandibular Titration – MATRx), UACP Multisensor Catheter and DISE (Drug Induced Sleep Endoscopy) that have better PPV & NPV that could be useful in clinical practice. As the only prospectively validated and commercially available technology for patient selection for OAT, MATRx would allow the physician to select responders to OAT AND to also provide a target protrusive position at which an efficacious treatment can be achieved, minimizing the chairtime required for treatment and the number of non-responders. MATRx has now been available in North America for a few years and recently, to further simplify the workflow and increase accuracy and efficiency of OAT, an “At-Home” version, MATRx Plus, has been developed and shows predictive accuracy comparable to that of its parent, MATRx. MATRx plus is commercially available in Canada and is in beta testing in the US. From DSM perspective, being able to accurately and confidently identify OAT responders, prior to initiation of OAT, could have many positive impacts that go beyond just selecting patients. By being able to identify OAT responders after initial OSA diagnosis, dentists could see an increase in referrals for OAT, per-
CONTINUING education haps as high as 50-60% of total patients diagnosed, as opposed to the current 5-10%. Not only the number of referrals would increase, the dentists will be minimizing the number of OAT non-responders, essentially eliminating the costs associated with this group of patients. This could change the nature of consultation with patients as the two unknown factors that currently complicate the process (i.e. whether the appliance will work AND where to set the mandible/calibration) will be eliminated, giving both the dentist and the patient more confidence in therapy. This could also result in improved treatment acceptance by patients during consultation. Another very important advantage would be the ability to have a confident and evidence-based dialogue with referring physicians, and giving them confidence in recommending OAT as the first line of treatment. With the increased number of referrals, higher treatment acceptance, minimized (perhaps eliminated) OAT non-responders, less chair time required for achieving efficacious treatment (because of the known target protrusion) and avoidance of subjective calibration, the economics of DSM could improve significantly, making it more appealing to a higher number of dentists. With more dentists involved and more screening, we can make a meaningful impact on the OSA epidemic and move in the right direction: Precision Medicine.
What’s next as we see more and more patients?
No individual technology or advancement in the field is going to magically resolve all the existing problems. This reminds me of a documentary that I watched a while ago on the Second Industrial Revolution; “Between 18601900, many new technologies, including electric power, were put to use. These inventions launched a transition to a new economy, a period of about 70 years of ongoing, rapid technical change. After this revolution began, however, several decades passed before measured productivity growth increased. This delay is paradoxical from the point of view of the standard growth model. Historians hypothesize that this delay was due to the slow diffusion of new technologies among manufacturing plants together with the ongoing learning in plants after the new technologies had been adopted. The slow diffusion is thought to be due to manufacturers’ reluctance to abandon their
accumulated expertise with old technologies, which were embodied in the design of existing plants and trying to fit the new technology into their existing work-flow models and set their production goals based on their current resources and models. In fact they needed to do the opposite: Designing the Workflow and Protocols based on the “Final Goal” & “Available Resources & Technologies.” Perhaps DSM needs the same approach and thinking outside the box. With increased demand for OAT, DSM requires: • Better patient selection ° Avoidance of Non-responders • More efficient workflow ° Less chair-time ° “Target” Oriented models ° Avoidance of Failures • Improved Clinical Protocols and Techniques ° Digital Workflow ° Better chair-side techniques ° Better “bite registration techniques” • Better Guidelines (Evidence-Based) ° That cannot be easily challenged by other industries • More Efficient Device Manufacturing An exciting journey ahead!!!
1. 2. 3. 4. 5.
American Academy of Sleep Medicine; Exploring the Economic Benefits of OSA Diagnosis and Treatment Commissioned by the American Academy of Sleep Medicine - Published August 2016 https://en.wikipedia.org/wiki/Precision_medicine The Prevalence of General Dentists who Screen for Obstructive Sleep Apnea; Long A, Chiang H, Best A, Leszczyszyn D The Transition to a New Economy After the Second Industrial Revolution Andrew Atkeson and Patrick J. Kehoe NBER Working Paper No. 8676 December 2001 JEL No. O4, O47, O51, E13, L6 Remmers J; Charkhandeh S; Grosse J; Topor Z; Brant R; Santosham P; Bruehlmann S. Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. SLEEP 2013;36(10): 1517-1525.
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Precision Medicine in a Dental Sleep Practice Dr. Shouresh Charkhandeh 1. Only _____ of patients on CPAP remain adherent to this therapy; the rest discontinue treatment for various reasons. a. 30% b. 40% c. 50% d. 60% 2. A medical model that proposes the customization of healthcare, with medical decisions, practices, and/or products being tailored to the individual patient is called: __________ . a. Custom Practice b. Precision Medicine c. Collaborative Health d. Obamacare 3. The reality is that ___________ of OAT patients will fully respond, leaving the rest uncontrolled. a. 30-40% b. 40-50% c. 50-60% d. 60-80% 4. Frost and Sullivan Report that the US market will grow from 180,000-200,000 patients fitted with a custom made oral
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appliance in 2013 to ______________ patients in 2023. a. Over 1,000,000 b. 450,000 c. 360,000 d. 750,000 5. OAT non-responders require an average _____ additional appointments compared to OAT responders. a. 1-3 b. 4-6 c. 7-9 d. 10-12 6. Today less than ______ of dentists screen for OSA. a. Half b. One quarter c. One third d. Twenty percent 7. From the patients that make it to the diagnostic phase, only ______ are referred to the dentist for OAT and the majority are prescribed CPAP. a. 5-10% b. 20-30%
c. 1-2 % d. About half 8. This “____________” model could perhaps be a novel, yet very effective approach in our battle against the epidemic. a. Precision b. No-Guess c. Test, Select, Treat d. Trial and Error 9. Two unknown factors that currently complicate the OAT process are __________ . a. which appliance and lab cost b. whether it will work and where to set it c. will insurance cover it and which appliance d. which color and material will the patient like 10. With increased demand for OAT, DSM requires: ____________ . a. All patients be treated first with oral appliances b. Acceptance that most patients will fail treatment c. Better, evidence-based guidelines d. in-office 3D printed oral appliances
INDUSTRYinterview DSP: Please tell us how you got started in sleep, and when was it you realized the importance of dental involvement?
Richard Bonato, PhD, RPSGT
RAEBON has been a leader in sleep therapy for 20 years with Co-Founder Dr. Richard Bonato as the public face of the company. Many dentists may not be aware of the giant contributions BRAEBON has made to their ability to successfully manage sleepy patients. DSP sat down with Dr. Bonato recently for this enlightening interview.
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RB: I began studying sleep during my undergrad days in 1986 after I picked up an issue of National Geographic which had a cover article entitled “Why We Sleep?” Back then sleep disorders medicine was in its infancy and only a fraction of the clinical sleep laboratories found today existed worldwide. I found the article fascinating, figured there had to be a career in it somewhere because everyone sleeps and I decided to pursue this as an area of specialty. During my Master’s and Ph.D. studies I became the 604th person in the world to become registered as a polysomnographic technologist (RPSGT) while I worked in a hospital sleep laboratory. Afterward I completed my Ph.D. and decided to enter the industry where I worked for a large multinational corporation for two years. In 1998, myself and Don Bradley founded BRAEBON Medical Corporation in his basement with the vision of getting into home sleep diagnostics which we did in 2003 when we launched our MediPalm full PSG system capable of either home or laboratory use. In 2004, I had the vision of getting into dental sleep medicine because I saw oral appliance therapy as a future growth market. BRAEBON began working on a simpler home recording device called MediByte – Medi for medical and Byte as a play on bite registration – which was the first tool intended for use in both medical and dental settings. BRAEBON attended its first AADSM conference in 2005 and has been steadily growing in dental sleep medicine ever since.
DSP: We know that HST is becoming the most common method of identifying sleep disorders – can you tell us more about BRAEBON’s involvement with providing several solutions for testing? Do you see testing in dental offices as a growing part of the specialty? RB: The founders of BRAEBON collaborated on the original Sandman PSG system in 1991-92. We used this vast experience in PSG product development in the development of our home sleep apnea recorders. As we evolved we developed powerful yet easy
INDUSTRYinterview to use devices which used the same technology as used by leading sleep laboratories. Our goal today remains the same: to offer physicians and dentists the ability to test patients in the comfort of the home with the same powerful technology as used in the laboratory. Same biosensors, same waveforms, just a different sleeping environment. The testing in dental offices will certainly grow in the future, however, the optimal model will be structured in a cooperative fashion between physicians and dentists. One of the primary drivers for this increased testing is the need to address the sleep apnea epidemic. There will never be enough sleep laboratories to address the vast numbers of people who require sleep apnea testing. This fact, coupled with the average national CPAP compliance rate of around 50%, means that dentists and oral appliance therapy have a substantial role to play in identifying and screening patients at risk and offering alternative therapy to CPAP intolerant patients.
DSP: Compliance monitoring has been a longstanding goal in the field, and the DentiTrac has some significant history – for the practicing dentist today, how does the DentiTrac help provide ways to improve care?
RB: The DentiTrac micro-recorder represents BRAEBON’s first next-generation wearable technology and DentiTrac is the first in the world to receive FDA clearance for use in certain oral appliances. It measures about 8 x 10 x 5 mm and is embedded inside of a sleep apnea oral appliance which is worn during sleep. DentiTrac addresses one of the two Achilles’ heels of oral appliance therapy: the need for objective measurement of treatment compliance. CPAP machines have had objective compliance measurement for years and this information is now required by insurance companies for CPAP reimbursement. For the practicing dentist, DentiTrac levels the playing field with CPAP and provides the objective therapy adherence information expected by both physicians and insurance companies. Dentists are now able to identify precisely when an appliance is placed into the mouth, when it is removed, hours of daily use, and determine percentages of supine and nonsupine head position. The data is uploaded from anywhere in the
world to the secure BRAEBON BridgeBuilder Cloud Portal where the information may be shared between clinicians. The DentiTrac merges oral appliance therapy with modern wearable electronics and represents a significant leap in the expansion of dental sleep medicine.
DSP: Once therapy has been started, dentists have choices to make about testing for effectiveness before the patient sees the sleep physician again, or managing to symptom relief then sending the patient back for testing. I’m curious what you, as a third party not directly involved in treating patients, thinks about these choices and strategies for patient care.
RB: I believe it is important for dentists to understand how to use home sleep testing devices properly and obviously I have always advocated using the same technology as used in sleep laboratories. After the patient receives a diagnosis from a sleep physician and there is an indication for oral appliance therapy, the dentist should perform a new baseline test on the patient prior to oral appliance delivery and use. This should be done regardless of whether the patient had a pervious PSG or home sleep apnea test (HSAT) because the apples-to-apples comparison is important. After adaptation and habituation and the oral appliance has been used for a matter of 3-4 weeks it is appropriate for a second test to be performed to determine oral appliance effectiveness. The baseline is now compared to the treatment result. This comparison dictates whether adjustment and further testing is needed. After both the patient and dentist are satisfied with results it is usually recommended that the patient is sent back to the referring physician to close
Top: MediByte recording device Middle: Richard Bonato in the BRAEBON lab Bottom: DentiTrac micro-recorder
Richard A. Bonato, PhD, MA, RPSGT, is the CEO and Co-Founder of BRAEBON® Medical. Richard has been involved in the study of sleep and its disorders since 1986. He has taught courses on Sleeping & Dreaming at Carleton University in Ottawa Canada and has lectured on sleep medicine and technology on four continents worldwide. He was the director of a sleep disorders laboratory and has been an author, co-author, reviewer, and examiner in various educational organizations within the sleep field, including the AASM, AAST, BRPT. Richard has served on the Executive Board of the Canadian Sleep Society.
INDUSTRYinterview By taking CPAP intolerant patients and turning them into successful OAT patients both the dentist and physician will look better in the eyes of the patient. the loop. Note that variations on this clinical workflow exist and it is important that a physician is involved at the beginning and end of the process and the dentist is managing titration with objective data. The relationship between physician and dentist are key and the office staff play a crucial role in its success.
DSP: You have a killer app testing user’s knowledge about Dental Sleep Medicine that should be part of every dentist’s learning path. How did that come about?
Somnomed appliance with DentiTrac micro-recorder
RB: I used to teach a third-year undergraduate program at Carleton University in Ottawa. One day it occurred to me that there are very limited educational resources available to dentists to help learn about dental sleep medicine. I revisited some of the university exam questions and adapted many of them for the Dental Sleep Medicine Study Guide in the hope of assisting dental health practitioners learn about the field. The free app is available for both Apple and Android platforms.
DSP: One of the biggest leaps for dentists treating sleep disorders is the need to work closely with physicians on every patient. BRAEBON spans the entire treatment spectrum – what do you wish every dentist would know about making this connection? RB: When first approaching sleep physicians tell them you want to make them look better by helping their CPAP intolerant patients. Too many dentists push OAT as better than CPAP, but in reality it may or may not be better for a particular patient. After this goal is reached broaden the relationship whereby the dentist becomes both a referral source and treatment destination. Dentists have a huge advantage over physicians in a number of patient related areas. First, patient recall. Patients have become ingrained to see their dentist twice a year and dental offices ha-
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bitually contact patients to recall them for a checkup. This is not typically done in physician offices; the average middle-aged male will go see their physician perhaps once every two years. Second, virtually every dentist has a front office staff member who knows every patient by name, the number of people in their family, age of the children, etc. This relationship can be leveraged to open conversations about snoring and sleep apnea. Third, hygienists are excellent touchpoints to explore sleep disordered breathing and a valuable first line of screening. BRAEBON has actually developed a free snoring and apnea poster for the hygienist’s operatory as a tool to start a conversation about sleep and breathing. For these reasons, dentists have a valuable and important role to play in the identification and treatment of sleep disordered breathing patients and can refer vast numbers of patients to sleep physicians. Every dentist needs to understand this. The key to the successful dentist – physician relationship is that the dentist wants to make the physician look better. By taking CPAP intolerant patients and turning them into successful OAT patients both the dentist and physician will look better in the eyes of the patient.
DSP: Education for dentists is a big part of what Dental Sleep Practice is about – in your lectures and interactions with dentists interested in this field, what do you find is the biggest gap in education? What would you like to see in dental sleep training?
RB: Ultimately, courses in nocturnal airway management should become part of the standard dental school curriculum. Many dentists attending weekend CE courses have little to no hands-on experience in OAT or sleep technology and are starting from the ground floor. Comprehensive courses are available but it requires a dedicated effort on the part of the clinician to embark on this journey towards a recognized dental sleep credential. In addition, office auxiliary staff play a very important role in the overall success of the office dental sleep program and auxiliaries should be encouraged to seek additional sleep training. A recognized dental auxiliary sleep credential would also be a valuable asset to help grow the field of dental sleep medicine.
IDTF Sleep Centers and Guidelines by Dr. Warren Schlott
n this rapidly changing world of medical insurance and American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine guidelines, understanding the difference between types of sleep labs is imperative. Independent Diagnostic Test Facilities (IDTF) and sleep centers provide many of the same services, but have concurrent distinct differences dictated by Safe Harbor, Stark, and anti-kickback laws. Knowing the differences can impact the dental sleep practice.
Sleep dentists are probably more familiar with independent diagnostic testing facilities. Most home sleep companies fall in to this category. IDTFs can provide sleep studies, be it a polysomnogram, split studies, titration studies, REM behavior disorders study (RBD), expanded EEG Sleep Recording (NPSG), multiple sleep latency test (MSLT), maintenance of wakefulness test (MWT), or a home sleep study. A sleep physician can read and interpret the sleep study and make treatment recommendations. However, no patients can be physically seen at the facility by the physician. This means a prescription for an oral appliance should not be provided. If a patient is seen by the interpreting physician, a violation of Medicare rules occurs and the IDTF can lose its Medicare number and will not be able to see any future Medicare patients. IDTFs are generally owned by business people who employ the interpreting physician. The IDTF bills insurance with the company’s national provider identification number (NPI). An IDTF can market their services directly to the public, physicians, and dentists with virtually no restrictions. IDTFs can test Medicare patients, but cannot provide any treatment for these patients. However, many knowingly circumvent this rule by having a friend or relative own the
durable medical equipment (DME) company. This is a clear violation of Medicare rules. If an IDTF does not test Medicare patients, it can probably be assumed that at some time in the past a Medicare violation has occurred and their provider number has been revoked. “Sleep centers” operate under different rules. Sleep centers are often owned by physicians, hospitals, and independent practice associations (IPAs). However, they can be owned by business people who hire a physician as a medical director. Oddly, insurance billing is under the physician’s NPI. Sleep centers can provide the same sleep studies as an IDTF. Historically, sleep centers generally favored PSG studies over home sleep studies. The supposition is that the physician will select the appropriate sleep study, PSG or HST, based on the patient’s health requirements. However, medical insurance companies are often insisting that home studies be performed unless the patient has co-morbidities. Even with the presence of co-morbidities, insurance companies are often overriding physician requests for a PSG and only paying for a home sleep study. Unlike an IDTF, sleep center physicians must see at least 40% of their patient’s pre and post study. Furthermore, at least 60% of the patients of the sleep center must be referred in by other DentalSleepPractice.com
MEANINGFULconversations physicians and dentists. Hence, at most only 40% of the patients tested can be self- generated. Sleep centers can test Medicare patients, but they can’t provide CPAP/BiPAP treatment for this group of patients. Regardless of which type of sleep center chosen for a sleep study, problems exist. It is the position of the AASM and the AADSM that sleep apnea is medical condition that should be managed by a sleep physician, and ideally be tested by an accredited sleep facility. Few would argue with this position. But this does create a conundrum. The sleep dentist should Many areas of the country only have an independent testing facility. As develop a relationship previously stated, these facilities do with a physician who not provide a sleep physician who can see the patient. In addition, the is willing to see and number of boarded sleep physicians manage sleep patients. who see patients is reportedly declining. A possible solution would be for the patient to be managed by a primary care physician. Unfortunately, the PCP has little to no education in sleep and most often has little desire or motivation to work with sleep patients. If the sleep dentist chooses to manage the patient, he or she is guilty of practicing medicine without a license, and furthermore, could possibly set themselves up for a malpractice lawsuit involving gross negligence...an event not covered by malpractice insurance. It would seem prudent to use a sleep center for testing, but sleep centers can be few and far between. Complicating matters, sleep centers often have long wait periods for sleep testing. So the million dollar question is what is the sleep dentist to do? Often patients will learn about oral appliance therapy from other patients, the internet, or sources other than their physician. If the dentist lives in a state that permits dentists to order a sleep study, and the dentist wishes to send the patient for a sleep study, he or she
Warren J. Schlott has been a practicing dentist in Brea, California since 1978. Dr. Schlott developed a thriving restorative dental practice and then in the early 2000’s developed a busy full time sleep practice. He has published numerous articles, and has helped other dentists establish sleep practices. Dr. Schlott is a member of the American Academy of Sleep medicine and is a Diplomate of the American Academy of Dental Sleep medicine. Dr. Schlott can be reached at firstname.lastname@example.org.
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needs to select an IDTF or a sleep center. At either facility the results should be interpreted by a boarded sleep physician. Before treatment should begin, guidelines suggest that the patient should be seen by a physician. If a sleep center has been used, the resident sleep physician there can see the patient. If an IDTF has been used, it would be logical for the patient’s primary care physician to see the patient. If an oral appliance is to be used, either physician can provide a prescription for oral appliance therapy. Medical insurance companies want to see the prescription for oral appliance therapy before payment is made. If the patient does not have a PCP, the sleep dentist should develop a relationship with a physician who is willing to see and manage sleep patients. Of course, insurance companies can complicate this by insisting the patient see only a physician in network. For this situation the patient will probably have to pay cash for services rendered, and this can be tricky as many patients believe all medical services should be paid by insurance. No one said life is easy. But there is more. Not all patients will consent to a follow-up study, or will not consent to CPAP therapy if oral appliance treatment fails. If a sleep center is used, a follow-up pulse ox study of appliance efficacy, performed by the dental office, can be forwarded to the sleep center. The sleep physician then should decide on the ifs and when of a follow-up sleep study, and if further treatment is warranted. This places the burden on the sleep center. It is recommended that proper documentation be made. If an IDTF is used, then it may be wise to test efficacy with a pulse ox and forward the results to the PCP or your physician friend, who upon review of the pulse ox can prescribe a follow-up study and add additional therapy if needed. It should be noted that Medicare does not pay for any sleep studies ordered by a dentist. If the patient does not consent, the sleep dentist should insist that the patient should sign documentation that states he or she is refusing protocol. There is no simple answer to the question of which should be used, an IDTF or a sleep center. The sleep dentist needs to understand the differences and act accordingly. Insurance coverage and mandates are intruding on the sleep practice and complicating matters. The sleep dentist also should understand the legal ramifications of his or her choices. Regardless, there is an obligation to treat sleepy patients and help them achieve better health. This means we have to find solutions.
The Healthy Start System Begins with Educating Your Community Behind every yawn is a child who deserves a Healthy Start!
dult dental sleep medicine has become a key component for many dental practices, focusing on the use of oral appliance or PAP therapy to address snoring and obstructive sleep apnea. While evaluating adults for sleep issues, it becomes apparent that many of their symptoms have been present since childhood, revealing a critical need to begin evaluations for sleep issues at a much younger age. Research shows that nine out of ten children suffer from at least one symptom of Sleep Disordered Breathing (Stevens et al, 2016). These outward symptoms include snoring, mouth breathing, allergies, bedwetting, and many more. The Healthy Start system addresses the underlying root cause of Sleep Disordered Breathing in children by combining comprehensive dental and health issues into one system, expanding the realm of dental sleep medicine to children. Between 4 and 12 years of age, 92.6% of SDB symptoms do not self-correct, while 30% actually worsen with age (Stevens et al. 2016). Healthy Start promotes proper oral habits, develops the airway, and creates proper jaw development, often resulting in straight teeth without braces. As dental professionals, we understand the urgency for treatment and the widespread impact that SDB has on children. The current condition, sometimes referred to as a “silent epidemic”, manifests itself in a variety of symptoms that can be easily overlooked, misdiagnosed, and, most unfortunately, left untreated. It is extremely important to reach these children before it is too late. Healthy Start provides more than a Band-Aid – it is a permanent solution if started early enough in a child’s growth and development. Four out of ten of the most common outward symptoms of SDB are directly related to dentistry. These symptoms include mouth breathing at night, snoring, tooth grinding, and mouth breathing during the day (Stevens et al, 2016). Our healthcare system simply does not have a comprehensive and permanent solution to this crisis. Dental professionals have the knowledge
Figure 1: Stations Telerama and Uno, Ecuador Healthy Start Editorial reaching parents in communities and available at Pediatricians’ offices.
28 DSP | Spring 2017
and tools needed to impact the development of a child’s airway, and Healthy Start has the solution to ensure permanent changes in a growing child to help unlock their potential and provide a more healthy life.
How do we educate the public?
Healthy Start has begun a media push to educate parents, teachers, nurses, doctors, and other professionals whose work brings them into contact with children. The message is simple – first arm the public with the knowledge of the outward symptoms and the need for a dental professional to evaluate the child for the responsible underlying conditions. Then, explain that treatment for these root causes can be addressed with a non-pharmaceutical, non-invasive, conservative method. Healthy Start has used TV, radio, newspaper, podcasts, and social media to educate the public. These media outlets have reached our providers across the country and allowed them to reach out to their communities, educating and stressing upon them the necessity of treating at an early age for a more permanent change. Social media venues are also being used to capture the public’s attention, specifically the Healthy Start Facebook Live presentations available to the general public. These virtual meetings are conducted by the Healthy Start team and their providers, showcasing an exciting and informative presentation. Invitations are distibuted to families, ADD/ ADHA awareness groups, teaching organizations, mommy bloggers, etc. RSVP’s to these live presentations are a launching pad to begin the conversation between dental professionals and parents. Healthy Start will provide surveys to participants prior to the live presentation. These Healthy Start Sleep Questionnaires inform parents of the 27 most prevalent outward symptoms of SDB, and ask them to observe and evaluate their child
STARTINGearly using a point system to determine severity of each symptom. The Facebook Live presentation occurs during the week and lasts approximately 45 minutes, and any question can be answered on or offline by the team members. The presentations are stored for the participants, and can be viewed at a later date or shared with friends and family members. This is the beginning of educating the public on sleep and breathing issues that we observe every day, but have not understood as a sign of a more serious underlying problem for children. Healthy Start has created an app that becomes an educational tool for both parents and other medical professionals to understand SDB, identify the outward symptoms, and find dental professionals who treat the underlying root cause. This app also aids in monitoring, motivating, rewarding, and documenting the progress of each patient. Parents can see the progress their child is making and visually monitor their facial development. This picture book that tracks the child’s progress can be used as a conversational piece for parents and family members to share with and educate other parents on Sleep Disordered Breathing.
How do we inform parents to understand the importance of sleep and teach them to identify the outward symptoms?
The Healthy Start Sleep Questionnaire is a tool that will aid the parent and dental professional in understanding and evaluating a child’s SDB symptoms. It identifies many of the most prevalent SDB symptoms and asks parents to rate these symptoms on a scale of 1 to 5 to determine severity. This questionnaire will be completed many times throughout the Healthy Start treatment to monitor changes and improvements in symptoms from the initial intake. With these forms, parents play a critical role in their child’s treatment by evaluating their child during the 30 days that the dental professional does not see the patient. The Healthy Start app is designed to monitor and document the child’s progress. It allows the treating dental professional to monitor each case and ensure that progress is occurring during the time between appointments. It is a valuable tool in the educational and treatment processes of Healthy Start.
Figure 2: Parent Magazine’s Healthy Start Editorial reaching parents in communities and available at Pediatricians’ offices.
How do we educate medical professionals?
It is critical that every medical professional involved with children be educated to identify the outward symptoms of Sleep Disordered Breathing, and the importance of referring these patients to their local dentists. Healthy Start is working with providers to create a “Dream Team” of medical professionals within their community who can work together as resources and team players in treating these children. Healthy Start hosts various dinner meetings, lunch and learns, and offers a vast variety of educational resources to aid our doctors in beginning the conversation with their local medical professionals. Currently there are ear nose and throat specialists, pediatricians, allergists, psychologists, and myofunctional and speech therapists working as a team to identify patients, evaluate children, monitor and document progress, and celebrate success. Healthy Start has reached out to these medical groups and attended lectures at their organization’s meetings, as well as made presentations at universities. It is vital to unite these various entities and reach out to our communities in order to educate and promote awareness, but more importantly to help build a provider’s “Dream Team” for the good of the children that we treat. We are on a mission to ensure that the entire medical community whether it be dentists, pediatricians, ENT’s, school nurses, etc. – along with parents and educators are able to identify the outward symptoms of SDB in children and understand the urgency for evaluation and treatment. It is about far more than cavities and straight teeth, it is about the future overall health and well-being of every child. To become a Healthy Start provider or to learn more about the system, please visit our website www.thehealthystart.com or call 844-KID-HEALTHY. DentalSleepPractice.com
Insider’s Guide to Home Sleep Testing for the by Randy Clare
Why is home sleep testing an important tool for sleep apnea treatment providers?
Perhaps the greatest challenge presented to the sleep apnea dentist is the fact that calibrating the oral appliance on an awake patient leaves you with, um,…a well-adjusted awake patient. The patient’s sleep apnea occurs unobserved at night and often one night is not exactly like another night. How then can the clinical team avoid over- and under-titrations (recognized as the major cause of treatment noncompliance)? Or in cases where the clinical team has decided that from a dental perspective, further appliance titration may compromise dentition or raise joint concerns, can they select a combination therapy with CPAP, positional therapy or weight loss to support a dental sleep apnea treatment plan? For years there was no option beyond full in lab polysomnogram (PSG). Even with all of its flaws it would be hard to argue that PSG isn’t the best way to examine sleep efficiency and quantitively evaluate sleep treatments (PAP is perfect for this model). The challenge for dentists is that the cost of attended studies is just too high to use PSG for titration, leaving home sleep testing as the only option. In the United States, insurance companies have begun to resist PSG in favor of home diagnostic for simple sleep apnea (their term, not mine). The great news is that these sleep diagnostic devices are giving dentists the ability to calibrate their appliances with a degree of accuracy that is similar to a CPAP titrated in the sleep lab. Table 1: In 1994 the American Academy of Sleep Medicine divided sleep diagnostic devices into 4 types Type I
Full attended polysomnography (>7 channels) in a laboratory setting
Full unattended polysomnography (> 7 channels)
Limited channel devices (usually 4-7 channels)
1 or 2 channels usually using oximetry as 1 of the parameters
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I feel that when comparing Continuous Positive Airway Pressure (CPAP) therapy with Oral Appliance Therapy (OAT) there are a few major differences generally centered on the initial calibration and ongoing titration. CPAP is titrated in lab with a sleep technician observing the sleeping patient while adjusting the CPAP pressure (often this is the only time the patient’s pressure will be calibrated). Oral Appliances, on the other hand, are titrated in the dental office using subjective patient or bed partner reports of snoring and sleepiness. A further complication is that as patients habituate to the appliance, muscles and ligaments relax and lengthen over the first few months of appliance wear. The patient may be 100% compliant with the appliance however the adjustment may no longer be adequate to maintain a patent airway. The dental relationship is such that the patient will receive an annual or biannual follow-up in order to manage their therapy. Home testing is an important part of this ongoing management of the patient’s sleep apnea. Clearly, using a home sleep diagnostic device gives the clinical team the opportunity to monitor, evaluate and adjust therapy to suit each individual’s needs. So how to select an HST device that will provide enough clinical value while at the same time be simple enough for the patient to use unattended in their home?
MEASURINGsleep What choices are available for sleep testing?
HST devices fall into two basic categories: Screeners and Home Sleep Diagnostic devices. A screener (type IV: 1 or 2 channels usually using oximetry as 1 of the parameters) is designed to provide enough information to identify that the patient has sleep disordered breathing but without enough information to establish a treatment pathway. Data driven discussions of sleep quality initiated by patients using portable and wearable sleep tracking devices is a very new trend in patient education. It goes without saying that the 1994 guidelines couldn’t predict this recent trend. The wearable sleep tracker device revolution has really started to get into the Type IV sleep screener arena with products that are steadily improving in accuracy and usability. The Apple Watch, for example, has a sophisticated heart rate monitor that is capable of acting as a pulse oximeter. This feature is turned off in the device so it is a product for the future. It remains to be seen if the Apple Watch will qualify as a level IV device. Based on the current guidelines and the computing power of the Apple Watch, the product may eventually have the feature set to reach Level III Home Sleep Diagnostic Device capability. Mattress manufacturers have started pursuing sleep quality data as a way of encouraging mattress choices based on style data. The Beddit 3 Sleep Tracker for example is a thin flexible sensor that lies across the mattress reading heart rate, breathing, temperature, humidity and even snoring. The folks at Sleep Number have released a product, Sleep IQ, that tracks sleep quality and connects to your favorite health and wellness apps. Is it possible that diagnostic mattresses will test the line between screener and diagnostic device? Today wearable devices like Jawbone, Fitbit or bedside monitors like the S+ from ResMed are designed to provide data about sleep efficiency and sleep quality. In general, these devices provide excellent sleep quality data. They cannot provide data that can be used to determine appropriate treatment pathways, and reliability and accuracy have been concerns. Wearable trackers may record the subject to be asleep when they are
simply sitting and watching TV. Clearly, there is still some work to do in this area. The big question when working with patients who use fitness trackers is how to use the reams of information that the patient presents with. To date there are no standards in the “wellness” field, which is where the trackers are rated by the FDA. Many patients realize that the sleep tracker is not a medical grade device however when compared to the fee for a sleep study some patients are willing to compromise on accuracy in favor of low cost. The clinician, however, cannot work with the data regardless of the amount of detail in the Excel spreadsheet. There just isn’t a lot of medical information to be gleaned from number of steps in a day or how restless the patient was over the last week. This presents a relationship dilemma requiring more skills and often more clinic time to merge the patient’s expectations with clinical reality. The key to success with level IV devices rests with moving the patient into a home sleep diagnostic device so that a therapy can be prescribed and delivered in a way that can be objectively monitored, titrated and managed. The Home Sleep Diagnostic Devices category (Type III limited channel devices 4-7 channels) is much more crowded and the decisions are complicated by insurance reimbursement and other factors. The guidelines used today were established by a task force in 2007 by the American Academy of Sleep Medicine (AASM). The guidelines for portable monitoring state that at minimum a device must record airflow, effort and oximetry, biosensors conventionally used for in lab PSG. This leaves a tremendous range of equipment capability, from units with few measured parameters like the ARES from SleepMed or the WatchPat from Itamar, to devices with 18 channels or more like the
Type III home sleep diagnostic device
Randy Clare is a sales and business development manager for Carefusion, and is based in Yorba Linda, California. He has been involved with the development and distribution of sleep therapy products including CPAP supplies, oral appliances and sleep diagnostic devices for over 20 years. He can be reached at email@example.com. For more information, follow thesleepandrespiratoryscholar.com.
MEASURINGsleep Nox T3 from CareFusion or the MediByte from Braebon. There are many more. The task force went on to determine that whichever device is selected, the raw data from the device should be output for scoring by a sleep technician and interpretation by a board-certified sleep physician. Devices at one end of the spectrum cannot share a common description with devices on the other end of the spectrum, yet most of the devices on the market meet these broad guidelines. So what are the key features that may make the difference to the dental clinician? In my opinion these criteria should be taken into account before committing to a home testing device. There are a number of opinions in the works that may affect how we all will work with these devices. Below is a top 5 list of things to look for (barring a change in guidelines) 1. Does the device meet or exceed AASM level III definition. This is a requirement for reimbursement. Insurance companies tend to use national regulatory bodies to establish standards. If the standards change, so too might the value of your equipment. I understand that there are new standards in the works and that some States have established their own standards and rules. Research your region or at minimum pick a national standard and follow that one. 2. Cost per test and cost per patient are terms that are used interchangeably? High pertest disposable costs may be acceptable in a diagnostic situation but in a titration protocol with a challenging case, several tests may be required. In that case, more reusable materials help keep costs down. Cost and complexity are the two biggest impediments to home testing in the dental office. Rule of thumb is the more you test, the better your outcomes. 3. Has the device been validated against PSG? a. PSG is the standard in sleep testing make sure the device you use has been thoroughly tested against the gold standard. b. I believe the key phrase in the AASM guidelines is “the airflow, effort and oximetric biosensors conventionally used for in-laboratory PSG should be used in PM.” (PM is Portable Monitoring or Home Diagnostic Testing). It the
32 DSP | Spring 2017
device you select uses methods that are not in use in sleep labs you should find out why. i. Guidelines suggest that a device should be able to use thermistor or pressure transducer for apnea detection and hypopnea detection respectively ii. Respiratory effort should be identified with calibrated or uncalibrated inductance plethysmography iii. Blood Oxygen should be detected using pulse oximetry with signal averaging time and accommodation for motion artifact. Plethysmography for arousal detection using Pulse Wave Analysis is new and should be considered iv. Snoring recorded using audio, not from the nasal cannula, per recent research v. Alternate channels should be available to collect data like Bruxism, ECG, EMG, EOG c. Scoring according to the AASM Manual for Scoring of Sleep and Associated Events is also a requirement, same as the PSG lab. 4. Body position is a critical parameter for dental patients and can mean the difference between treated and untreated for patients with compromised dentition or TMJ issues 5. Perhaps the most important aspect of any home sleep device is the following: “Can the patient attach the device and initiate a study in their home without problems?” If the patient does not return in the morning with a good test or the device was hot, loud, distracting or impossible to turn on, the study will not yield what is required. Retests cost money, especially if the per test price is high or if more office time is required to train the patient. Sleep labs who dispense HST often have 24-hour troubleshooting support – if you want to provide that from your dental office, choose a device that is least likely to generate a call. Patient satisfaction will suffer and, perhaps worst of all, staff confidence will take a hit. The optimum home sleep testing device to buy for your practice is the one that is out every night on patients, indispensably part of your sleep therapy.
September 14, 2017
Airway Summit White Flag Event II San Juan, Puerto Rico
For this event, weâ€™re asking you to set aside the focus on competition in the marketplace and serve patients by articulating a unified airway health message. Only 15% of airway/sleep disorders are diagnosed. Help address this major unrecognized public healthcare crisis by joining thought leaders, academies, organizations and corporations to create and bring a unified message to the public.
Foundation for Airway Health Pledge We want to fill our pledge rolls with practitioners of any modality that believe in the importance and priority of airway. Those interested can use this form or visit the Foundation website and find the pledge under the Healthcare Professionals tab. Thank for your support and partnership in our airway mission.
n I am committed to championing the recognition, diagnosis and treatment of airway disorders through collaboration,
awareness, research and education, and access to care. All patients seen in my office will be screened for airway/sleep problems and will be provided resources for diagnosis, treatment and referral.
I wish to be listed on the Foundation for Airway Health website as a referral resource for those seeking care for airway/ sleep problems. Airway is a priority.
Name nnnnnnnnnnnnnnnnnnnnnnnn Email nnnnnnnnnnnnnnnnnnnnnnnnn Send to Foundation for Airway Health, 355 Lexington Ave., 15th Floor, New York, NY 10017 or firstname.lastname@example.org
Objective Sleep Disorder Screening by Solveig Magnusdottir, MD, MBA
The Centers for Disease Control and Prevention (CDC) has stated that getting sufficient sleep is not a luxury – it is a necessity – and should be thought of as a “vital sign” of good health.1 This emphasizes the importance of sleep as an integral part of health and wellbeing, as sleep insufficiency is linked to motor vehicle accidents, industrial disasters, occupational errors and medical comorbidities, such as cardiovascular diseases, type 2 diabetes, depression and obesity as well as having reduced quality of life and increased mortality.2,3,4,5,6 Insomnia and Obstructive Sleep Apnea are the two most common sleep disorders. Now it is estimated that 12% of adults suffer from Obstructive Sleep Apnea (OSA) and that 80% of the patient population is undiagnosed.2,3 A recent European study found the prevalence in a middle-aged general population of 43.1% or 19% when looking at only moderate and severe OSA.7 Because of the potentially serious adverse consequences associated with untreated OSA, a prompt diagnosis and treatment is critical.2,3,5,8 Even though insomnia and sleep disordered breathing have a different etiology, individuals complaining of insomnia, even if they report no classic sleep breathing symptoms, are commonly diagnosed to be co-morbid with sleep disordered breathing, sharply contrasting their subjective perceptions about their awakenings. Frequent arousals may be classified as insomnia when they could be due to OSA, and consequently many patients who are actually suffering from undiagnosed and untreated OSA could be misclassified as having sleep-maintenance insomnia.9,10,11
The role of dentistry in sleep medicine
The primary methods that have been used for clinical screening for sleep disorders have mostly been limited to subjective questionnaires. This may have
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been for the lack of a practical physiological measure, although convenience, the little effort involved, and low cost may have contributed to the wide acceptance of patient-reported risk factors. Questionnaires are based on respondents’ own subjective evaluation of their sleep rather than physiological data. Though undoubtedly subjective estimates are of importance in OSA patients, sleepiness and daytime functioning vary widely between patients, as some report excessive daytime sleepiness while others do not.7,12 Even though questionnaires have been validated, when compared to physiological measures, their results have shown to be inconsistent and unreliable. For sleep apnea, there are high false-negative rates for questionnaire responses, and it is likely that, when relied upon as the sole determinant, most of the questionnaires will miss a significant proportion of patients suffering from sleep apnea.13,14,15 As the etiology and treatment for insomnia and SDB are different, it is important for clinical practice to adopt objective tests that are based on direct analysis of physiology to aid in the process of accurately identifying sleep complaints before treatment is initiated. In order to make that practical, it is
SLEEPstudy important that sleep medicine evolves to a multidisciplinary team approach. Dentists have an opportunity to play a vital role to serve this underserved population by expanding their practice to include sleep disorder screening. Dentists probably have a better opportunity to look at their patientsâ€™ airway than most other clinicians, providing an opportunity to improve the patient health and quality of life and strengthen the relationship. Using an accurate, efficient screening method that collects objective physiological data offers an opportunity for an accurate sleep disorder-screening test and, after diagnosis, test again to help optimize the treatment through device titration.
Tools and technology
The SleepImage system (www.sleepimage.com) is an FDA cleared and CE marked tool to screen for sleep disorders, presented through a HIPAA compliant cloud computing system. The data is analyzed automatically, using patented algorithms called Cardiopulmonary Coupling (CPC) and Cyclic Variation of Heart Rate (CVHR). The results can easily be shared through the cloud with a sleep physician who the dentist has partnered with for further evaluation, recommendations, and therapy decisions. Although constant positive airway pressure (CPAP) has been termed as the primary therapy for OSA, many patients have shown a preference for the use of a mandibular advancement device (MAD). The SleepImage system is based on collecting single lead ECG data using a small wearable device that also includes a high precision 3-axis accelerometer to obtain actigraphy, snoring and body position (Figure 1). The data is automatically analyzed to measure sleep quality based on coupling Heart Rate Variability16 and electrocardiogram derived respiration (EDR), to provide an operator-independent measure of sleep to guide clinical decisions and therapy management. This low cost solu-
LSU School of Dentistry in New Orleans
Sleep Disorders is One of the Continuumâ€™s Primary Areas of Emphasis The fourth continuum is an interactive, limitedattendance, one-year program for dentists designed around five weekend sessions in New Orleans. Session 1 starts June 2, 2017 and Session 5 ends May 12, 2018. This program is unique in that it begins with an indepth dissection of the head, neck, and airway over a 2-day period. After completing this continuum, participants should be better able to recognize, evaluate, diagnose, manage and refer patients with TMD, Sleep Disorders, and other types of orofacial pain.
An Interprofessional Faculty Continuum Directors are: Henry A. Gremillion, DDS, MAGD; A. Dale Ehrlich, MS, DDS, MAGD; Gary D. Klasser, DMD; and Christopher J. Spencer, DDS. Additional faculty in the following areas: Oral & Maxillofacial Surgery, Clinical & Health Psychology, Physical Medicine, Sleep Medicine & Neurology.
Now is the Time to Register There are a limited number of seats remaining in the fourth continuum. Tuition: $7,950. Registration Deadline: May 5, 2017. Call Robert M. (Bob) Leaman, MBA, Director of Continuing Dental Education, direct at 504.941.8404 to register. For a detailed course description and faculty biographies go to www.LSUOrofacialPainCE.org
Figure 1: SleepImage wearable device
Clinic Building, Room 4319 1100 Florida Avenue Box 142-B New Orleans, LA 70119-2799
SLEEPstudy tion is an opportunity to foster patient relationships and expand the practice area at the same time. The validation of the CardioPulmonary Coupling (CPC) and the cyclic variation of heart rate (CVHR) utilized clinical Polysomnography (PSG) recordings as the standard upon which it was compared. Simultaneous SleepImage and PSG It is ideal to serve the vast recordings were performed, validatpopulations of patients ed and published. The data confirms that both systems were correlated with undiagnosed and as a valid clinical measure to idenuntreated sleep disorders tify the presence of sleep disorders (www.sleepimage.com/research). by taking the “guessing” While the CPC technology does not have a direct measure of SpO2 out of identifying patients. or generate an Apnea Hypopnea Index (AHI), it inherently presents information useful for clinical decision making to identify sleep disorders, whether for screening purposes or to track treatment efficacy. Blood oxygen saturation levels are used as one of many measures of health. One association is with paused breathing is a reference point in apnea detection, but cannot be used to determine the presence or severity of apneas by itself, as it can drop for various health reasons not associated with apnea. The AHI consists of counting events over a time period. To make the count as apnea, breathing must pause for at least 10 seconds and be associated with a decrease in blood oxygenation, so if breathing is paused for 9
seconds, it is not counted as apnea. Hypopnea is not considered clinically significant unless there is 30% (or greater) reduction in flow lasting for 10 seconds or more and when there is 4% (or greater) desaturation in O2 levels, or if it results in arousal or fragmentation of sleep. The reality is that it can consequently be quite random if an event is scored as apnea, hypopnea or is not considered “severe” or “long” enough to make either category. It is driven by a manual and, to some extent, subjective evaluation of each event. The Sleep Apnea Indicator (SAI) on the other hand is based on a direct physiological measure of cardiovascular activity, looking for events of bradycardia followed by a sudden tachycardia at the end of an apnea event, a known condition based on cyclic variation of heart rate. There is no manually driven decision matrix to decide if the event is “severe” or “long” enough in seconds to make the count as it is not based on counting events. The Autonomic Nervous System does not care if a person stops breathing for 9 or 10 seconds; the severity and strain caused by it negatively affects the person’s cardiovascular system. The SAI reports all activity as a percentage of the overall sleep period and is fully automated. In summary the SAI presents events that are a reflection of the body’s physiological reaction to a drop in blood oxygenation. The parameters of the SleepImage system make it possible to identify sleep disordered breath-
Dr. Solveig Magnusdottir is the Chief Medical Officer of SleepImage. She became associated with sleep medicine through her investment and work with SleepImage to expand the awareness and use of sleep quality measurements for patients, as she believes that sleep is the most important part of our lives for improved health and wellbeing. Dr. Magnusdottir, a native of Iceland, started out her medical career in internal medicine and during that time spent a year with the British Armed Forces during the Bosnian war. Back in Iceland, she trained in family medicine and practiced as a family physician until she moved to the United States where she currently lives and works. Through her career she experienced how sleep deprivation and untreated sleep disorders have a devastating impact on health and wellbeing, from how sleep deprivation causes accidents in daily life and affects situations in the battlefield to how common untreated sleep disorders were during her years in family medicine. Dr. Magnusdottir is promoting that sleep disorders should be treated like other chronic diseases, with regular check-ups based on objective measurements of sleep quality. It needs to start in primary care settings, like dentistry with a multidisciplinary approach. Dentists have a unique opportunity to make a positive impact to help get their patients on the path to finding the right treatment or therapy.
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SLEEPstudy ing and differentiate between obstructive and non-obstructive sleep apnea.
While use of the SleepImage system in a dental practice is not reimbursable, the cost of using it is very low and the value of the output is very meaningful. It provides an easy to understand report for the patient with metrics that are easy to track during therapy measured against the baseline screening test. For communicating with sleep physicians, the dentist can be very confident of recommendations given to the sleep physician based on the screening test, as it is an objective measure of physiology that has a very high correlation with PSG tests, yet it is not a test of parameters that are subject to the rules of sleep diagnostic tests that require a sleep physician to interpret the results. The system is fully automated and designed to provide operator-independent output that is intuitive for a multidisciplinary team approach. It is ideal to serve the vast populations of patients with undi-
agnosed and untreated sleep disorders by taking the “guessing” out of identifying patients who would benefit from a diagnostic assessment with a sleep physician.
Multidisciplinary team approach
The SleepImage system is an easy to use clinical solution. A multidisciplinary team approach starts with a screening test performed through the dental office, followed by a clinical diagnosis by a sleep physician on the team. Those patients who have untreated OSA are offered therapy choices and for many MAD therapy offered through the dental office is the therapy of choice. But it does not stop there, as a key to successful therapy is that it benefits the patient in subjective and objective improvements. Follow-up tests with therapy can be administered by the dental practice. These results can be shared over the cloud with the sleep physician on the team and the patient is much more likely to stay compliant on therapy if he/she feels the benefit of the therapy.
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SLEEPstudy Workflow and metrics
The SleepImage system is operator-independent with metrics and workflow suggestions based on automatic analysis of ECG data collected during sleep. The primary metrics can be explained as follows: • Sleep Quality Index (SQI) is a summary index of sleep duration, sleep stability and sleep pathology.17,18,19,20,21
• Sleep Apnea Indicator (SAI) is a measure of Cyclic Variation of Heart Rate (CVHR) detecting oscillations in cardiac intervals that are often associated with prolonged cycles of sleep apnea. 22,23 • Stable sleep (HFC) is driven by the parasympathetic nervous system (Rest & Digest), dominated by integrated activity around individual respiratory cycles. Heart rate slows down and speeds up in synchrony with respiration. Characterized by stable breathing, high vagal tone and non-cyclic alternating pattern on the electroencephalogram, high delta power and blood pressure dipping, stable sleep may be considered to be “effective” NREM sleep. Effective sleep enables the normal functions of sleep, such as recovery and restoration processes. • Unstable sleep (LFC) is driven by sympathetic nervous system (Fight & Flight), it is dominated by low frequency cycling of respiration and heart rate, with tidal volume fluctuations, cyclic variation in heart rate, a cyclic alternating pattern, electroencephalogram low delta power and stable (non-dipping) blood pressure. Unstable sleep may be considered “ineffective” NREM sleep, sleep that fails to accomplish the normal functions of healthy sleep. • Using SQI together with SAI and biomarkers for sleep pathology called elevated Low Frequency Coupling broad-band (eLFCbb) and elevated Low Frequency Coupling narrow-band (eLFCnb), it is possible to identify the presence of SDB and categorize it as either obstructive or non-obstructive sleep apnea.17,18,19,20,21 The workflow to identify the presence of sleep disorders, using the SleepImage system can be demonstrated in Figure 2.
Figure 2: Suggested workflow protocol for objective sleep screening
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The subject is a 57 year old male, BMI>35, with a history of daytime somnolence, snoring and waking up gasping or choking for air. In addition to the above-mentioned metrics, the SleepImage system provides a spectrographic picture of the sleep parameters. A frontal view of the spectrogram presents
SLEEPstudy the frequency ranges on the y axis and the sleep timeline on the x axis, while the 90° view presents a cross-sectional view of the frequency bands on the x axis and paints the peaks that are indicative of periodic breathing or non-obstructive sleep apnea as red peaks that tend to line up in a narrow band (eLFCnb), while obstructive sleep apnea footprint can be seen as white peaks that stretch across a broad frequency band (eLFCbb). Metrics before treatment: • SQI=31 • SAI=35 • eLFCbb=27% • eLFCnb15% • Snore count 1360 The frontal view of the spectrogram before treatment indicates a lack of Stable sleep (HFC) with long periods of Unstable sleep and both eLFCbb and eLFCnb (Figure 3).
Table 1: Summary of SleepImage parameters before and with therapy Test before therapy
Test with therapy
8 hours 4 minutes
6 hours 56 minutes
Unstable sleep may be considered “ineffective” NREM sleep, sleep that fails to accomplish the normal functions of healthy sleep. The 90° view of the spectrogram before therapy further confirms that the patient is suffering from complex sleep apnea, narrow red colored peaks indicative of central events and the white peaks ranging across the frequency band indicative of obstructive sleep apnea events (Figure 5). Metrics with treatment: • SQI=49 • SAI=0 • eLFCbb=25% • eLFCnb=0% • Snore count 101. The frontal view of the spectrogram with therapy displays slight improvements in Stable sleep (HFC), limited improvement in Unstable sleep, with eLFCbb still above and the SQI still below expected value indicative that there is room to optimize therapy with better titration of the device (Figure 4). The 90° view spectrogram with therapy confirms that the central and obstructive component of the sleep apnea has been successfully treated, while there is still room
Figure 3: Spectrogram, frontal view, before treatment
Figure 4: Spectrogram, frontal view, with treatment
Figure 5: Spectrogram, 90º view, before and with treatment
to optimize the therapy by increasing stable sleep (Figure 5).
For this patient, although his sleep apnea has been treated to a degree of success (SAI and eLFCnb are both within expected values) his sleep quality and eLFCbb are still not within the expected values. This is a classic case of what research has shown to occur in more than 50% of sleep apnea therapy cases, namely that the patients stop using the therapy as they are is not feeling the benefit. This is an opportunity for dental practices that see their patients on a regular basis for 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
check-up and cleaning services to add sleep quality tests that can build a lasting relationship of happier and healthier patients. These tests will: • Identify the presence of sleep disorders for patients who have not been previously diagnosed using a simple test that is objective and scientifically tested to motivate them to seek additional diagnoses and treatment. • Help patients who are on MAD therapy for OSA optimize their treatment with regular device titration based on repeated sleep quality tests.
Centers for Disease Control and Prevention. Sleep and Sleep Disorders: Available at (www.cdc.gov/sleep/index.html.) Assessed January 2017. Frost & Sullivan. Hidden Health Crisis Costing America Billions. American Academy of Sleep Medicine 2016 (http://www.aasmnet.org/Resources/pdf/sleep-apnea-economic-crisis.pdf). Assessed January 2017. Peppard PE, Young TE, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013 May; 177 (9): 1006-1014. DOI: 10.1093/aje/kws342. US Department of Transportation, national Highway Traffic Safety Administration, national Center on Sleep Disorders Research national Health and Blood Institute. Drowsy driving and automobile crashes (National Highway Traffic Safety Administration Web Site). Available at (http://www.nhtsa.gov/people/injury/drowsy_driving1/Drowsy.html#NCSDR/NHTSA). Assessed January 2017. Rosekind MR, Gregory KR. Insomnia risks and costs: health, safety, and quality of life. Am J Manag Care 2010 Aug; 16 (8): 617-26. U.S Department of Health and Human services. Healthy People 2020. 2015. Office of Disease Prevention and Health promotion. Washington Dc. (https://www.healthypeople.gov/) Accessed January 2017. Arnardottir ES, Bjornsdottir E, Olafsdottir KA, Benediktsdottir B, Gislasson T. Obastructive sleep apnea in the general population: highly prevalent but minimal symptoms. Eur Respir J 2016 Jan; 47(1): 194-202. PMID: 26541533 DOI:10.1183/13993003.01148-2015 Dong JY, Zhang YH, Qin LQ. Obstructive sleep apnea and cardiovascular risk; Meta-analysis of prospective cohort studies. Atheroscl 229(2); 489-95. http://dx.doi.org/10.1016/j.atherosclerosis.2013.04.026 Krakow B, Ulibarri V, Romero E, Mclever N. A two-year prospective study on the frequency of co-occurrence of insomnia and sleep-disordered breathing symptoms in primary care population. Sleep Med. 2013; 14: 814-23 Bianchi MT, Williams KL, McKinney S, Ellenbogen JM. The subjective-objective mismatch in sleep perception among those with insomnia and sleep apnea. J Sleep Res 2013 Oct; 22(5): 557-58. DOI:10.1111/ jsr.12046 Bianchi MT, Goparaju B, Moro M. Sleep apnea in patients reporting insomnia or restless leg symptoms. Acta Neurol Scand. 2016 Jan; 133(1): 61-7. DOI:10.1111/ane.12439 Vakulin A, Catcheside PG, Baulk SD, Antic NA, Banks S, Dorrian J, et al. Individual variability and predictors of driving simulator impairment in patients with obstructive sleep apnea. J Clin Sleep Med 2014; 10(6) 647-55. DOI:10.5664/jcsm.3792 Westlake K, Plihalova A, Pretl M, Lattova Z, Polak J. Screening for obstructive sleep apnea syndrome in patients with type 2 diabetes mellitus: a prospective study on sensitivity of Berlin and STOP-Bang questionnaires. Sleep Med 2016; 26:71-76. PubMed: 27613528 DOI: 10.1016/j.sleep.2016.07.009 Pereira E, Driver H, Stewart S, Fitzpatrick M. Comparing a Combination of Validated Questionnaires and Level III Portable Monitor with Polysomnography to Diagnose and Exclude Sleep Apnea. Journal of Clinical Sleep Medicine 2013; 9(12): 1259-66. DOI:10.5664/jcsm.3264 Ramachandran SK, Josephs L. A Meta-analysis of Clinical Screening Test for Obstructive Sleep Apnea. Anesthesiology 2009; 110:928-939. DOI:10.1097/ALN.0b013e31819c47b6 Jeffrey Hindin. Dental sleep Practice. Accessed January 2017. (https://dentalsleeppractice.com/articles/expanding-airway-education-heart-rate-variability-autonomic-nervous-system) Kryger, Roth, Dement. Principles and Practice of Sleep Medicine 6th Edition:2016 (166); 1615-1623 (https://www.us.elsevierhealth.com/principles-and-practice-of-sleep-medicine-9780323242882.html) Thomas RJ, Mietus JE, Peng CK, Goldberger AL. (2005) An electrocardiogram-based technique to assess cardiopulmonary coupling during sleep. Sleep; 28:1151 [PubMed: 16268385] Thomas RJ, Mietus JE, Peng CK, Guo D, Montgomery-Downs H, Gottlieb DJ, Wang CY, Goldberger AL. Relationship between delta power and the electrocardiogram-derived cardiopulmonary spectrogram, possible implications for assessing the effectiveness of sleep. Sleep Med. 2014; 15:1.125 Thomas RJ, Mietus JE, Peng CK, Gilmarin G, Daly RW, Goldberger AL, Gottlie DJ. Differentiation obstructive from central and complex sleep apnea using an automated electrocardiogram-based method. Sleep, 2007; 30(12); 1756 A Clinician´s Guide to SleepImage. Assessed January 2017. (http://www.sleepimage.com/getmedia/7102476f-7236-4668- 92b5-8befca0cf35f/A_Clinicians_Guide_to_SleepImage.aspx) Mietus JE, Peng CK, Ivanov PC, Goldberger AL. Detection of obstructive sleep apnea from cardiac interbeat interval time series. Comput Cardiol. 2000; 753 Guilleminault C, Connolly S, Winkle R, Melvin K, Tilkian A. Cyclical variation of the heart rate in sleep apnea syndrome: mechanisms, and usefulness of 24h electrocardiography as a screening technique Lancet. 1984; 1:126
40 DSP | Spring 2017
How Much Does a Sleep Dentist Need to Know? by Samuel J. Higdon, DDS
f asked, most dentists would describe â€œTMJâ€? as a pain problem. There is little doubt that pain is usually what causes a patient to seek treatment. But if dentists limit their understanding to see only pain, then no pain would equal no problem, leaving both patient and dentist open for negative consequences of this narrow view. For any dentist, whether or not they choose to treat TMD in their practice, this level of understanding of TMDs falls far short of meeting our professional obligation to the public with regard to these disorders. Having devoted over 30 years of practice to managing TMJ disorders, I can assure you that if these disorders are recognized in their early stages, perhaps even before the patient is aware of pain, the potential to treat them in a definitive manner is greatly enhanced. Early detection and treatment minimizes the probability of the patient experiencing recurring and persistent TMD in their life.
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For years, several professional organizations, including the ADA,1, 2, 3, 4, 5 have recommended that all dentists screen their patients for TMDs. However, my experience suggests that very few dentists comply with these recommendations. Perhaps one of the reasons for this is that most dentists do not really know what it means to screen their patients for TMDs or how to incorporate a screening procedure into their practice. In a later article, I will discuss the screening procedure, including a protocol for its use. But I also suspect that many dentists would prefer to believe that they can wait until the patient describes a specific TMD complaint before they need to be concerned and decide to do something about it. In my view, this is professionally short sighted. But because of the minimal training that most dentists received while in dental school, most are poorly prepared to take a more progressive approach to the identification and management of TMDs in their early stag-
TMDseries es. As with caries, periodontal disease, and heart disease, identifying and treating TMDs in their incipient stage is the best assurance of a favorable long-term prognosis. For the dentist providing mandibular advancement devices (MADs) for the treatment of sleep disordered breathing conditions, the stakes are much higher regarding the need to identify potential, even nonsymptomatic, TMD problems prior to initiating MAD treatment. Although the development of a TMD complaint in response to MAD treatment may occur infrequently, recognizing the potential for this to occur is extremely important for the sleep dentist.
Screening for TMD Signs and Symptoms — What Are We Looking For?
A screening history and exam can identify both muscle and joint conditions that have the potential, in response to MAD treatment, to evolve into significant clinical problems. A TMD screening history, if used routinely with all patients in any type of dental practice, can identify those patients who require a screening exam. However, because of the increased potential for triggering a TMD with MAD treatment, a screening history, alone, is not sufficient for SDB patients and both a history and a screening exam are always indicated. The objective of a screening history and exam is to rule in or rule out potential problems. TMD signs, even before the patient is aware of symptoms, may involve only muscles. However, there is clearly a need to rule out any potential for involvement of the temporomandibular joints. If early signs of joint involvement are present, even before there is joint pain, it is necessary to determine if these signs represent a potential to develop into a clinical problem involving the temporomandibular joints with MAD treatment. A PDF copy of a screening history and exam form is available for download at http://medmark.link/2iEiYNe. A discussion of this form and its implementation into your practice will be a part of a future article.
Muscle Signs in Screening History and Exam
Although the patient may not have made an association of certain signs suggesting involvement of the masticatory muscles, on the screening history muscle involvement is
strongly suggested when the patient indicates that they have temporalis headaches, tiredness when chewing or difficulty holding their mouth open wide at dental appointments. On a screening exam, tenderness to palpation of the temporalis and masseter muscles will confirm that the masticatory muscles display hypertonicity and tightness, if not overt pain. These findings may be suggestive of clenching or grinding of the teeth but it would be naive to assume that this is the only possible explanation. Certain occlusal conditions, in particular a lack of occlusal stability, are often involved with muscle complaints, even in the absence of clenching and grinding. A full discussion of occlusal issues is beyond the scope of this series of articles. In response to MAD treatment, muscle symptoms (in the absence of any TM joint signs) may not worsen. However, in a patient who is a clencher or grinder, where significant muscle tenderness is found on examination, the unavoidable increase in vertical dimension, due to the thickness of the MAD, may contribute to increased bruxism and potentially increased muscle symptoms. For this reason it is usually advisable to consider minimal thickness when choosing a MAD. In a patient with a deep, tight bite, the amount of vertical opening necessary to allow the advancement of the mandible using a MAD will, unfortunately, sometimes require a fairly significant increase in the vertical dimension and, thus, a fairly thick MAD. This presents a clinical dilemma that must be considered on a case by case basis. It has been advocated by some that a combination of mandibular advancement together with some degree of increase in
Clinical dilemmas must be considered on a case by case basis.
Dr. Samuel J. Higdon’s practice, for over 30 years, has been devoted to the non-surgical management of TMDs and other problems related to the function of the jaw system. He practices in Portland, Oregon. He is the author and illustrator of, “Illustrated Anatomy of the Temporomandibular Joint in Function/Dysfunction”, an education aid for both patients and dental professionals regarding the unique functional anatomy of the TMJs. It is available at TMJAnatomy.com. He is also the co-author of an educational website related to temporomandibular disorders for professionals and patients, at DrawbridgeDDS.com.
vertical dimension (beyond the minimum necessary for the appliance itself) may contribute to opening the airway. Currently, the literature supporting this approach is limited but suggests that an increase in vertical dimension for this purpose is not indicated.5, 6
Temporomandibular Joints Signs in Screening History and Exam
When there is retrodiscal tenderness of the temporomandibular joints, in response to palpation through the ear canal or with joint loading, even if the patient is relatively unaware of joint pain, there is a particular need to be cautious with MAD treatment. This pain, alone, suggests that the TM joints have sustained some degree of structural change that has allowed loading on retrodiscal tissues which, in an anatomically-normal joint, would not occur and would not result in pain. What this may mean, as related to MAD treatment, can vary depending on other findings involving the joints; in particular, the presence and nature of joints sounds, the patientâ€™s range of motion, and whether they experience pain with certain jaw movements. As background information regarding what all of these findings may mean, a thorough understanding of both normal TMJ anatomy and variations in dysfunctional TMJ anatomy is extremely important. When the signs and symptoms include the combination of â€œpain and restricted movement,â€? the pain must be treated first before an adequate differential diagnosis of the cause of the restricted movement can be made. Initial assessment of range of motion is essential, not simply how far the patient
44 DSP | Spring 2017
can open, but also their ability to move the jaw laterally and protrusively. The ratio of jaw opening vs. lateral movements in a healthy system is approximately 6:1.8 In a healthy system, bilateral movements would be expected to be approximately equal. Lateral movements of less than 8 mm are generally classified as restricted.9,10 The extent of protrusion ( i.e. condylar translation) provides important information on the mobility of the joints. When opening is restricted but lateral and protrusive movements are within normal limits, the limitation on opening can be a result of elevator muscular tightness. If this tightness is effectively treated, the opening range of motion may return to normal limits. The difference between the terms, deviation and deflection, and their significance needs to be understood (Fig. 1). Deviation on opening refers to a movement away from the midline but a return to midline at full opening. Deflection refers to a movement away from the midline that remains to the affected side at full opening. A deflection may be an indication of a disc displacement without reduction (joint locking) (Fig. 2). A deviation can be caused by a momentary interference (catching) of the disc that then is overcome (releases), usually accompanied by a click, and allowing a return to the midline. Evidence of nonsymptomatic catching and locking of a TM Joint should be seen as a red flag when considering MAD treatment. These anatomical variations will be addressed in greater detail in a future article. In some cases, such as nonsymptomatic clicking and popping of the joints, there may be minimal consequences in response to
TMDseries MAD treatment. In other cases, with similar findings, extreme caution may be indicated. Hard tissue crepitus or grinding sounds, if accentuated when opening the jaw from a protruded position, may be a contraindication for advancement of the mandible with a MAD. The clinical judgement required to make an appropriate clinical decision regarding MAD appliance selection can be largely dependent on experience in dealing with temporomandibular disorders. Assuming that many dentists who are providing MAD treatment for sleep disordered breathing disorders
lack this depth of experience, it is all the more important, following a careful screening of the patient, that the findings of the history and exam be explained to the patient as thoroughly as possible regarding the potential for the development of TMD problems, including pain in response to MAD treatment. In the next article, I will be explaining the use and implementation of the screening history and examination. In a future article, the findings related to a TMJ examination and the variations in TMJ anatomy will be discussed in much greater detail.
ADA — Clark GT: The President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders. JADA 1983 ADA — McNeill C, Mohl ND, Rugh JD, Tanaka TT: Temporomandibular Disorders, Diagnosis, Management, Education, and Research JADA 1990; 120(3):253, 55, 57 3. Academy of General Dentistry — Howard WW: Craniomandibular Disorders: No One Responsibility? Gen Dent 1987; 35(4):260 4. American Academy of Orofacial Pain — Okeson: Orofacial Pain Guidelines for Assessment, Diagnosis and Management. Quintessence 1983 5. American Academy of Craniofacial Pain — Talley RS et al: Standards for the History, Examination, Diagnosis and Treatment of TMD: A Position Paper. J Craniomand Pract 1990; 8(1):60-77 6. Pitsis J, Darendeliler A, Gotsopoulos H, Systole PA: Effect of Vertical Dimension on Efficacy of Oral Appliance Therapy in Obstructive Sleep Apnea. Am J Respir Cit Care Med — 2002; 166 (6): 860-864 7. Vroegop AV, Vanderveken OM, Van de Heyning PH, Braem MJ. Effects of vertical opening on pharyngeal dimensions in patients with obstructive sleep apnea. Sleep Med. 2012;13:314–16. 8. Dijkstra PU, DeBont LGH, Stegenga B, Boering G 1995 Temporomandibular joint mobility assessment: a comparison between four methods. J Oral Rehabil 22: 439-444 9. Ingervall B, Range of movement of mandible in children. Scand J Dent Res. 1970;78(4):311-322 10. Okeson JP, de Leeuw R. Differential diagnosis of temporomandibular disorders and other orofacial pain. Dent Clin North Am 2011 Jan;55(1): 105-120. doi: 10.1016/j.cden.2010.08.007.
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WRITTEN IN STONE by Rose Nierman CEO Nierman Practice Management
o you know how to interpret the sometimes cryptic codes and messages medical insurance payers provide on statements? Although it can be daunting at first, cracking these codes is detective work at its best and is a skill set that we’re all proud of…especially when we can help patients get lifesaving treatment and have their medical benefits kick in! The main goal is to avoid denials although some denials are out of our control when the insurer enters incorrect information. There are, however, many things that you can do to reduce the rate of errors and increase your reimbursements including being as knowledgeable as you can about the codes, processes, records needed, and medical insurer updated policies.
Many denials can be avoided Success truly depends on what you do upfront! It’s easier to bombard the insurance company with records showing medical necessity than to deal with an appeal. While insurance companies may not reveal all of their secrets, they are required to spell out the documentation needed to process Dental Sleep Medicine (DSM) and Temporomandibular Joint Disorder (TMD) claims. And once you know what’s needed, your clinical notes should be generated in a format that documents the medical necessity of the services. Taking the time to place an insurance benefit phone call to inquire about what’s needed is important, too. For oral appliances for sleep apnea this typically includes the
46 DSP | Spring 2017
excessive daytime sleepiness score (Epworth Sleepiness Scale at 10 or higher), a physician Rx, notes from your patient examination outlining subjective symptoms, objective exam findings, your assessment and plan (SOAP format) and a copy of the sleep study. Some questions to ask during the insurance verification call: • Does the claim need to be preauthorized? If so, may we FAX the clinicals? • Do we need to provide a CPAP intolerance affidavit signed by the patient (including if the patient declined PAP therapy)? • Is a “PDAC” Medicare cleared appliance needed? Some insurers are observing PDAC guidelines which refers to the Pricing, Data Analysis and Coding contractor who publishes the list of cleared appliances. • What is the reference number for this call? • When applicable; Is combination therapy covered (increasingly more insurers are covering both the oral appliance and PAP)
Denials are not written in stone There are several different reasons as to why claims or pre-authorizations are denied, but whatever the reason, a denial is not written in stone! More than half of denied claims are overturned with one appeal. Appeals can be started with a specific form, in some cases, by phone and/or by a Peer-to Peer conversation with the medical director.
PRACTICEmanagement In the world of medical commercial insurance, there is no standardized “error code library,” so take the time to study the Explanation of Benefits statement (EOB) in order to respond specifically to each “error or denial code”. It does take some skill to investigate each denial reason, but it’s our job to do the detective work and reap the rewards of a job well done.
Demographics. Demographics. Demographics.
There are many things that you can do to reduce the rate of errors and increase your reimbursements.
Demographics are the details on a patient’s insurance card and also provider detail such as Tax ID and NPI numbers. Demographics can be a problem area and should be checked and rechecked. When registering the patient ask these questions: • Is your name the same as on your insurance card? For instance, do you go by Jon or Jonathan? • Do you have original Medicare (the red, white and blue card) or a Medicare HMO? • Is your coverage active? (often the employer changes the insurance and you may be handed the older insurance card) • Is your address current? • Can I please see the back of your card? (so you can scour the card for group numbers and the insurance contact information).
Provider demographics – Information essentials
NPI, Tax ID, and taxonomy! All important for medical billing because the insurance carrier needs to know your specific creden-
Rose Nierman, RDH, is the Founder and CEO of Nierman Practice Management, an educational and software company (DentalWriter™ and CrossCode™ Software) for Medical Billing for Dentists, TMD and Dental Sleep Medicine advanced treatment, and co-founder of the SCOPE Institute, a non-profit educational organization dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry. Rose and her team of clinical and medical billing experts can be reached at Rose@Dentalwriter.com or at 1-800-879-6468.
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tials in order to provide reimbursement. If you’re already receiving medical insurance reimbursement, the cardinal rule is to avoid making any changes in your identifiers without contacting the insurance company first. This is to ensure that you continue to be a known provider with that insurer. When in doubt, contact the insurer to inquire about your identifiers on file. Recently, some insurance companies started requiring a Type 2, organizational National Provider Identifier (NPI) for oral appliance reimbursement. And some insurers now require a number called a taxonomy code, typically placed in the billing information section of the claim. A taxonomy code defines your type of organization, such as dentist. This is the web site doctors go to register for their NPI 1 OR NPI 2. The provider will also get a taxonomy code here as well: https://nppes.cms.hhs. gov/NPPES/Welcome.do.
Timely follow up
Billing administrators get to know how to interpret the sometimes cryptic codes and messages the insurance payers provide on the EOB. The sooner you determine the reason for the delay and follow up on a claim, the more likely it is to be paid. In healthcare claims processing, time is an enemy to getting reimbursed. Most insurance payers have timely filing limits, so identifying problems and resolving them promptly is crucial. Most insurance representatives will try their best to help you connect with the right department for appeals. And again, always ask for a reference number for any phone contact.
Patients can also make waves
If other avenues fail, a letter from a patient may catch the attention of an insurance manager. Patients are more proactive and knowledgeable about their healthcare than ever before. If a patient takes the time to call or write a letter to an insurance company manager or executive, then the insurance company may take notice, especially when you have provided the patient with copies of the documentation that you had provided. Many denied claims, just through good communication and by providing more information, can be resolved. And keep in mind: Your patients need your help. It’s worth the effort!
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The word is out... DSP is a huge success! Dental Sleep Practice magazine is the sleep apnea publication for dentists — encompassing everything they need to know to properly treat this condition. And subscribers will be able to earn up to 2 hours of AGD PACE CE in every issue by completing questions about an article and submitting to our website. Sponsored by Medmark and Seattle Sleep Education.
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ADA Updates Guidelines to Protect Patients Under Sedation by Geoffrey Archibald, DDS
hen new patients come into my office, I always ask if they have been diagnosed with sleep apnea. It’s an important piece of their medical history that I need to know before I begin sedation. If a patient has been diagnosed with sleep apnea, I will treat him or her differently and monitor them more closely. A few years ago, a patient said no when I asked her this question. I gave her our initial dose of anesthesia, and she completely stopped breathing. My assistant and I followed protocol, taking steps to get her breathing again. We were just about to get the reversal agents when the woman opened her eyes, took a nice, deep breath and said, “I am so relaxed.” It’s a good thing she was relaxed, because I definitely was not! It turns out that patient was later diagnosed with sleep apnea. Situations like these are rare; however, they can have drastic outcomes. Patients with breathing problems,
50 DSP | Spring 2017
like sleep apnea or asthma, are some of the most likely to stop breathing under anesthesia. With an estimated 22 million Americans¹ suffering from sleep apnea, and as many as 80% of those cases undiagnosed, it’s imperative that sedation dentists are aware of the risks. At the time that patient stopped breathing in the chair, I was not using a carbon dioxide monitor in my practice. I have since started using an end-tidal CO2 monitor, called a capnograph, as an extra line of defense in protecting my patients. Capnographs send an alert the instant a patient stops breathing; however, they are not widely used in general dentist’s office. That may start changing, as the American Dental Association adopted guidelines in October 2016 recommending all dentists – not just oral surgeons – apply capnography during sedation procedures. Most general dentists use pulse oximetry, which measures the amount of oxygen in the blood. A patient would have to hold his or
Figure 1: LifeSense
her breath for approximately a full minute before the monitor catches a drop in the O2 levels. Capnography, on the other hand, can raise an alarm within seconds, saving valuable time to get the patient breathing again. If a patient stops breathing in the chair, my first step is to simply tap him or her on the shoulder and give instructions to take a nice, deep breath. Because the capnograph catches the issue so early, that is enough to get them breathing again the majority of the time. I take it as an important warning sign as well. If I get an alert, I know I need to closely monitor the patient throughout the rest of the procedure and potentially alter the anesthesia regimen. I have been using capnography in my practice since 2011. The capnograph I use is made by Nonin Medical, Inc. The Minnesota company has a long history of inventing and driving the technology of noninvasive medical devices forward². In 2016, Nonin launched the next generation of end-tidal CO2 monitors, the LifeSense® II and RespSense® II. The capnographs are so simple they do not require much training. I cannot find a downside to using capnography in a dental practice. Also important to note is the growing use of sedation in general dentistry. Historically, sedation has been used for procedures like removing wisdom teeth, but these days it is not limited to that. What we’re seeing is patients with a fear of going to the dentist no longer “white knuckling” it at their appointments. They’re requesting mild sedation to help them relieve their discomfort for even minor procedures like fillings or teeth cleanings.
Figure 2: RespSense
A more recent patient visit serves as an example of the difference capnography can make. As always, I asked the patient if he had been diagnosed with sleep apnea. He told me no. During his procedure, he kept holding his breath. Because of the alerts from the capnograph, we were able to wake him up easily, modify our treatment to get the work done safely. At the end of the appointment, I suggested to him that he go to the doctor to get checked out. And it’s a good thing he did, because the doctor diagnosed him with sleep apnea. Bottom line: sedation dentistry is a very safe process, and technology is making it even safer all the time. It’s up to us, the dentists, to investigate, embrace and implement this new technology so that we can better protect our patients. 1. 2.
Capnographs send an alert the instant a patient stops breathing...
American Sleep Apnea Foundation Nonin Medical, Inc.
Dr. Geoffrey Archibald practices general dentistry at Twin Cities Sedation in Forest Lake, Minnesota and at North Branch Dental in North Branch, Minnesota. He graduated from the University of Minnesota School of Dentistry and completed his sedation training through the OMFS department of the University of Illinois-Chicago. He has completed further training to become a Master of the College of Sedation in Dentistry through the American Society of Dental Anesthesiology. When he is not practicing dentistry he is spending time with his wife and four children or riding a bicycle. His dream is to be the first dentist on Mars, but that may not happen, since he also likes being married.
Compliance and Adherence: Dysfunctional Concepts in Sleep Apnea Care
by Pat Mc Bride, BA, RDA, CCSH, Sleep Clinician
-PAP, oral appliance, medication, orthodontic, myofunctional therapy and dietary compliance/adherence are some of the everyday buzz words in the worlds of medicine and dentistry. A quick internet search reveals thousands of citations that either seek to identify or resolve problems around the non-compliance/adherence issue for breathing, sleep disorder therapy and numerous other chronic illnesses. It must be understood that successful treatment of most chronic disorders requires high levels of patient engagement and self-management. The numbers of studies citing issues with compliance/adherence show that what has been the gold standard methodology in patient management simply isn’t working for large numbers of patients. They also do not mention how compliance, or lack thereof, manifests itself in strained physician/patient relationships. Compliance/adherence theory stems from a traditional view of healthcare relationships developed during a time when most mortality and morbidity was caused by acute illness (Vital Statistics of the US, 1974). Patients got sick, they died, no follow up required. Disease management referred generally to the physician mandating what was best for the patient
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with no patient involvement in either treatment planning or therapy decision making. Breathing and sleep disorders are chronic illnesses, and primary therapy management is the responsibility of the patient. As care providers we are motivated by knowing that the consequences of untreated and poorly managed sleep apnea not only affects the individual patient, but their families and society as a whole. Overall increased healthcare costs, work related accidents, loss of income, automobile accidents are just a few highly impacted areas. We were all trained in school to believe that compliance/adherence management of disease is somehow in our control, and if a patient fails to “comply” we have failed in our duty to treat them. Our core beliefs about what patients should or should not do often colors our clinical perceptions and how we view patients as individuals. It can and does lead to frustration and difficulty when what we believe and what actually occurs with a patient do not sync. Compliance/adherence theory fails to address major concerns from the patient perspective. Of primary concern is the notion of control. The patient needs to be fully in control of all self-management decisions. Most of the frustration stems from our wish as providers that patients would maximize their self-management levels. Many of us lament that we feel more invested in our patients sleep apnea care than they do. If we’re honest, labeling a patient
COMMUNICATIONS non-compliant places blame away from us and minimizes how helpless we feel. It does nothing to help the actual situation. Understanding where patient choice factors in and how we must look at each individual helps to build collaborative physician/patient relationships which are far more conducive to managing breathing and sleep apnea disorders. Shifting thought processes, we must accept that patients make series of choices relating to the management of their disorders throughout the day. For example, what they eat, how they breathe, if they take medications as prescribed, manage their stress, wear their appliances or C-PAP or exercise. While we can educate the importance of following established protocols, there is no way we can ensure which and to what extent a patient’s decisions regarding therapy will be followed. We are responsible to educate/stress to our patients that their positive or negative self-management choices have greater impact than any therapy we offer. Decisions they either make or do not make right now, will indeed impact their health status down the road. As care providers we are accountable for the quality of care, education, and advice we provide. Ultimately, the disorder belongs to the patient. Treatment planning for breathing and sleep disorder care should be viewed as a collaboration between equals. The notions of compliance and adherence have no place in this new paradigm of care. Both the physician/ dentist and patient bring important elements to the development of an ongoing care plan. Patient input is paramount in the collaboration. Keeping this in mind allows us to help our patients reflect on their personal life situation and priorities so they will be prepared to make informed choices to improve their own care management success. The goal is to work with the patients to develop realistic breathing and sleep apnea self-management plans that fit the individual clinically, emotionally, psychologically, and socially. Patients who own the therapy plans they help create become invested in
the success and long term health outcomes. Finally, semantics matter. Removing compliance/adherence from our terminology resolves many conflicts which can arise in the doctor patient relationship. Labeling a patient “non-compliant/non-adherent” in an electronic health record that patients have full access to can create ill will and exacerbate the frustrations felt on both sides. There is As care providers no room for dysfunctional relationships be- we are accountable tween physicians, dentists, and patients in the management of chronic disorders. Giv- for the quality of ing up on such labeling is hard as many cli- care, education, and nicians presume that it shifts responsibility for failure to the clinician. Actually, it is the advice we provide. reverse. Replacing compliance/adherence Ultimately, the with empowerment/collaboration shifts a negative to a positive on both sides of the disorder belongs equation. This change means that clini- to the patient. cians will need to speak and behave differently when engaging patients in a clinical setting. Collaborating requires listening, and listening takes time. Even if it feels odd to say “we need to collaborate on a therapy plan you can live with,” practice makes perfect, and this is one thing all of us need to embrace and get right. If what we do as clinicians and educators is empower and collaborate with our patients in a joint effort to manage chronic illness, then we truly have embraced a new paradigm of patient focused precision medicine. Patients who own their disorders are more likely to focus on managing them effectively. Our job is to peel back the layers of each individual and create a pathway of empowerment for patient self-management as we walk them towards wellness and a healthier life.
1. 2. 3. 4.
Vital Statistics of the United States, 1900-1970, Vol I (up to 1954), II (Part A). Hyattsville, MD: National Center for Health Statistics, US Public Health Service 1974. Javors, J. R., & Bramble, J. E. (2003). Uncontrolled Chronic Disease: Patient Non-Compliance or Clinical Mismanagement? Disease Management, 6(3), 169-178. doi:10.1089/109350703322425518 MACNEIL, J. S. (2007). Is Your Apnea Patient at Risk for a Car Accident? Family Practice News, 37(6), 34. doi:10.1016/s0300-7073(07)70384-5 MACNEIL, J. S. (2014). Patient-Physician Collaboration. Encyclopedia of Quality of Life and Well-Being Research, 4661-4661. doi:10.1007/978-94-007-0753-5_102938
Pat Mc Bride, BA, RDA, CCSH, has spent 35 years as a full time clinician in the fields of dentistry, respiratory medicine, and dental sleep medicine. Her extensive experience in clinical, laboratory and educational arenas led to the development of interdisciplinary care model delivery systems used by physicians and dentists across the globe. She sits on the Board of Directors for the Academy of Dental and Physiological Medicine in New York. Pat continues to work as hands on with patients while lecturing internationally on subjects relating to sleep medicine, dentistry, and protocol development to best serve patient populations. Serving the underserved remains a priority and passion for her. She has one grown daughter, a teacher in Spain.
Patient Selection: Understanding Overlooked Sleep Disordered Breathing Symptoms by Mayoor Patel, DDS, MS, RPSGT
here are many signs and symptoms to look for in our patients that are indicative of Sleep Disordered Breathing (SDB), but what signs and symptoms could we be missing? We can simply ask our patients how well they’re sleeping, but when answering that question; many patients won’t consider that they may be suffering from the most common form of SDB, Obstructive Sleep Apnea (OSA). The typical patient does not fully understand the consequences of untreated OSA, so in this article, I will discuss the visual indicators of OSA to look out for that could potentially save your patients’ lives, and reiterate that dentists are at the forefront for identifying and treating OSA with oral appliance therapy. I have included findings from an internal analysis I conducted in my practice that supports these visual indicators as indicative of OSA.
SDB Symptoms Overlooked
Table 1 Lateral tongue scalloping Mallampati classification of grade 3 or 4 Cervical abfractions Tooth wear (occlusal) Vaulted palate / unilateral crossbite Retrognathic mandible / Class II molar relationship Bicuspid extracted orthodontic cases
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As dentists, we see our patients more regularly, and for longer periods of time than most other healthcare professionals. During your patients’ routine dental visits, it is important that not only we as dentists but our team members be on the lookout for both the obvious and not-so-obvious signs and symptoms. The obvious include reported snoring and choking/gasping during sleep, daytime fatigue, large neck circumference, and retrognathia. So what are some of the not-so-obvious signs and symptoms that we may be overlooking? Some predictions of OSA probability include bruxism, abfractions, enlarged tongue size or a vaulted palate. The first example, bruxism, may be a way for the brain to attempt to reopen the airway in an unconscious state. Frequently, a patient who grinds their teeth at night has sore or clicking jaw joints, or flat, worn-down teeth. On the other hand, symptoms of bruxism might even be far less obvious, including earaches or sensitive teeth. Dentists need to be on the lookout for all symptoms and conditions beyond abfractions that might signal grinding and an even deeper problem. Evaluating tongue and palate size, uvula (elongated/ battered) and airway space takes only min-
utes and can easily become standard in a routine dental exam.
Positive Intraoral Findings
As seen in the Summer 2016 issue of Dental Sleep Practice, there are many intraoral findings that strongly suggest a patient at high risk for some form of SDB. The question is: what do we do with these findings? After dental school, we are immersed in the mindset of prevention, biannual dental hygiene appointments to prevent periodontal disease, placement of dental sealants to prevent caries, interceptive orthodontics and the list goes on. So why not prevent or reduce the risk of hypertension, cardiovascular disease, diabetes, stroke, and other conditions that are linked to OSA? In my opinion, as well as others’ opinions, we need to take a strong stand and become more active in assisting our medical colleagues in identifying potential patients at risk. Remember, early treatment is key to preventing the development of worsening symptoms and dangerous conditions. To illustrate the power of your clinical judgment, I engaged in an internal analysis of patients that I identified with any of the indicators listed in Table 1. In 2010, I screened my patients for the visual indicators listed in
Table 1 and referred patients with positive findings to a local sleep center for further evaluation. After writing 51 consecutive referrals, I decided to evaluate how many patients got tested and what the outcome was. Out of those 51 referrals, 21 got tested with a fullnight PSG study. What was interesting is that only one patient (arrow) did not have an AHI greater than 5 (dotted line) (figure 1). I decided to repeat the same process in 2011, and out of 55 consecutive referrals, 26 got tested with a full-night PSG study. This set showed two patients (arrows) that did not have an AHI greater than 5 (figure 2). The findings from this internal analysis prove to be very powerful in that these visual indicators during our oral examination can help identify patients suffering from OSA, without considering age, BMI, medical history, gender, or even sleep questionnaires (Berlin, Epworth Sleepiness Scale). If we add these visual indicators to our tool box, more patients can be identified and treated for OSA.
Expand Your Patient Pool
The ability to efficiently communicate with your medical community is crucial, not only to a successful practice but to ensure that our patients get tested and that comorbidities are addressed. Where I see many of my dental colleagues struggle in this arena is in building relationships with local sleep physicians. We keep these relationships intact is by consistently communicating with physicians. Our system is very efficient in that we enter the patient symptoms, clinical
findings, assessment, and plan into DentalWriter software and share our cloud-based narrative reports with our mutual patients’ physicians. My staff also sends progress reports with post-treatment AHI’s which helps to promote awareness of the successes we have with OSA and TMD oral appliances. All of our physician reports are in a “medical-model” format and have proven to be essential to developing and maintaining referrals and relationships. As we all know, SDB can lead to many secondary health conditions, which means treatment is essential. While we can ask our patients if they snore until we’re blue in the face, we might not get the answers we need until we can spot those commonly overlooked signs and symptoms of OSA. Dentists continue to remain in a unique position to screen patients for SDB, so take charge of your practice through continuing education and expanded screening tools for SBD.
We need to take a strong stand and become more active in assisting our medical colleagues in identifying potential patients at risk.
Having a limited practice to Craniofacial Pain and Dental Sleep Medicine, Dr. Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP, utilizes his experience and expertise to help dentists across the country excel in these areas within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops upto-date curriculum for their sleep apnea and craniofacial pain programs. Dr. Patel serves as a board member with the Georgia Association of Sleep Professionals, the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain and American Academy of Craniofacial Pain. He also has taken the role as examination chair for the American Board of Craniofacial Dental Sleep Medicine and American Board of Craniofacial Pain.
The Critical Role of Team with Sleep Tests in the Practice by Glennine Varga, AAS, RDA, CTA
leep tests are vital when treating any sort of sleep breathing disorder. Think of them as your x-rays or imaging in dentistry. It may be possible for any dentist to complete a root canal without an PA x-ray or digital image but most will refuse, as it will be impossible to know what you will find without it. The same goes for sleep tests. Don’t get me wrong – taking records for a sleep appliance is not the same as a root canal by any means, but the sleep test for a custom-made sleep appliance is just as important as a PA x-ray or digital image are to a root canal procedure. Therefore, team should be educated on all the aspects related to testing just as we are to all the aspects related with x-rays and imaging. Let’s take a quick look at some rules regarding dental offices when it comes to sleep testing, how to talk to patients about them and what to do with them once we have them. First off, should every dental office offering oral appliance therapy have a home sleep test (HSTs) unit? I say yes! I am a firm believer in helping your patients to make educated decisions and there is no better way to teach someone then looking at the situation head on. Home sleep tests minimally allow us to evaluate if they stop breathing, how much oxygen they are depriving their bodies of and how many times this happens over several nights. Brilliant! In fact, the retail industry happens to think so too! There are several new products on the market that help us to evaluate our sleep – none as sophisticated as home sleep apnea tests (HSATs) to score breathing but some evaluate how much sleep we are getting and what stage of sleep we spend our time at night in. The more we learn about sleep the more we will want to know the quality of our own, our family and our team’s sleep and HSTs are the way to go! As a DSM coach I am constantly asked about rules of using HSTs so here are the rules as I understand them in a nutshell:
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Rule 1. Dentists cannot diagnose any kind of sleep disordered breathing condition. Unfortunately, a dental license does not include diagnosing medical conditions in any state at this time. But, a sleep test in a dental practice can be used for three good purposes. A. Screener, B. Diagnosis with physician interpretation and C. Follow up testing after device placed with physician interpretation. Rule 2. Focus on how it can be used to educate your patients. Different sleep test units record and report data differently. Some will record real sleep time and sleep staging, others have cannulas and chest belts to record nasal resistance and respiratory effort and some will record muscle activity to analyze clenching. What is important to understand is there could be a big difference between units and no matter which unit you use, focus on how it can be used to educate your patients. Rule 3. Don’t count on medical insurance reimbursement. Yes, there are codes and if the patient has been previously diagnosed billing a follow up efficacy sleep test may qualify for benefit. However, just as mentioned above, any sleep disordered breathing condition cannot be diagnosed by a dentist and those diagnostic codes happen to be the only codes medical insurance companies will pay for when it comes to the use of a home sleep test. Therefore, a physician’s diagnosis is required. It is my experience about 50% of insurance companies follow Medicare’s policy, which states that a home sleep test cannot be ordered, dispensed, or billed by a DME supplier (aka dentist providing an oral appliance enrolled as a Medicare DME supplier). Also, a home sleep apnea test can be used for primary diagnosis only if ordered by a physician
TEAMfocus as result of a face-to-face evaluation. Lots of rules to follow! So if we are not billing the insurance but rather focusing on how we can use the information for educating the patient, we can help our patients choose what is best for them. Once educated, patients always have the option to do what is necessary for insurance reimbursement. You may be surprised how many patients opt for a “out of pocket” objective test once they understand the process of what is needed to gain benefit. Ok, now that we got that out of the way, we can focus on communicating with patients and what to do with the tests once we have them. As team members, we pride ourselves on understanding and following systems which means we like to keep our office moving and producing. This requires us to look ahead to make sure we have all we need to deliver the product. A sleep test in a dental sleep medicine practice is one of the first action steps in any system or process. When we are communicating with patients that have never had a sleep test, the message we strive to deliver should be all about getting tested and finding out how that specific patient is breathing during sleep. Once this occurs, we and our doctors can spend time educating the patients on their results and our doctors can suggest the appropriate treatment. In order to educate the patients on their results their base line sleep test must be in hand; this will allow us to talk about all the great information these tests reveal. As team we are responsible for getting a copy of our patient’s base line sleep test to our doctors for them to evaluate and prepare themselves for the patient visit. It should be part of room set up just like a mouth mirror – have a copy of the base line sleep test in the room before the evaluation starts. As a team member personally, I got into the habit of highlighting information “for my doctor,” which really was for my use. Things like confirmation of base-line study versus PAP titration, date of study, notes from physician, diagnosis, AHI, Nadir SPO2 (lowest oxygen level) and percentage of N3 (deep sleep). If a copy of the test is not obtained the evaluation cannot be completed. If patients who have not had a sleep test call your practice don’t turn them away to go get a test. Get them in the door! We team can play a vital role in educating the patient about the process to get diagnosed and referrals can be
made to physicians, which should strengthen referral relationships. If a patient has insurance that requires a physician face-to-face evaluation to order a sleep test, educate the patient about this process. An educated patient may choose a different approach to obtain a diagnosis, deciding what’s in their best interest regardless of insurance coverage. When using HSATs in the practice it is important to track them. One unit is easier to track then five, but a system is needed. A pick-up, drop-off system should be put in place to know where they are at all times. Get training with your product – some units require you to change batteries between patients and others require 4-8 hours of charging before being able to record data. These are important factors with scheduling pick up and drop off times. Learn how to use the unit(s); most require you to pre-load minimal patient information and get it ready for each patient. It’s never fun when patients return units only to find out no information was recorded because it was not set up properly. Downloading the data is equally important for the same reason. When delivering the HSAT to your patients demonstrate how they are used. Each unit should have written instructions and most have video instruction for the patient to follow. It’s always a great idea to try out the unit(s) yourself! Not only will it give you the experience of wearing it so you can explain to patients what to expect, but it will also give you great knowledge about your quality of sleep!
A sleep test in a dental sleep medicine practice is one of the first action steps in any system or process.
Editor’s Note: This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. Let us know your specific issues by email to: SteveC@MedMarkAZ. com, while we can’t respond to every individual. Your feedback will help us create the most useful Sleep Team Column we can!
Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain. She has been employed in dental education for over 19 years. Glennine has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and a trainer of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp and a Total Team Training instructor for Arrowhead Dental Lab. For more information, visit www. dsmbootcamp.com or email firstname.lastname@example.org.
Important Facebook developments
by Ian McNickle, MBA
t should be no surprise that the largest social media site on the planet continues to change and innovate at a rapid pace. It has been very interesting to monitor recent developments and understand their impact for dental practice marketing. Facebook newsfeed algorithm — how to get seen
Last year, Facebook® announced they would be making a change to the newsfeed algorithm so that they could better deliver relevant content to their users. They started to track what users were engaging with (likes and comments) and then gave higher relevance to similar stories being in someone’s newsfeed. This means if someone has liked or commented on a post from your practice, he/she would be more likely to see your posts again in the future. Facebook is essentially trying to understand your interests and match those topics with what would be shown to
you in the future. This is similar to Internet radio stations like Pandora® that learn what you like and attempt to give you more of what you like over time. Earlier this year, Facebook announced another change to take this concept a step further. Now they are going to track how long you interact with an article or piece of content after leaving Facebook. Monitoring engagement time gives them additional insight into what a particular user likes to read and see in their newsfeed.
What does this mean for your practice?
Relevant and engaging content is more important than ever! If a Facebook user clicks on your content and immediately bounces right back to Facebook without taking much time to read it, then this could negatively impact your visibility in the future. On the other hand, if a user goes to your page and takes the time to read the en-
Receive your free marketing consultation today: 888-246-6906 or email@example.com
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PRACTICEdevelopment tire article, then you’re likely to rank higher in the newsfeed. The interesting thing to note is that although this information is valuable to track user engagement and relevant content, it’s also part of Facebook’s push to get publishers using their new tool “Instant Articles,” which means more content is being published behind Facebook’s wall and less on other sites. Essentially, they are trying to keep people within the walls of Facebook and not link to external websites, thereby leaving Facebook during that browsing session. For now, it’s important for your practice to take note of the changes and be sure that your blogs and other social media posts are engaging and targeted specifically to your audience. In addition to creating engaging posts and content, there are other strategies to generate new patient leads from Facebook. These strategies primarily fall into two categories: 1) boosted posts, and 2) paid ads. In our next
marketing column, we will continue with our Facebook theme and dig deeper into these new patient-generating strategies.
If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication.
Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant “Best of Class” Award for Dental Marketing and Dental Websites. If you have questions about any marketing related topic, please contact Ian McNickle directly at firstname.lastname@example.org, or by calling 888-246-6906. For more information, you can visit WEO Media online at www.weodental.com.
Save the Date
AIRWAY SUMMIT ‘17 San Juan, Puerto Rico September 14-16, 2017
The Condado Plaza Hilton www.aapmd.org
FRIEND OR FOE? Part 1
by Ken Berley, DDS, JD, DABDSM and Courtney Snow, Medical Insurance Consultant
have avoided writing on Medicare. It is a bottomless pit of questions. Many of the questions that pertain to Medicare are complicated because we are dentists providing & monitoring a medically necessary treatment for a diagnosed medical condition, but functioning as Durable Medical Equipment (DME) suppliers. However, over the next three editions I am going to attempt to address and clarify some of the issues that frequently arise regarding Medicare. So here we go!
First, I would like to thank Courtney Snow with Nierman Practice Management, who has been invaluable in helping me with the research necessary Medicare rules and regulations to write this series of articles. Thank you Courtstate that all Medicare beneficiaries ney, youâ€™re the best! As a disclaimer, I do must be informed of existence not consider myself to of Medicare benefits whether you be an expert in Medicare participate in Medicare or not. rules and regulations, and I am not providing any legal opinions in this article on how any dentist should practice Dental Sleep Medicine (DSM). For definitive answers to your specific questions, contact a Medicare Law practitioner in your area.
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The question for today is: Have you opted-out of Medicare or are you a Medicare DMEPOS supplier? Your answer to this question determines the specific Medicare rules that apply to your practice. Unfortunately, many dentists who have opted-out of Medicare believe that they do not have to follow any Medicare regulations because they have opted-out. This could not be further from the truth. However, as many of you are aware, if your practice location is enrolled as a Medicare DME supplier, Medicare offers coverage for dentists who provide custom made Mandibular Advancement Appliances (MAD) to treat Obstructive Sleep Apnea (OSA) that are approved by the Pricing, Data Analysis & Coding (PDAC) contractor as qualifying for
LEGALledger code E0486 (of course, other patient coverage criteria must be met as well). To qualify for reimbursement the dental practice location must be properly enrolled as a DMEPOS Medicare supplier, as well as follow Medicare regulations. During a recent “Protect Your DSM Practice” lecture the subject was brought up that many dental practices enroll as a non-participating Medicare DME supplier, and I quickly found out that many of the attendees that were not currently enrolled as participating or non-participating DME suppliers have been providing Oral Appliance Therapy (OAT) to Medicare beneficiaries without informing them that Medicare DME benefits are available for the treatment of OSA. When questioned, these attendees stated that they did not think they were required to inform Medicare beneficiaries of potential coverage because their office had opted-out of Medicare. In my opinion, and per Medicare policy, that is a violation of Medicare rules and regulations. Subsequently, I have become aware that some dentists are simply informing Medicare beneficiaries that no coverage for OAT is available through Medicare and, therefore, require that all Medicare patients pay cash for their MAD’s. Medicare rules and regulations state that all Medicare beneficiaries must be informed of existence of Medicare benefits whether you participate in Medicare or not. These patients MUST be informed that OAT can be a covered benefit if the patient goes to a dental practice who is an enrolled Medicare DMEPOS supplier, the beneficiary meets coverage criteria (i.e. has
received a Medicare covered sleep test, etc.), and a PDAC approved MAD is used. If an office/provider has officially opted out of Medicare, the dentist must still inform the patient of the existence of Medicare DMEPOS benefits and let the patient know that their practice is not enrolled as a Medicare DME supplier. Frequently I find that practices who have opted out of Medicare simply have the patient sign an Advanced Beneficiary Notice (ABN) of Nonpayment, and then have the patient pay cash for the service/equipment. Per Medicare policy, ABN’s are only to be used if you are an enrolled Medicare provider or supplier and you are not expecting Medicare to pay for the recommended services. If you have opted-out of Medicare, your Medicare patients should be provided a “Medicare Private Contract” to be executed. The Medicare Private Contract must be signed prior to commencing the DMEPOS service. If you enter into a private contract with a Medicare beneficiary neither they nor the provider/supplier can file a claim to Medicare for the services. If you have been excluded from participating in Medicare or State Health Care programs for legal or fraudulent reasons, you cannot enter into a Medicare Private Contract. This restriction applies to all individuals or corporations who have lost their right to participate in Medicare for any reason. The following sample contract was modified from a sample Physician Medicare Private Contract provided by Noridian Healthcare Solutions. I have adapted it for use by dentists.
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.
As Director of Training and DentalWriter™ Software Implementation at Nierman Practice Management, Courtney Snow is well known in the Dental Sleep Medicine industry for her work with medical insurance reimbursement for Oral Appliance Therapy for Obstructive Sleep Apnea. She is also an excellent resource for medical billing for Temporomandibular Disorders (TMD), oral surgery services, and other medically necessary services performed in the dental practice setting. Courtney can be reached at 1-800-879-6468 and through Courtney@DentalWriter.com.
Medicare Private Contract Section 4507 of the 1997 Balanced Budget Act allows a dentist or other practitioner to enter a private contract with a Medicare Beneficiary for services which will not be covered by Medicare. I _______________ (provider’s name) have submitted an affidavit to Medicare expressing my decision to opt-out of as a Medicare provider. I _______________ (provider’s name) have not been excluded from Medicare under sections 1128, 1156 or 1892 of the Social Security Act. My NPI is __________. (Provider’s NPI) I _______________ (Medicare beneficiary) or my legal representative accept full responsibility for payment of charges for all services furnished by Dr. ____________. (Provider’s name)
E L P
I _______________ (Medicare beneficiary) or my legal representative understand that Medicare limits do not apply to what Dr. ___________ (provider’s name) may charge for items or services furnished. I _______________ (Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Dr. ____________ (provider’s name) to submit a claim to Medicare. I _______________ (Medicare beneficiary) or my legal representative understand that Medicare payment will not be made for any item or services furnished by Dr. ____________ (provider’s name) that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
M A S
I _______________ (Medicare Beneficiary) or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a dentist and/or practitioner who has not opted-out of Medicare, and I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other dentists or physicians who have not opted-out. The expected or known effective date and expected or known expiration date of the opt-out period is _____________ (effective date) and _____________ (expiration date). I _______________ (Medicare beneficiary) or my legal representative understand that Medigap plans do not, and other plans may not, make payments for items and services not paid for by Medicare. This contract cannot be entered into by me, ____________ (Medicare Beneficiary) or by my legal representative during a time when I (Medicare beneficiary), require emergency care services or urgent care services. I am aware that a physician or other practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with Section 3044.28 of the Medicare Carriers Manuel. I _______________ (Medicare beneficiary) or my legal representative will receive a copy of this contract, before services or items are furnished to me under the terms of this contract. I _______________ (Provider’s Name) will retain the original contract (original signatures of both parties required) for the duration of the opt-out period. I _______________ (Provider’s Name) will supply CMS with a copy of this contract upon request. I _______________ (Provider’s Name) understand that the current private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers. Provider’s NPI: _______________________ Provider’s Signature: _____________________________________________________ Date:___________________________ Patient’s Signature:_______________________________________________________ Date:___________________________ Patient’s Legal Representative Signature:____________________________________ Date:___________________________ Witness:_______________________________________________________________ Date:___________________________ Name of Patient Contact:______________________________________________ Phone #:___________________________ Patient Contact Email:_____________________________________________________________________________________
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LEGALledger Medicare laws include Refund Requirement which apply to both assigned and nonassigned claims for DMEPOS servicesâ€Ś. Refund Requirements state that suppliers must make refunds of any amounts collected if the beneficiary was not properly notified of possible disallowed Medicare claims. The Refund Requirement provisions require that the beneficiary is notified and agrees to be financially liable.
Refund Requirements state that suppliers must make refunds of any amounts collected if the beneficiary was not properly notified of possible disallowed Medicare claims.
If you do not inform a Medicare beneficiary that Medicare coverage may be available for a MAD you have violated Medicare regulations. Additionally, if you have optedout of Medicare you must tell the patient that he/she has the right to go to a dentist who is a DMEPOS Medicare supplier for OAT for OSA. If, after full disclosure, the Medicare beneficiary decides to let you treat his/ her OSA, a Medicare Patient Private Contract must be signed. It is my personal opinion
that dentists who practice DSM should be DMEPOS suppliers. However, if you have opted-out you can enroll two years from the date you opted out, or decide to opt out for another 2 year period. Hopefully this information helps those who have opted-out of Medicare understand your obligations to your Medicare beneficiaries.
Physiological Monitoring for Dentistry and Medicine The future of dentistry lies in recognizing the dentistâ€™s role in understanding and improving patient physiology.
Join us at the AIRWAY-kening Academy March 17-18, 2017 at the Hampton Inn Agoura Hills in California for 2 days of learning with Drs. Jeffrey Hindin and John Kelly. Or save the date for the east coast event to be held May 12-13, 2017.
SLEEPgame This is for a team meeting: Everyone gets a copy of the same sleep test. The first one to find five results from the test that line up on the bingo card, and can say why those results are important, wins! Be creative â€“ learning is more fun with games! For a printable version of the bingo card, visit https://dentalsleeppractice.com/bingo/.
S L E E P
T E S T
HST or PSG
Date of Test
Supine Sleep AHI
Mean O 2%
Oxygen Nadir %
Reason for the Test
Time in Supine Sleep
Prescription for Therapy
Time O2 < 88%
Central Apnea Index
64 DSP | Spring 2017
Supporting Dentists through Practical Sleep Apnea Education Share your Passion – Become an Author for DSP!
Practicing dentists, their team members, and other health professionals who are striving to improve community health need accessible means to enhance their ability to make an impact. If you have a message to get across to this audience, DSP would like to help. Think about scenarios like these and imagine how you would respond: • The passion you enjoy for helping sleepy patients get better demands to be shared with your colleagues and you have important things to say about it. • You are invited to speak to an audience of dentists about sleep medicine and you have crafted a unique way of presenting the material. • You have an interest in a subject and, after study, have created a teachable message. • There is something you have always wished the dentists treating patients knew about. • You have an interesting case study illuminating some aspect of SDB therapy. • You have conducted original research and wish to share what you have learned. • A technology you work with has made serving patients better and provides optimum patient and team experiences, and you would like others to learn about it.
These and many other opportunities await the interested author. Dental Sleep Practice will contain scientific articles as well as writing intended to share the wisdom accumulated by years of practice and solving clinical puzzles. We value an approachable, conversational style that maintains the highest levels of scientific and behavioral integrity.
Contact Steve Carstensen DDS, Editor in Chief, at SteveC@medmarkaz.com with your ideas.
The veteran writer will find DSP easy, yet professional, to work with. Those new to writing will enjoy how our team of experienced writers, editors and publishers can help develop thoughts into articles that can be proudly shared in the community. Full information for authors can be found on our website, www.DentalSleepPractice.com
Guided Implantology CERECÂŽ Integration
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Contact your Patterson Representative for more information. Or call Dentsply Sirona directly 800.659.5977. sirona3D.com
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