Dental Sleep Practice Spring 2018 by MedMark, LLC

Sleep Medicine’s Seismic Shift to Dentists – Are You Ready?

Compliance Monitoring in OAT Therapy

by Dr. Neal Seltzer

Improving Management of OSA by OAT – A

Sleep Physician’s Perspective by Dr. Jonathan S. Lown

SPRING 2018

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INTRODUCTION

Airway is Everywhere

othing is going to have more impact on your practice than the American Dental Association’s new Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders, covered well in this issue by Ken Berley from his perspective as a dentist and lawyer. The Policy says we dentists must take a more active role, alongside our medical colleagues, in helping our community health by identifying and treating people who breathe badly at night. You may be serious about this effort but many dentists have decided this service is not for them. You can help both your friends and their patients by giving them a place to send their patients. Provide screeners, referral slips, and a promise to treat only the SRBD and you’ll quickly be as busy as you want to be. Each January, the Seattle Study Club organization holds Symposium, where directors of the local clubs come together for education, connections, and planning their next year’s CE agenda. It’s a big, fun, focused week, with world-class speakers and top shelf entertainment. As an airway-focused dentist, it was interesting to hear the restorative experts talk about treatment planning, materials, and techniques with new ears. For most of my career, I would have paid closest attention to how to solve the clinical puzzles presented by my patients and work out the path to optimum dental health. Maybe I was overly tuned to hear ‘airway,’ but I don’t recall a single talk where that term wasn’t part of the thought process or discussion. Heavily worn dentition given new life was blamed in part on airway problems, orthodontic treatment wasn’t just about straight teeth, and facial esthetics included discussion of the value of a good night’s sleep. If you haven’t read Matthew Walker’s new book, “Why We Sleep” order a copy today and discover the science behind what you’ve been telling your patients. I think Dr. Walker’s writing will be accessible to only the most dedicated consumers, but it’s perfect for us to have scientific foundations to communicate the importance of sleep to our

patients. His focus is mostly on the time of sleep, not so much on the quality of it, but if your patients are battling sleep breathing disorders every night, their sleep cycles are disrupted and, according to Walker, very bad things are going to happen. Near the very end of the book, Dr. Walker mentions childhood sleep breathing problems and laments the lifetime of poor health that lies ahead if nothing is done. Increasingly, scientists, researchers, leading clinicians, and authors are singing the same tune: an early open airway is the best way for a child to grow up healthy.

Steve Carstensen, DDS Diplomate, American Board of Dental Sleep Medicine

An early open airway is the best way for a child to grow up healthy. This summer, the American Dental Association is following through on the Policy Statement by hosting a Children’s Airway CE event in Chicago, so dentists can learn practical ways of treating kids. Our profession suffered as TMD became a dental, not medical, problem, and dentists couldn’t agree on therapeutic approaches. I think we must not let children’s airway take the same path. It’s an exciting time to be an airway-aware dentist. Enjoy the journey!

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in each issue by completing questions about an article (see page 32) and submitting them either online or via mail. Sponsored by MedMark , LLC, and Seattle Sleep Education.

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CONTENTS

10 Cover Story

Sleep Medicine’s Seismic Shift to Dentists – Are You Ready? Momentum is building for dental solutions to airway problems.

Improving Management of Obstructive Sleep Apnea with Oral Appliance Therapy – A Sleep Physician’s Perspective

Dr. W. Keith Thornton (foreground), inventor of the TAP, and Charles F. Collins (background), CEO of Airway Management

Expert View

by Jonathan S. Lown, MD, D.ABIM Approaching sleep patients with a common purpose.

Problem Solving

Compliance Monitoring in Oral Appliance Therapy for OSA

by Neal Seltzer, DMD, FAGD, D.ABDSM, D.ACSDD, D.ASBD There is a way to prove they wear it.

Continuing Education

Lab Communication

The Value of Making Oral Appliance Labs Part of Your Team by Steve Marinkovich, DDS Putting everyone’s expertise to work.

2 DSP | Spring 2018

2 CE CREDITS

CONTENTS

Technology

Digital Scans and Digital Bite Record for Oral Sleep Appliance Fabrication by Gregory K. Ross, DDS Simplify your workflow.

Practice Management

Don’t Price Yourself Out of the Game by Randy Curran Take care of business, but also health.

Product Study

Minimizing Side Effects: A Retrospective Case Series Analysis of Tooth Movement in Oral Appliance Therapy by Dr. Jerry Hu Challenging assumptions about side effects.

Publisher | Lisa Moler lmoler@medmarkmedia.com

Practice Growth

Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com

by Chris Bez, opportunity engineer Be positive about new approaches.

Editorial Advisors

Starting Early

How Children Breathe Sets the Stage for Life

Temporomandibular Joint Anatomy as Related to OAT by Samuel J. Higdon, DDS Baseline assessment is critical.

Team Focus

Fun opportunities to awaken DSM in your practice! by Glennine Varga, AAS, RDA, CTA Take advantage of the skills you have in your team.

4 DSP | Spring 2018

Steve Bender, DDS Ken Berley, DDS, JD Howard Hindin, DDS Ofer Jacobowitz, MD Christina LaJoie Steve Lamberg, DDS, DABDSM Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA

by Daniel S. Bruce, DDS, D,ABDSM, and Bethany A. Bewley, RDH, MS Early open airways means better health. Advanced Treatment

Combination Therapy TMD Series

Editor in Chief | Steve Carstensen, DDS stevec@medmarkmedia.com

Marketing From a Culture of Innovation

48 28

Spring 2018

by Ronald S. Prehn, ThM, DDS Innovative way to help those special patients.

Legal Ledger

ADA Policy Statement on Sleep Disordered Breathing From a Lawyer’s Perspective by Ken Berley, DDS, JD, DABDSM Critical information that touches every bit of your practice.

Seek and Sleep

DSP Word Search

Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Office Manager/Executive Assistant Mystey Helm | mystey@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349

©MedMark, LLC 2018. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

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EXPERT view

Improving Management of Obstructive Sleep Apnea with Oral Appliance Therapy – A Sleep Physician’s Perspective by Jonathan S. Lown, MD, D.ABIM

he US and global impact of Obstructive Sleep Apnea (OSA) is staggering. An estimated 52 million Americans have sleep disordered breathing, with 1 in 5 having mild apnea, and 1 in 15 having moderate to severe apnea. To quote Dr. John Remmers, “Obstructive Sleep Apnea is the most common non-communicable disease in the western world with over 200 million apneics and approximately 20 million new cases identified each year.” In the US in particular, that’s more patients than can possibly be treated with current available resources. It’s therefore imperative for all practitioners involved with Sleep Apnea management to unify – sleep physicians and sleep dentists. We need to think about ways to best serve our patients, because this is a problem that’s not going away. Briefly about my background: I’m boarded both in Internal Medicine and Sleep Medicine, was diagnosed with OSA in 2000 and have been a compliant CPAP (Continuous Positive Airway Pressure) user ever since. In 2004, I was recommended to try OAT (Oral Appliance Therapy) as an alternative to CPAP. Unfortunately, this turned out to be a bad experience resulting in my rejection of oral appliances for some time. The failure of that

6 DSP | Spring 2018

appliance was, in retrospect, both my fault (for not being more proactive in voicing discomfort issues) as well as the sleep dentist, who was not vested in the appliance’s overall success. As a result, I was quite disinterested in oral appliances for many years. It took the realization that patients would be better served if they were offered an alternative to CPAP, namely oral appliances, and that actual CPAP compliance, even with coaching, was far from perfect. I also learned valuable lessons in treating patients with oral appliance therapy and some pitfalls to avoid. OSA can have a profound impact our patients, whether they are aware of it or not, with numerous associations between sleep apnea and Cardiovascular diseases, including Stroke, MI, A fib, Diabetes and Hypertension. For example, 80% of Resistant Hypertension patients (defined as 3 or more BP meds with persistent BP elevation) have sleep apnea. Approximately 50% of patients with Atrial Fibrillation have sleep apnea. The combination of obesity (BMI>30) and Type 2 diabetes poses a 90% chance of having OSA. Another way to look at this is that the obese diabetic patient has a 1 in 10 chance of NOT having sleep apnea. In addition to OSA’s strong association with common dis-

EXPERT view eases, we have numerous studies demonstrating adverse outcomes in OSA patients. In the Wisconsin sleep study, severe sleep apnea was associated with reduced life expectancy of approximately 7 years. In the Bussleton Health Study (which published 20 yr. follow-up data in 2014), patients that had untreated moderate and severe sleep apnea had a higher all-cause mortality rate, higher stroke rate and higher cancer rate than patients who either had mild OSA or no OSA at all. This data collectively makes the diagnosis and management of OSA not only an imperative, it obligates us to impress upon all OSA patients the necessity of continued therapy, usually indefinitely. Despite much improved compliance rates with OAT vs CPAP therapy, both therapies still suffer from significant discontinuation rates that are at least partially our fault (both Sleep Physicians and Sleep Dentists). From my perspective, at least part of this compliance issue stems from patient expectations and general misunderstanding of the importance of treatment. In the past, patients, and even practitioners, have made the mistake of presuming that sleep apnea is snoring and daytime sleepiness. This creates a problem for future management if a patient has neither apparent daytime sleepiness nor obvious snoring. Regardless of symptoms and signs, untreated patients with significant apnea run the risk of future cardiovascular events and must be treated. Most of the CPAP cardiovascular outcome studies (which are plagued by poor compliance) enrolled mostly nonsleepy OSA patients. The analogy of Hypertension is a simple but accurate one, that can be utilized in the Sleep Apnea arena. The majority of patients with Hypertension understand they need to be treated if their blood pressure is high, regardless of symptoms. Continuation or discontinuation of therapy is not a real choice. Because of a lack of a clearcut association between elevated blood pressure and symptoms, Hypertension has been deemed “The Silent Killer.” Management of sleep apnea should be thought of in a similar way. We should impress upon our patients that we are treating sleep apnea, also a silent killer, because of the cardiovascular ramifications, and not solely to improve symptomology. This seems obvious, but often falls short in clinical practice. I would suggest that we clearly communicate to our patients

that it is an imperative to eliminate apnea to the best of our abilities, with the secondary goal being improvement in symptomology. Unfortunately, all too often we are focusing on the latter and forgetting about the former. This leads to dissatisfaction and poor compliance and a somewhat laissez-faire attitude about all available therapies, including oral appliance and CPAP therapy. I’ve seen numerous patients over the years that sheepishly admit that they’ve discontinued CPAP or OAT, but without the conFar too often patients nection that this would be as bold as discontinuation of their blood pressure view OSA therapy as therapy. Because of the lack of obvia nuisance and fail to ous worsening from discontinuation of OSA therapy, and the frequent lack recognize that untreated of correlating any change in quality of OSA causes measurable life with lack of therapy, patients are confused about the necessity of com- insults to their bodies. pliance. I recently saw a patient for routine follow up who complained that he had a major increase in frequency of nocturia (from 1 time per night to 3 times per night). When asked about his CPAP/OAT compliance, he chortled that he stopped using both approximately 3 months before, but was blissfully unaware that the worsening of nocturia was probably related to discontinuation (improvement in nocturia is often a harbinger of OSA therapeutic improvement). The association between untreated OSA, the subsequent rise in noctur-

Jonathan Lown, MD, is a highly-regarded physician board certified in the areas of Sleep, Internal Medicine and Lipidology and is a Diplomate of Sleep and Internal Medicine (ABIM). He is the Clinical Director of Delta Sleep Center of Long Island, and Co-founder of Delta Sleep International, established to disseminate knowledge about Sleep, worldwide. In addition, Dr. Lown is Assistant Professor of Medicine, Stony Brook University Medical School. Dr. Lown is passionate about treating patients with sleep difficulties including Obstructive Sleep Apnea and was diagnosed with Obstructive Sleep Apnea himself in 2000, and has been a compliant CPAP user for over 17 years. He has also partnered with Sleep Dentists, to improve awareness and treatment alternatives for OSA and is an active member of both the AASM (American Academy of Sleep Medicine) and AADSM (American Academy of Dental Sleep Medicine), and is a member of the AADSM education committee.

DentalSleepPractice.com

EXPERT view nal ANP (Atrial Natriuretic Peptide), and a resultant increased nocturia, has been well described. But the majority of patients and clinicians are unaware of this phenomenon. Far too often patients view OSA therapy as a nuisance and fail to recognize that untreated OSA causes measurable insults to their bodies. It’s for that reason that I’m a firm believer in imparting some of the basic pathophysiology of OSA to all my patients in the hope that they will think twice before avoiding therapy each night. OSA’s impact on the body comes in three forms – Sleep Fragmentation, InWe should impress creased Adrenergic Tone, and Repeatupon our patients ed Hypoxic Episodes. The first, sleep is not unique to OSA that we are treating fragmentation, but can be seen in other sleep disorders sleep apnea, also a such as RLS. The brief arousals that folapneic episodes (as well hypopnesilent killer, because low as and RERAs) are protective in restorof the cardiovascular ing CO2 and Oxygen levels but cause interruption in sleep continuity which ramifications, and may or not translate into daytime not solely to improve symptoms, including EDS, grogginess, concentration and memory, and symptomology. poor irritability. The association between daytime symptoms and the degree of sleep fragmentation often doesn’t correlate (described by Chervin and others), but the general rule would be the more the fragmentation, the greater degree of impairment. As a cautionary note I would suggest not relying solely on daytime symptoms to guide diagnosis and therapy. The second feature that drives OSA pathophysiology is repeated brief episodes of increased sympathetic tone during apneic episodes, first described by Mignot in the early 80’s, which leads to alpha vasoconstriction, and eventually increased daytime sympathetic tone. This increased sympathetic tone is at least one of the driving forces in OSA’s association with HTN, CVA, A-fib and even Insulin Resistance and Diabetes. Repeated drops in oxygen (which in most OSA patients are not severe) has been associated with increased inflammatory response. The associations with both Cardiovascular Disease, Diabetes and even Cancer seem to be driven in part by chronic inflammation. Three entities are hallmarks of successful OSA therapy: Decreased Sleep Fragmentation, Decreased Adrenergic Tone and Decreased Hypoxic episodes. And it’s these three things that I attempt to remind

8 DSP | Spring 2018

patients of so that they can make rational decisions in regards to their care. But cogent words alone don’t always shape behaviors to a satisfactory degree, and many patients and clinicians will be frustrated and mystified that despite good compliance with OAT and or CPAP therapy, they don’t feel hugely different. It is therefore important for us as sleep clinicians to think about the whole gestalt of sleep. This includes stressing good sleep hygiene, circadian alignment and even diet and exercise. As a resident in training, I was introduced to the concept of Good Sleep Hygiene by a forensic psychiatrist who believed strongly that all patients should be aware that their overall wellbeing can be influenced by sleep habits. At first, I was reluctant to embrace this and believed that good sleep hygiene was a bromide platitude, obvious to most people. But over the years it is amazing how powerful reinforcement of good sleep habits can be, especially when you’re passionate about it. Use it like a prescription. Shutting off electronics before bed, not getting into bed until you’re ready to sleep, avoidance of caffeine after 2 p.m., avoidance of alcohol close to bedtime, and having relatively the same wake time, to name a few, are easy to initiate with rapid results. I always tell my patients and non-sleep colleagues that the secret to regulating sleep is not the time you go to bed but the time you wake up. Simply put, if someone is forced to wake up every morning (7 days per week) at the same time, and not allowed to nap, they will have tremendous sleep drive in the evening that can minimize issues with sleep continuity. It’s important to remember with sleep patients that there are many factors that can impact how patients feel overall. The long-term success of oral appliance and CPAP therapy is not only contingent on reducing and or eliminating obstructive events, but is also dependent on improvement in sleep quality. Sleep quality is a somewhat nebulous construct with multiple elements making direct or indirect contributions including sleep architecture, undocumented sleep fragmentation, sleep continuity, sleep efficiency, circadian alignment, and of course sleep duration. As a sleep dentist, you must have some understanding and comfort level in this area if you wish to have long term success and retention of OSA patients.

EXPERT view It’s important to remember that sleep quality and sleep apnea are often unrelated. An example is the lack of improvement in AHI with nasal patency devices, despite improvements in sleep quality. Or the supposition that if an OSA patient begins remembering dreams after OAT that this necessarily reflects objective improvements in the AHI. In addition to good sleep hygiene and sleep quality, a crucial, but often overlooked factor is sleep duration. Short sleep duration is by far the most common reason for daytime sleepiness, and although there’s much debate about the actual requirement for health, most individuals require between 7 and 8 hours of sleep. It’s necessary to stress this to patients since use of any OSA therapy in someone with self-imposed sleep restriction will often have minimal to no abrogation of their symptoms, nor any benefit of therapy. Terry Weaver, RN, PhD, showed that Moderate to Severe OSA patients who used CPAP for less

than 6 hours a night had evidence of objective and subjective daytime sleepiness. Those who used it for only 4 hours or less were no different from baseline (prior to therapy). The recommendation to increase sleep duration from the sleep clinician can improve your patient’s quality of life, feeling of restfulness, and perceived wellness. There is a great opportunity for all of us in the field of sleep to have a major impact on our patients’ health. As our OSA patients adopt some simple rules and concepts, we can not only improve treatment efficacy, but they will feel improved quality of life. Together, we can potentially improve their morbidity and mortality, which is tremendously rewarding and very powerful. We need to stress the importance of treatment in terms of the broader picture and not focus on only improving symptoms. Both the Sleep Dentist and the Sleep Physician must speak with one unified message.

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COVERstory

Sleep Medicine’s Seismic Shift to

Are You Ready?

or years, many members of the dental sleep medicine community have been predicting that this segment of dentistry is poised for exponential growth. It’s right around the corner…

“The diagnosis and management of sleep apnea to this point, has been, in my view, too complicated, too time consuming, too expensive, too patient unfriendly, too test-oriented and not nearly enough followup, chronic management, oriented.” – Dr. Barbara Phillips President, American College of Chest Physicians

10 DSP | Spring 2018

As the CEO of Airway Management, I’ve been fortunate to serve clinicians on the front line for the last 16 years. To effectively support the community, we constantly evaluate the big picture of dental sleep medicine and look for evidence of future growth and market direction. It involves thinking like a business, too. The Dallas Business Journal included Dr. Thornton’s original vision: “I am trying to develop a disease management approach that is more USER friendly, has more options for the patient and is much less expensive.” There are several significant signs that indicate the Dental Sleep Medicine segment is in fact poised to become main stream. This will radically increase the number of patients treated with oral appliance therapy, good for my company but, far more importantly, good for our population health.

1. The current medical approach is not working.

Most professionals would agree that a huge percentage of our population is afflicted with some level of sleep disordered breathing. It has been reported that the CDC considers Sleep Apnea to be an epidemic. The numbers range from 25 – 40 million undiagnosed sleep apnea patients. The full sleep disordered breathing range, including snoring puts the number at close to 90 million, and that’s just in the United States. Getting a patient diagnosed has changed from only clinic-based, overnight events to home-based, portable studies. They can still be difficult to access because of the need to see a physician with special training. These doctors are often scheduled for weeks ahead and, in many communities, very few in number. Not only are people not getting diagnosed, but the most common treatment, utilizing a

by Charles F. Collins CEO – Airway Management

CPAP machine, has very poor compliance. It doesn’t really matter how good the treatment is if the patients don’t use it. A recent publication from Stanford stated: “Approximately 1% of all obstructive sleep apnea patients are receiving treatment at the present time.” A diagnostic protocol that is expensive with numerous barriers has proven to be ineffective in diagnosing large numbers of patients. A treatment protocol that is expensive and difficult to achieve compliance is ineffective for the majority of patients that need help. But, I think you already know that… What is new is the rapidly shifting mindset of a growing number of physicians, like Dr. Barbara Phillips, the president of the American College of Chest Physicians, who said “The diagnosis and management of sleep apnea to this point, has been, in my view, too complicated, too time consuming, too expensive, too patient unfriendly, too test-oriented and not nearly enough follow-up, chronic management, oriented.” Drs. David Gozal and Atul Malhotra, both past presidents of the American Thoracic Society, agree. Furthermore, Dr. David White, Chief Medical Officer at Respironics, Inc., said that “CPAP was not great to begin with and “there are great opportunities for new therapies”

2. The ADA recommends that all Dentists should screen patients for Sleep Disordered Breathing.

For the first time, the ADA has taken a leadership role to finding a new path. Enlisting the 150,000-strong army of Dentists in the fight against sleep apnea will absolutely improve health care in America. These dedicated professionals are perfectly suited to getting patients diagnosed and properly treated. If our health care system has any chance of helping the millions of patients breathe better at night, getting oxygen in the bloodstream and avoiding all the related medical conditions, we unequivocally need dentists in the lead. Having the ADA support this cause will make a big difference. Pioneering Dentists can

COVERstory

Dentists – now count on a very large lobbying entity to change the political environment and support their membership in the quest to help their fellow citizen.

3. The FDA has cleared simple, low cost, oral appliances for over the counter sales.

In most countries, these appliances are already sold at pharmacies and online stores, without a required prescription. Because of the massive number of people afflicted with sleep disordered breathing, removing this regulation will allow people to become knowledgeable about oral appliance therapy. We live in a capitalistic society and the invisible hand will guide investments to satisfy this enormous market. The entrepreneurial spirit will be unleashed to make sure everyone knows that advancing your mandible forward a few millimeters makes a big difference in your life expectancy. This will eliminate one of the biggest obstacles to treating the population: Knowledge that oral appliance treatment exists and works. Don’t be fooled that cheap over the counter products will ruin the professional market. They actually support the professional market by doing the hard job of educating the general population. People can brush their teeth and floss on their own. But, they still go to the Dentist for professional cleaning and proper maintenance of dental health. And they will also go to the Dentist for professional sleep disordered breathing care.

4. Large multinational and Private Equity companies have recognized the opportunity.

In the last couple years, large multi-billion dollar organizations have decided to invest in this segment. Here’s a few examples: • ResMed has operations in 72 countries. In 2009, it introduced the Narval oral appliance. Since then, they DentalSleepPractice.com

COVERstory

Dr. Thornton’s TAP devices, the Thornton Adjustable Positioner, has proven to be a simple and effective tool.

have invested tremendous sums of money to perfect and market the device. As the founder of CPAP and leader in the multi-billion-dollar market, it would appear that this investment would cannibalize their CPAP market and lower overall revenues. Unless they expect the oral appliance market to be much bigger than the CPAP market. • In 2016, a large private equity fund named Health Point Capital sold MicroDental Laboratories. They spun out a new company from MicroDental just prior to selling, named ProSomnus Sleep Technologies. Selling a profitable, large dental laboratory and investing in a start-up oral appliance business would seem like a foolish move, unless they projected huge market opportunities in the oral appliance market. • SomnoMed, a leader in the oral appliance segment, licensed a direct to consumer model. Frustrated that the oral appliance business is not reaching significant market share, they decided to go direct to the public. Employing their own medical and dental professionals in a DSO, they are investing significantly in the business-to-consumer model. Even at the risk of alienating their core clients by competing directly against them. Why would they make such a risky strategic move, unless they projected it would eventually increase their unit volume way beyond the established lab-to-professional model?

What does this mean for me?

As you contemplate the signs that the DSM world is changing, the next thought is, “What do I need to do to ready myself and my practice?” If the approximately 5,000 DSM dentists in the US treated the 90 million patients, each dentist would need to treat 18,000 patients. We need all hands on deck!

12 DSP | Spring 2018

Fortunately, the cottage industry has grown since Dr. Thornton first introduced the TAP 1 in 1996. We now have very good companies to help Dentists learn about DSM and oral appliance therapy. This includes several trade groups that offer certificates and diplomas. We have companies that support dental practices with the necessary practice management techniques and tools. We have excellent companies that help the dentist get paid for their services. We have great media organizations, like Dental Sleep Practice, to serve as a rally point for the industry and share the latest information. The educational and practice management services are readily available to provide the skills and knowledge for any dentist to participate in this critical community medical service. Your friends, colleagues and neighbors need your help.

Devices

The treatment provided by Dentists most commonly involve oral appliances, referred to as Mandibular Advancement Devices (MAD). The FDA has cleared over 100 appliances to be used to treat obstructive sleep apnea. Although many appear to be similar, the choices can be a bit overwhelming. Mastering the delivery and adjustments for multiple devices can become an obstacle for the Clinician. The investment to master the devices can be simplified by using the TAP system. Dr. Thornton’s TAP devices, the Thornton Adjustable Positioner, has proven to be a simple and effective tool. Here’s some of the reasons most DSM Dentists have chosen to use the TAP appliances every day. • It works ¡ Since 1996, the TAP devices have been used in over 36 peer reviewed studies. These studies compare the effectiveness of oral appliance therapy, many studies are compared to CPAP. For mild to moderate OSA, the TAP devices indisputably

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COVERstory

Our time is nearly at hand. By offering increased treatment options that are far less invasive, we will get more people treating their SDB.

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work. No other appliance has been studied to this level. • It’s Simple ¡ The single point of adjustment eliminates any concern about changing the midline that is a potential negative issue with all bi-lateral adjustment devices. Over-adjust one side and TMJ issues flare up. • It can treat the widest range of Sleep Disordered Breathing ¡ Snoring and Upper Airway Resistance – myTAP / dreamTAP ¡ Mild to Moderate OSA – myTAP / dreamTAP ¡ Severe OSA – dreamTAP + TAP PAP CS • It has the most options and features – customize for any patient ¡ 15mm protrusion range – biggest in industry, by double. - Establishing the initial protrusion is not crucial. It will always work. ¡ Multiple tray systems - TAP Classic - Urethane lined or ThermAcryl lined - Many custom trays from lab partners - Glidewell – 5 colors with Urethane lined trays - National Dentex – Crystal Clear® Thermoplastic - Great Lakes - Rhea® custom fit trays ¡ All hardware made in the USA from CrCo alloy. - The most bio-compatible alloy for the oral environment ¡ 10 mm of lateral excursion with no posterior obstructions - Perfect for lateral bruxers – the majority of OSA patients. ¡ Every case comes with a free AM Aligner

Charles F. Collins began his career with Airway Labs in 2002; after holding multiple positions within the company, including General Manager, was promoted to Chief Operations officer of Airway Management. In 2017, he was promoted to CEO. Both Airway Labs and Airway Management recorded their most profitable and continuous revenue growth in years while under his leadership. His ability to stabilize operations and contain costs while maintaining aggressive product development has afforded Airway success without the need of outside capital. Under Charles leadership, Airway has grown from a one product company to now include a full suite of products that treat all levels of sleep disordered breathing and assist each patient in various life stages/diagnosis.

14 DSP | Spring 2018

- the industry standard to treat the most common side effect • Work with your most trusted lab partner ¡ The TAP appliance can be ordered from over 150 authorized dental labs in North America. ¡ Work with the technicians you know and trust. Our family company, Airway Management, has been around long enough to have developed a full suite of products that offer treatment at all levels of sleep disordered breathing and assist each patient in various life stages/ diagnosis. Our lead product, the dreamTAP, is now the 5th generation of the TAP appliance. We continue to reinvest in research and development. You can expect more innovations from Airway Management. For 2018, we are launching an online educational and training platform for how to use the TAP system and how to build TAP appliances. Always up to date and accessible from any device with a web: browser, desktops, laptops, tablets and phones. • www.TAP.wiki is a free site that shows how to use the suite of products. Drill down quickly for specific topics like “how to change hooks”, “appliance design options” or “seating a ThermAcryl lined dreamTAP”. ¡ There are over 30 guides, which can be downloaded and printed. Complete with lots of images, documents and videos. ¡ Great for Dentists & staff, Lab representatives and technicians. • www.TAPlab.wiki is a free site that has all our work instructions for dental laboratories. ¡ This is for authorized TAP manufacturing partners only ¡ Can only access via invitation from Airway Management. ¡ Great for training, always up to date.

In Conclusion

To my friends in the Dental Sleep Medicine business: Our time is nearly at hand. By offering increased treatment options that are far less invasive, we will get more people treating their SDB. Instead of 10% getting treatment with CPAP only, we can move the needle and make it 90% with oral appliances. Together we can make a significant contribution to our communities and improve the lives of millions of our neighbors. As Anne Frank said: “How wonderful it is that nobody need wait a single moment before starting to improve the world.”

PROBLEMsolving

Compliance Monitoring in Oral Appliance Therapy for OSA â&#x20AC;&#x153;Time to Level the Playing Fieldâ&#x20AC;? by Neal Seltzer, DMD, FAGD, D.ABDSM, D.ACSDD, D.ASBD

he time-tested, leading treatment options for Obstructive Sleep Apnea have been variations of surgery, Positive Air Pressure, Oral Appliance Therapy, or any combination of the three. There have been several other valid attempts to treat OSA such as EPAP (expiratory positive air pressure), hypoglossal nerve stimulation, weight loss, and positional therapy.

DentalSleepPractice.com

PROBLEMsolving All treatments must be proven to work by an efficacy study showing reduction of a patient’s AHI and ODI to a healthy level. In the cases where surgery has been performed, if efficacy is proven successful the patient is deemed “cured”. For treatments that require the cooperation of the patient People tell their dentists using technology such as a PAP mathat oral appliance chine, an oral appliance, EPAP, or positional therapy, compliance is vital in therapy has given them assuring that the results are consistent. Compliance is necessary to ensure an answer where other effective treatment. CPAP machines treatments have failed. have had the advantage of built in smart cards and modems to record and transmit data for years, enabling physicians to monitor patients’ usage. The definition of compliance use for CPAP has been “a minimum of four hours of use per night and a minimum of 21 nights in a 30-day period”. The bar has certainly been set low for CPAP compliance. This is most likely due to the difficulty so many patients have living with CPAP. Inherent issues CPAP present such as intolerance to air pressure, ill-fitting masks, noise in the bedroom, maintenance of the machine, and a myriad of side effects such as facial sores, dry mouth and airway, upper respiratory infections, and ingesting air into the stomach, to name a few. According to recent studies, up to 83 % of patients with OSA were reported to be non-adherent to CPAP treatment within several months of initiating treatment. In addition, people forced to wear CPAP to prove

compliance for work related issues have often tampered with the compliance monitoring to “fool” the machine. Some examples of this tampering include having other people wear it for them or staying awake for the four required hours while they use it and sleeping the rest of the night without it. Non-compliance results in continued morbidity, daytime sleepiness, poor work performance, affects systemic illness, increased medical costs and increased mortality from health-related deaths, as well as traffic, transportation, and industrial accidents. It has taken the medical world quite some time to “warm up” to the concept of Oral Appliance Therapy as a valid treatment option for Obstructive Sleep Apnea. For over two decades, the dental community has worked diligently and proven, through research and science, that oral appliances can be equal to and sometimes better than CPAP in helping patients conquer OSA Efficacy studies have shown that oral appliances do indeed work. People tell their dentists that oral appliance therapy has given them an answer where other treatments have failed. Despite these remarkable, life changing, success stories, there has remained one hurdle to truly enabling Oral Appliance Therapy to compete with CPAP in the eyes of the medical world. That hurdle has been an inability to prove compliance like there is with CPAP therapy...until now. It is time to level the playing field. In June of 2015, the FDA cleared select appli-

Dr. Neal Seltzer is a dentist in private practice on Long Island, New York. He received his dental degree from Tufts University in Boston, MA. He continued his education in a general practice residency at Bird S Coler Memorial Hospital in New York City. He was an Assistant Professor, NYU School of Dentistry in the Department of Restorative Dentistry, where he served as the Director of an outreach clinic for special care and geriatric patients. He has also served in the Department of Oral Medicine specifically related to teaching about treating Obstructive Sleep Apnea. He is currently the Clinical Director of the Equipoise Dental Center in Bergenfield, NJ. He has been so for over 20 years. This is a world renowned teaching facility that teaches the Equipoise philosophy of prosthetic design based on physics and engineering principles. Dr. Seltzer has published articles on this topic and has lectured throughout the United States, as well as Canada and Mexico on this topic. He is a Fellow of the Academy of General Dentistry. For over 25 years, his dental practice has focused on Oral Appliance Therapy to treat obstructive sleep apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, Diplomate of the American Sleep and Breathing Academy, and a Diplomate of the Academy of Clinical Sleep Disorders Disciplines. He was one of only five dentists in the country chosen by the American Sleep and Breathing Academy to speak in Washington D.C. before a congressional caucus on the effect of undiagnosed and untreated obstructive sleep apnea.

16 DSP | Spring 2018

PROBLEMsolving ances to incorporate the Braebon DentiTrac microrecorder into their design. The micro recorder, approximately the size of a fingernail, is embedded into the oral appliance. Itâ&#x20AC;&#x2122;s tiny CPU measures temperature change, time, and positional changes via a triple axis accelerometer. This data is transferred using infrared signals to a proprietary reader and then downloaded to create reports yielding the compliance information. This remarkable device enables the doctor to record: number of days used; days since first use; average daily use; average weekly, monthly and semiannual information; and positional information. Additionally, it is HIPAA compliant, has a 6-month memory and a 5-year power supply. Probably the greatest attribute this tiny compliance monitor brings to the field is its high reliability based on sophisticated algorithms. This accuracy, along with the fact that oral appliances are custom made for an individual and cannot be worn by anyone else, ensure results that are virtually tamper proof. The ever-growing public safety issue of undiagnosed and untreated OSA has made the highways, railways, and air travel industry a concern for all. The increased association of sleep apnea related transportation accidents has influenced the federal government and many states to instill laws mandating testing for sleep apnea. Along with pressure from insurance companies, workers who can affect the safety of the public and who test positive for sleep apnea must be treated successfully and show compliance. Although things are progressing in the right direction, some obstacles still need to be addressed. Adding the compliance recorder adds additional lab cost and overhead expense for downloading from the recorder and generating a report. Despite the added benefit of compliance for the patient, the public, and ironically the insurance companies themselves, they have not recognized this value and there are no provisions for insurance companies to pay for this additional cost. This will come down to a business (marketing, branding, service mix) decision for the dentist. Ultimately, the patients will pay. Until recently, CPAP was the only technology capable of proving compliance. Unfortunately, many individuals cannot tolerate CPAP. With the new laws in place, these individuals will not be able to prove compli-

ance and therefore will not be able to legally work or meet insurance standards. However, with the advent of compliance monitoring in oral appliances using the DentiTrac, an alternative treatment option is now available. Moreover, according to Braebon, objective data gathered to date in early stage university studies confirm subjective data recorded over the last two decades showing Oral Appliances, with their high compliance rate of close to 90% over a long period of time, and an average daily use of almost 8 hours (double the standard for CPAP), are an excellent treatment option for treating OSA in general and when compliance is mandated for industry and public safety.

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DentalSleepPractice.com

TECHNOLOGY

Digital Scans and Digital Bite Record for Oral Sleep Appliance Fabrication by Gregory K. Ross, DDS

he fabrication of custom oral sleep appliance has conventionally required dental impressions and a bite record of the therapeutic starting point. Once this is done these records must be shipped to the dental lab. Shipping the records can add several days to the construction process of the appliance. In addition, the impression procedure in general is one that patients do not look forward to and may even forgo a dental appliance just to avoid it. Recently, intra oral scanners have proliferated giving the patient the option of digital scans without any type of impression material in their mouth. A series of pictures are taken of the patient’s dental arch and stitched together with software to create a digital dental model. Manufacturers also claim that appliances made from these models are more accurate than those made from conventional dental impressions. This article shows you what is needed to fabricate an oral sleep appliance using digital scans and a digital bite. The flow chart shows the steps from start to finish. Figure 1 shows the occlusion of a patient in need of a sleep appliance. In this patient, the therapeutic bite was taken using an Airway Metrics gauge (Airway Metrics LLC, Tacoma, USA) as seen in figure 2. The first step

when using an iTero scanner (Align Technology, San Jose, USA) is scan the upper arch then the lower arch. Then the construction bite must be recorded using the dentist’s method of choice, such as shown in Figure 3a. Here the patient’s bite is supported in the anterior using a Pro Gauge (Airway Management, Carrolton, USA) with polyvinyl siloxane where the dentists wants the initial position of the appliance. With this in place the right buccal and left buccal are scanned to record the bite as shown in figure 3b and 3c, respectfully. Once we have the upper arch, lower arch and bite scanned in, the itero softSteps to Fabricate an Oral Sleep Appliance Using Digital Scans and a Digital Bite Step 1 Dental Office Scans Maxillary Arch Step 2 Dental Office Scans Mandibular Arch Step 3 Dental Office Scans Therapeutic Bite Step 4 Dental Office Processes Files into Stereolithography (STL) Format Step 5 Dental Office Uploads STL Files to Dental Lab through Online Portal

Figure 1: Intraoral photos showing the right buccal, center buccal and left buccal of an OSA patient in maximum intercuspation.

Step 6 Dental Lab Prints 3D Models of Mx, Mn and Bite Step 7 Dental Lab Mounts Models and Fabricates Appliances as Usual

Figure 2: Intraoral photos showing the right buccal, center buccal and left buccal with Airway Metrics guide in place showing therapeutic position of the same patient in Figure 1.

18 DSP | Spring 2018

Step 8 Dental Lab Sends to Dental Office for Delivery to Patient

TECHNOLOGY

Figure 3a: Intra oral picture showing a construction bite using a shortened Pro Gauge with polyvinyl siloxane index of the anterior teeth.

ware will create a digital file in the bite position as shown in Figure 4 which is the same patient as in Figure 1. This file can then be converted to Stereolithography (STL) files which can be electronically sent to a dental lab. This avoids shipping time delays. Different scanners produce STL files natively and do not require conversion. Once the lab processes the STL files of the upper arch, lower arch and bite, all three can be 3D printed. Then the lab mounts the case in the therapeutic position as shown in Figure 5. From here the lab fabricates the oral sleep appliance as they normally would do such as the one in Figure 6, made for the patient in Figure 1. The advantages of this method are improvements of the doctorâ&#x20AC;&#x2122;s work flow with the elimination of initial shipping of records and impression materials, patient comfort by avoiding traditional impressions and more accurately fitting appliances as found with aligners made from digital scans verses from impressions. This method will most likely, become the standard of care for fabricating oral appliances in the near future.

Figure 3b: Right intra oral showing itero wand and bite gauge in position to capture right side of therapeutic bite.

Figure 3c: Left intra-oral showing iTero wand and bite gauge in position to capture left side of therapeutic bite.

Figure 4: Right, center and left views of digital scans in therapeutic position as seen Figure 2.

Figure 5: Right, center and left views of 3 D printed upper arch, lower arch and bite record use to mount on an articulator to fabricate an oral appliance.

Figure 6: Right, center and left views of an oral appliance made through digital scans and bite record for patient in Figure 1.

Gregory K. Ross, DDS, is a diplomate of the American Board of Orthodontics. He is in private practice specializing in orthodontics and dental sleep medicine in Forest Lake, MN and Hudson WI. He received his dental degree from the University of Minnesota, School of Dentistry in 1990 and received the Dentist Scientist Award the same year. In 1995, he received certificate in Orthodontics from the University of Minnesota, School of Dentistry. Also, he is the inventor of the patented Ross Appliance to treat snoring and obstructive sleep apnea. He is a member of the American Association of Orthodontist, American Academy of Dental Sleep Medicine, American Sleep and Breathing Academy and the American Academy of Craniofacial Pain.

DentalSleepPractice.com

LABcommunication

The Value of Making Oral Appliance Labs Part of Your Team by Steve Marinkovich, DDS

he value of a good working relationship with your dental lab cannot be overestimated. Long before I started treating Dental Sleep Medicine patients, I became aware that a lab could make or break a dental practice. In the past for me, it was crowns, bridges, night guards and removable prosthetics. Now itâ&#x20AC;&#x2122;s Oral Appliances for Sleep Apnea and Snoring. However, what I learned in those earlier years serves me well now.

Letâ&#x20AC;&#x2122;s start with the size and location of the lab. I was never one to use large or distant labs in those days. I always liked to keep it local and small. My intent was to have as much control over the final product as possible without going to the time and expense of having an in house lab. I physically spent much time at the lab, not to mention almost daily phone contact. However, once I converted to Sleep Appliances, that type of interaction was not possible in my community. It became necessary to change my approach and find a lab out of the area. I could no longer run down the street and have face to face contact with my lab person. I felt that the company that designed a particular appliance would be the best place to have it made. First, I decided which appliance I wanted to use, and then found who would do the best job making it. Iâ&#x20AC;&#x2122;ve discovered that many labs have the expertise to perform quality work on several different Oral Appliance designs.

20 DSP | Spring 2018

I had to develop new ways to communicate, but in this day and age that was not a big problem. I still wanted, however, to build relationships with the lab techs that were directly associated with fabricating my appliances. Many of the larger labs had local reps and they could introduce me, over the phone, to the actual techs that were responsible for my cases. When that was not possible, the alternative was to speak to supervisors who had direct contact with the lab techs. This was not what I was used to, but I could make this work. Many of these lab techs are, in fact, very knowledgeable because they have worked with dentists who have made many more appliances than I have. I have always sought out techs that were not only experienced, but easy to communicate with, and accessible. When either of those two factors were not working out, and did not seem rectifiable, I would find a new lab. Incidentally, if you are just getting start-

LABcommunication

only

ed, ask other more experienced dentists who they would recommend. In terms of communication, I have even gone to the extent of drawing detailed diagrams of exactly how I want ball clasps placed in the appliances for added retention. I look for labs that are consistent and reliable in quality. Also, having appliances delivered on time is vitally important. You cannot have your patient show up for a delivery and the Oral Appliance not be on hand. More than once, I have found that labs that are doing well for a TEAMWORK is the while by all my criteria, would deway for a relationship teriorate over time. This becomes frustrating but must to survive. particularly be considered part of an ongoing process of continued open communication. My theory is that labs decline periodically because they have trouble estimating how many OAs will come in at any given time. Plus, more dentists are beginning to treat Sleep Apnea. Thus, labs get overwhelmed and the quality can suffer. They hire/train techs, but underestimate the learning curve involved in making a good Oral Appliance. It is my thought that a lab will try much harder in the early working relationship and this will sometimes decrease over time. More than once I have worked with a lab, moved on to another lab, and then gone back to the first. This is, of course, not the best business model but it must be considered as a possibility. Techs in larger labs change over time and thus so does the quality. To help them help us, we must always strive to be consistent from our end as well. For better dealing with lab techs and companies, find those that are willing to have

Dr. Steve Marinkovich has been in private practice in Tacoma, WA since graduating from the University of Washington Dental School in 1976. He has spent more than 20 years as part time faculty in the Restorative Dental Department of that school. He holds fellowships in both the American and International Colleges. He also served on the Washington State Board of Dental Examiners for six years. He has practiced Dental Sleep Medicine for over twenty years and has restricted his practice to that discipline for the last three plus years. He is a Diplomate of the American Board of Dental Sleep Medicine, and his clinic is accredited by the American Academy of Dental Sleep Medicine.

22 DSP | Spring 2018

constructive conversations. That said, I must be able to take constructive criticism myself, and this can be very difficult for dentists to do. Itâ&#x20AC;&#x2122;s called TEAMWORK and itâ&#x20AC;&#x2122;s the only way for a relationship to survive. There are other responsibilities on the part of the dental office. First, and foremost, is providing the lab with excellent study models (impressions scanned or not). I prefer to take standard impressions and pour the models myself at my office. How to accomplish this is fodder for another column, but suffice it to say you have NO leeway in this responsibility. For most appliances, you will also be providing an accurate bite registration, which provides the lab a starting position for the Oral Appliance. This needs to be accompanied by clear, concise instructions which often need to go beyond just checking off some boxes on the standard Rx forms. Take no shortcuts here. You must have the ability to explain precisely what you expect. It would be nice to think that the lab keeps a log of your likes and dislikes, and hopefully many do. Do not assume that this is universally true. Take the particular lab slip for each lab, add your specific preferences to it. Then make copies, and use those with each case. That way you do not need to keep writing the same added instructions on each Rx. For me, these added notes include: Do not place ball clasps between last two teeth in the arch (more chance of opening contacts), advice on particular starting position with the advancement mechanism (i.e. start at 0.5 mm advancement, which leaves the possibility of backing up the OA slightly if necessary), wrap the distal of the last tooth in the arch when impression permits and cover at least the mesial marginal ridge of the third molars, if erupted. Many times I will add additional notes when I deem it necessary. Another example would be on cases where, for one reason (short, unretentive teeth) or another, I think retention will be an issue. With those cases, I suggest a way to handle the situation, or ask them to call me to discuss options. To some degree, it helps to learn what obstacles the labs face with regard to materials and procedures. Do not expect the lab to get it right every time, and be willing to admit when the problem originates at your dental office.

LABcommunication Don’t get everything right up to mailing the case and then do a poor job of packing the models (for non-scanned cases). That creates the chance that they will arrive at the lab damaged. Always leave the door open for timely contact and conversation. This starts with interviewing the lab with which you hope to work. If you get bad vibes early on, or they don’t even have time for conversation, it’s best to keep looking. While writing this article, I interviewed a long time lab tech with a large US lab to get his perspective on where he thought things tend to go wrong. Here is a synopsis of that conversation. 1. Not enough information or correct information on the Rx form. Apparently, labs for Sleep OAs have been required to become medical device companies and thus must consider the prescription gospel. They cannot proceed unless everything is filled out: doctor’s name, patient’s name, device type and retention type. He said that more cases are held up for this reason, than any other. Be sure to make your instructions legible. Labs are sometimes reluctant to call to tell you they can’t read what you wrote. Plus, it just adds more time to the procedure for no real reason. 2. Insufficient models/impressions/bites. He said many cases are stopped for poor model work, bite registrations with no verticals, no coverage of posterior teeth, rocking or deviated bites. Also, requests like, “make it work”, “open up or close the bite a little”, drive them crazy. This reminds me of a story from my general dentistry days when my lab tech was sent a die only and was asked to remake a crown on it. Problem: There was no impression of the approximating teeth or opposing occlusion. When the tech questioned the dentist, he said “JUST REMAKE IT! You lab guys always want to work under ideal conditions!” Seriously. That really happened. 3. Lack of communication. Please tell the lab which is the best way to communicate with your office (email, phone, etc.) and to whom they should talk. Let them know the best time to

call. Don’t just tell them what is going wrong, but also what is going right. I personally like labs that send questionnaires along with the cases, as long as they actually read them when I send them back. In fact, I am surprised more labs do not do this. I had a lab, in my crown and bridge days, that sent the questionnaires with their cases, and coincidentally, they were one of the best labs I ever used. Could there be a connection?

Final thoughts

Labs would agree, we are all in this together. We both want the same thing, which is to provide the best service to our patients. It is not always easy, but keeping the door open to great communication is the key. In the end, there is no use in creating a contentious relationship. There are many dentists, and there are many labs. Finding and maintaining a good working relationship takes time. Unless the door actually closes, always (that’s always) strive for frequent contact and constructive conversation. Try not to burn bridges, because at some point you may need to come together again. Remember, we need to all work on this very difficult healthcare problem together and our patients will all benefit. If we accomplish this, we will have a win-winwin situation.

DentalSleepPractice.com

PRACTICEmanagement

Don’t Price Yourself Out of the Game by Randy Curran

ver the past several years billing sleep appliances for dental practices, I’ve had the opportunity to witness many successes and failures. Success can be achieved through a process of these steps: getting effective training for the doctor and team, giving team members optimal time and resources to implement new practices, using a third-party billing service for at least the first year or two, and most important – putting patient care first. Bottom line, do everything you can to ensure your patients’ finances don’t stand in the way of the treatment they need. In my experience, many practices have expressed with me that their biggest hurdle is getting their patients to own their treatment and move forward. Countless practices are on the verge of giving up on treating sleep due to patients’ reluctance to accept treatment. There are usually two common factors that cause this: a lack of understanding on how to quote the patient using their insurance benefits, and always reaching to get $3,500 -$4,000 on every patient they treat. Practices shouldn’t get stuck on specific numbers, because they heard it from their former classmate across the country. Policies, plans and reimbursement rates vary state by state. Great payments will come as long as you stay the course and treat more patients. Most patients want to use their medical insurance and keep their out-of-pocket cost below $600. The practice can usually do this by obtaining a GAP waiver that uses the in network benefits, and also by keeping the minimum amount expected to collect on Randy Curran is the founder and CEO of Pristine Medical Billing. After 5 years as Director of Operations for a CPAP care company, he realized that the wave of the future for compliance was treating mild and moderate Sleep Apnea patients with an oral appliance. In 2012, he started helping dental practices across the nation understand medical insurance coverage and how to help patients accept treatment. He has now helped hundreds of dental practices and collected over 22 million dollars on behalf of these practices.

24 DSP | Spring 2018

each patient between $2,200-$2,600…depending on the state that they’re doing business in. Key word there was minimum. Many times the insurance carrier will pay more and at the end of the annual cycle, the practice will find that they averaged well over $3,000 per patient treated. Our job as your third-party partner is to give our clients what we think the insurance will pay, and to just let the practice charge the difference. For example, if a patient has met their deductible and we think a payer is going to reimburse at least $1,800 or more based on their benefits plan, the practice will then charge the the patient $600 to get to the minimum $2,400 mark. The appliance is around $500, and our charge in that situation is $99 – so that still leaves at least $1,800 or more in gross margin. When I tell some dentists to do this, a lot of times I’ll get push back – saying they can’t make enough money on it. So then, I ask them the following questions: “Will you bring in more revenue by treating 2 patients for $3,500 per month minimum, or by treating 10 patients at $2,500 per month? “Will you drive more referrals from friends and families when you treat 10 patients or 2 patients a month?” Most important, “Are you working at your clinical potential – helping as many people you can help?” Think about those questions for a moment and how they will impact your patients’ lives, your practice and your life. Once we sit down and crunch the numbers, even the most stubborn practices change their expected amount, and see an immediate increase in patient acceptance due to keeping it simple and affordable for the patient. So keep treatment affordable and stay in the game. You will help more people and continue to grow your practice. It’s a win-win for all.

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PRODUCTstudy

Minimizing Side Effects

A Retrospective Case Series Analysis of Tooth Movement in Oral Appliance Therapy by Dr. Jerry Hu

ral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA) has been well established as a viable alternative to Continuous Positive Airway Pressure (CPAP) for lowering the Apnea Hypopnea Index (AHI). Recently the EFFECTS1 study (Effectiveness and Efficiency of the ProSomnus [IA] Sleep Device for the Treatment of Obstructive Sleep Apnea) demonstrated that Mean Disease Alleviation (compliance and efficacy combined) was equal to or greater than CPAP therapy. Exciting news to be sure, yet physicians are still hesitant to cross the aisle to work with dentists on this health epidemic. One reason often cited is the untoward side effects that can complicate treatment outcomes with oral appliances. At the 2017 American Academy of Dental Sleep Medicine meeting, Tom Schell, DMD, and Rose Sheats, DMD, MPH, presented a Consensus Conference preliminary report on Appliance Side Effects. One of the undesirable outcomes was tooth movement. The nature of flexible materials, unprotected or uncovered incisal edges and/ or imprecise fit of oral appliances leaves teeth more able to move during therapy2. Although open contacts, slight posterior interferences and other minor movements

3Shape Trios Scan and Little’s Index Measurements

26 DSP | Spring 2018

ProSomnus [IA] and MicrO2 Platform

are often well tolerated by patients, changes that affect esthetics are not. It would be preferable to minimize or even eliminate all unwanted tooth movement when treating an OSA patient. This study sought to determine if the new, precision milled devices, like the lingualess ProSomnus MicrO2 or [IA] with their rigid retainer-like fit would prevent or minimize such movement. For the study, Little’s Index3 and 3Shape Trios scans were used to perform an orthodontic analysis of where teeth were before and after treatment with a ProSomnus device for nine patients. Treatment times varied, with an average of 10 months and a range of 8 to 32 months. Scans were obtained from the before and after models and tooth position changes were as shown. The digital overlays provided objective data. Across the nine subjects, the there were no visible or perceivable changes in tooth position. The global variation was less than +/- 0.75mm with a 95% Confidence level, P-values >0.1. This result was better than Norrhem’s2 rigid appliance measurements and the observations of Rose et al., Chen et al., and Pliska et al. who found changes of between −1 to −2 mm in the lower teeth during treatment4. No statistically significant difference between Little’s Irregularity Index from the initial to the final models was observed. The precision milled, control-cured acrylic platform ProSomnus uses to design and manufacture their custom devices is superior to other cold-cured or flexible platforms in several ways. The denser material is less porous, easier to clean, stronger, and more precise; the close fit and stability likely is responsible for their retainer-like results. Like the fit and

PRODUCTstudy

Digital Overlay Showing No Statistical Changes

intended movement design for clear orthodontic aligners, the digital precision of the milled devices helps manage an unwanted side effect and may serve to allay a common perception of sleep physicians that tooth movement is inevitable. It is important to note that this result was accomplished using a lingualess appliance; the precision match to the buccal surfaces did not allow the unfettered tongue to move teeth, either. The ProSomnus [IA] and MicrO2 platforms are metal free and customizable to meet the doctor’s specifications, allowing for the highest level of precision dental medicine. The future is bright. With milled and printed CAD CAM devices (Computer Aided Design and Computer Aided Manufacturing), intraoral scanning, smaller compliance sensor and other innovations on the horizon, oral appliance therapy will continue to

improve. Dialogue with physicians, better compliance, treatment efficiencies, patient experience and effectiveness will drive payers to look at mandibular advancement as the first treatment option, even before CPAP. We are still challenged to model our protocols within the umbrella of medical care. The recent American Medical Association and American Academy of Sleep Medicine’s resolutions regarding the use of home sleep tests by dentists are not to be ignored. They speak to a deeper problem with what has traditionally been an anecdotal approach to care. By repeating and expanding studies like this one on side effects and sharing with medicine, we can strengthen the bond and gain a respected place in the health care paradigm for obstructive sleep apnea.

2. 3. 4.

Jordan Stern MD, David Kuhns PhD, Poster Presented at the World Sleep Society Oct. 2017. “Effectiveness and Efficiency of the ProSomnus [IA] Sleep Device for the Treatment of Obstructive Sleep Apnea-The EFFECTS Study” Niclas Norrhem, Hans Nemeczek and Marie Marklund “Changes in lower incisor irregularity during treatment with oral sleep apnea appliances” Sleep Breath. 2017 Jan 23. doi: 10.1007/s11325-016-1456-3. Robert M. Little, D.D.S., M.S.D., Ph.D. “The Irregularity Index: A quantitative score of mandibular anterior alignment” American J. Orthod. NOV1975;554-563 Benjamin T. Pliska, D.D.S., M.Sc., Hyejin Nam, Hui Chen, D.M.D., Ph.D., Alan A. Lowe, D.M.D., Ph.D., and Fernanda R. Almeida, D.D.S., Ph.D. “Obstructive Sleep Apnea and Mandibular Advancement Splints: Occlusal Effects and Progression of Changes Associated with a Decade of Treatment” J Clin Sleep Med. 2014 Dec 15; 10(12): 1285–1291.

Jerry Hu, DDS, DABDSM, DASBA, MICOI, FICOI, AFAAID, LVIF, FIAPA, FIADFE practices in Anchorage and Soldotna, Alaska. His practice is focused on Cosmetic, Implants, and Dental Sleep Medicine. He has published clinical research in all of these areas and has also lectured many times both nationally and outside of United States and won numerous awards for his treatment. Lingualess CAD Design with Incisal Coverage

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TMDseries

Temporomandibular Joint Anatomy as Related to OAT by Samuel J. Higdon, DDS

his is the fourth article in a series that has addressed the issues of Temporomandibular Disorders (TMDs) as they relate to providing Oral Appliance Treatment (OAT) for Sleep Disordered Breathing (SDB) such as Obstructive Sleep Apnea (OSA). In previous articles I have discussed the risks of developing a TMD in response to OAT (Winter 2016), what the Sleep Dentist needs to know about TMDs (Spring 2017), and what is involved in screening your SDB patients for potential TMDs (Fall 2017), even if there are no overt signs and symptoms of such problems. For those who find this information valuable, I recommend reviewing these previous articles prior to reading this fourth article, as I will reference several things I have mentioned previously. In this fourth article, I will discuss some aspects of the anatomy of the temporomandibular joints as it relates to potential TMD issues associated with OAT. The limitations of space prevent an in depth discussion of TMJ anatomy. However, a free ebook, Illustrated Anatomy of the Temporomandibular Joint in Function / Dysfunction with text and illustrations by this author, is available for download at http://tmjoregon.com/downloads/ TMJ_Anatomy_eBook.pdf/. This will provide a foundation for understanding many aspects of TMJ anatomy. In a recent issue of the Journal of Dental Sleep Medicine1 (JDSM), a panel of experts appointed by the American Academy of Dental Sleep Medicine discusses in some depth several potential side effects of OAT. It addresses four categories of side effects â&#x20AC;&#x201C; I will be discussing only those related to the anatomy of the temporomandibular joint. First, some context. It is important to appreciate that structural changes within the temporomandibular joints are common, as represented by a quite high prevalence of joint sounds, clicking and popping of the

28 DSP | Spring 2018

joints, caused primarily by displacement of the articular disc. Many studies have demonstrated that this occurs more frequently in females than in males. As just one indication of this high prevalence, Nebbe and Major2 found that in pre-orthodontic adolescents who presented for orthodontic treatment, MRI of the TM joints demonstrated disc displacement of 50% in males and up to 75% in females. Not only is the prevalence of disc displacement extremely common, the disc can displace in a number of directions (Fig. 1).3 This variability of disc displacement challenges some assumptions that have existed since disc displacements were first described by William Farrar in 1971.4 Most dentists are aware of how common joint sounds are but tend not to give them much consideration. As discussed in previous issues, the prevalence of joints sounds in a potential OAT patient should NOT be treated with complacency. An understanding of TMJ anatomy, in general, and its implications for OAT is essential knowledge for the Sleep Dentist. In all potential OAT patients, a clear understanding of the condition of the patientâ&#x20AC;&#x2122;s TM joints is a must. Therefore, a screening TMJ exam, (as previously described), must be done to minimize the potential for a problem of the temporomandibular joints developing in response to OAT.

Figure 1: Directions of Disc Displacement

TMDseries The authors of the JDSM side effects article list four sub-categories; 1) Transient morning jaw pain, 2) Persistent temporomandibular joint pain, 3) Tenderness in muscles of mastication, and 4) Joint sounds. A screening TMJ exam will reveal the likelihood of any of these to develop, providing the basis for an informed consent discussion with the patient prior to beginning OAT. I will describe three possible scenarios that might be encountered with OAT as related to the anatomy of the TM joints:

Joint Clicking/Popping With or Without TMJ Pain

Clicking and popping of jaw joints is common (Fig. 2). In a patient in which it occurs easily, with no indication of catching or locking, it will be important to evaluate for pain from the TM joints. Use palpation through the ear canal to the distal of the joint, as well as provocational joint loading. If there is no increase in pain in response to this testing, the potential for any untoward side effects from OAT are minimal. Your joint exam ruled out pain arising from intracapsular structures. Even when clicking/popping of the TMJs occurs easily, if pain is found from this type of joint examination, positioning the mandible forward for several hours is likely to unload the retrodiscal tissues and thereby relieve the intracapsular pain. This can be beneficial. However, after removing the Mandibular Advancement Device (MAD), the mandible would be expected to return to the original position within the fossa, allowing normal intercuspal position (ICP) of the teeth, but would allow loading the retrodiscal tissues again. If the patient had previously not been particularly aware of pain subjectively, from the joint(s), the re-loading of the retrodiscal tissues may produce joint pain that the patient will then notice, resulting in blame being assigned to OAT. They might discontinue using the MAD, seek other treatment, or create complications for ongoing OAT. It would be far better to have discovered the joint pain, prior to initiating OAT, and discussed it with the patient.

Joint “Reluctance” to Return to ICP Upon Removal of the MAD As discussed in a previous issue, it is considered standard protocol when doing OAT, to provide the patient with an “AM reposi-

Figure.2: Articular Disc Displacement with Reduction (Click/pop)

tioner” that encourages the condyles to resume their original joint position in the fossae, thereby allowing the dental occlusion to return to ICP. However, cases have been reported in which, after the condyles have been maintained in an “on disc” protrusive position for several hours, there has clearly been a “reluctance” of the condyles to resume their original position within the fossae, even with the use of the “AM repositioner”. The author has personally had this occur with his own jaw. The cause of this “reluctance” is not known with certainty but it is presumed that, once the condyle is able to assume an “on disc” position, the morphology of the disc, primarily the shape of the posterior band of the disc, is such that it is somewhat difficult for the condyle to once again move off the disc. When this occurs, the result will be a change in the dental occlusion, usually with a posterior open bite, most notable on the side of the affected condyle. There may also be a slight shift of the mandible away from the affected side as a result of a slightly more anterior condylar position on that side.

It is best to have discovered the joint pain and discussed it with the patient prior to initiating OAT.

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. He can be reached at TMJOregon@easystreet.net.

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TMDseries

Most dentists are aware of how common joint sounds are but tend not to give them much consideration.

It is difficult to anticipate when this may occur. It seems less likely to occur when clicking/popping of the joint, prior to OAT treatment, has been mild, indicating that the condyle is easily moving on and off the disc. When the tendency to maintain an “on disc” position does occur, the question then arises as to whether this new condylar position should be maintained, possibly requiring treatment of the resulting occlusal change, or whether the condyle should be allowed to return to its previous position, probably off the disc, and usually suggesting that OAT treatment is no longer a viable option for treatment of OSA. The considerations will vary, based on differing findings. But a decision to maintain the “on disc” position and to treat the resulting occlusal change is a challenging treatment option, requiring quite a lot of clinical experience. It definitely does not represent a conventional case of treatment of malocclusion and will often require a combination of treatment options.

Joint Pain Resulting From OAT

Joints that are most likely to become painful with OAT are joints that have either locked (disc displacement without reduction) or joints that have undergone degenerative changes (osteoarthrosis). In a joint that has locked (Fig. 3), certain clinical findings will be seen with a fairly high degree of consistency. With recently locked joints, opening range of motion will be limited and typically, with opening, the mandible will deflect toward the locked side. Similarly, there will often be a protrusive deflection toward the affected side and lateral condylar movement on the affected side will typically be less than on the non-affected side. However, in joints that have been locked for some time,

these clinical findings will be less apparent. Perhaps the most important finding that may suggest whether OAT is appropriate would be pain from the affected joint with any of the movements mentioned above. With a joint that is locked, the disc has been displaced and the condyle does not move on to the disc. The condyle, during any translatory movement, simply encounters the folded posterior band of the disc and, with protrusion, pushes on the disc. This can produce intracapsular pain. If, with the screening exam, joint pain occurs with joint movement, it may be possible to test the possibility for OAT with the use of a temporary trial appliance. The author has used several for this purpose. One possible temporary appliance would be the ZQuiet, which is available in several configurations from 0 mm to 6mm of protrusion. In joints that have undergone degenerative changes (osteoarthrosis), frequently these will be pain-free on examination, even when course crepitation can be heard with auscultation. If, in such joints, range of motion is near normal and no pain is produced with such movements, the patient may tolerate a MAD. However, caution will be the watchword and a temporary trial appliance may be a good starting point. There will be the possibility of joint pain developing in degenerative joints and change in the dental occlusion may be seen. Again, these are considerations that should be discussed with the patient prior to initiating OAT. Clearly, not all patients with mild to moderate OSA are candidates for OAT. When a patient does not seem to be an OAT candidate, there are other options. One that the author has used effectively is a tongue stabilizing device (aveoTSD), which, by utilizing suction on the tongue, brings the tongue forward to open the airway without having any effect on the position of the jaw. All Sleep Dentists are encouraged to become knowledgeable regarding the normal and dysfunctional anatomy of the temporomandibular joints. The ebook offered earlier in this article is a very good place to begin. 1. 2. 3.

Figure 3: Disc Displacement without Reduction (Locked)

30 DSP | Spring 2018

Therapy for Sleep-Disordered Breathing. J Dent Sleep Med. 2017; 4(4):111-125 Nebbe B, Major P. Prevalence of TMJ Disc Displacement in a Pre-Orthodontic Adolescent Sample. Angle Orthodontist. 2000;70(6):454-463 Tasaki MM, Westesson P-L, Isberg AM, Ren Y-F, Tallents RH. Classification and Prevalence of Temporomandibular Joint Disk Displacement in Patients and Symptom-free Volunteers. Am J Orthod Dentofac Orthop. 1996;109:249-262 Farrar WB. Diagnosis and Treatment of Anterior Dislocation of the Articular Disc. 1971; New York Dental Journal. 41(10):348-351

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&#x20AC;&#x2122;t be prouder to offer the very best in dental sleep.

CONTINUING education

Incision and Coagulation/Hemostasis Depth Control During a

CO2 Laser Lingual Frenectomy by Cara Riek, DNP, RN, FNP-BC, IBCLC, DABLS and Peter Vitruk, PhD, MInstP, CPhys, DABLS Introduction

Educational aims

This article addresses the control over (1) the Depth of Incision, and (2) the Depth of Coagulation / Hemostasis during a CO2 laser frenectomy, and (3) illustrates these concepts through a Case Study: the revision of a tongue tie that was previously released with a hot tip diode.

Learning objectives

Dental Sleep Practice subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader will: • Learn that laser’s ability to photothermally cut and coagulate soft tissue depends on laser wavelength. • Learn that CO2 laser is neither the best coagulator like diode, nor the best cutter like Erbium laser, but allows for just deep enough coagulation depth on the surgical margin when cutting photothermally. • Learn that the depth of CO2 laser incision is proportional to laser fluence. It is proportional to laser power and inversely proportional to laser beam diameter and hand speed. • Learn that the depth of CO2 laser incision during frenectomies can be adjusted to a fraction of a millimeter, while the depth of coagulation can be maintained under 100 µm for the utmost control and for the minimal collateral damage.

32 DSP | Spring 2018

The treatment for ankyloglossia is a lingual frenectomy,1 which leaves a diamond-shaped surgical wound (see Figure 1), the edges of which are either approximated and sutured or left to heal by secondary intention. Caution should be taken to control bleeding and not to disturb nerves and the salivary glands. With a CO2 laser frenectomy, patients reported less post-operative pain and discomfort than with the scalpel.1,2 A CO2 laser cuts, while coagulating capillaries and small blood and lymphatic vasculature; this creates a clear surgical site and helps preventing post-surgical edema. Typically, a tongue-tie revision with the CO2 laser does not involve suturing, and the wound heals without a scar (see Figure 2). Normally, patients return to their everyday routine immediately after the frenectomy procedure, and are advised to follow with orofacial myofunctional therapy (OMT).1

Photo-Thermal Laser-Tissue Interaction

The key to the success of soft tissue lasers is their ability to cut and coagulate the soft tissue at the same time, which makes many soft tissue procedures much simpler and far more enjoyable for practitioners: consider bloodless laser blepharoplasty or laser

Figures 1-2: 1. Surgical site immediately after a lingual CO2 laser frenectomy. Immediately after the tongue-tie release, the patient could open her mouth to 46 mm. Immediately pre-surgery, the opening was at 36 mm. 2. Completely healed, scar-free tongue 4 weeks after the CO2 laser lingual frenectomy. By that time, the patient had undergone additional OMT work and was able to open to 52 mm – a 16 mm improvement (44%) over pre-surgery measurement.

CONTINUING education

Figure 3: Spectra of Absorption Coefficient, 1/cm, at histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2) in sub-epithelial oral soft tissue, and: Thermal Relaxation Time, TRT, msec; short pulse Ablation Threshold Fluence, Eth , J/cm2 ; and short pulse Photo-Thermal Coagulation Depth, H, mm. B is gingival blood vessel diameter.

frenectomy, etc. performed by modern day surgical CO2 lasers. Figure 3 presents the known optical absorption coefficient spectra of the oral soft tissue’s three main chromophores3-6 – water, hemoglobin (Hb) and oxyhemoglobin (HbO2), which are needed to understand the photo-thermal ablation (or photovaporolysis3,4) and photo-thermal coagulation (or photopyrolysis3,4) efficiencies for the soft tissue dental lasers7 on the market today: Near-IR diodes at 808 - 1,064 nm; Mid-IR Erbium lasers at 2,780 nm and 2,940 nm; and IR CO2 laser at 9,300 nm and 10,600 nm. As can be seen from Figure 3, both Erbium laser (approx. 3,000 nm) and CO2 laser (approx. 10,000 nm) wavelengths are highly efficiently absorbed by the soft tissue and, as will be shown below, are efficient at cutting and ablating the soft tissue purely radiantly (non-contact). At the same time, diode lasers (approx. 1,000 nm) are highly inefficiently absorbed by the soft tissue and, therefore, cannot be used radiantly (non-contact) for cutting and ablating the soft tissue. Besides the absorption coefficient spectra for the soft tissue’s main chromophores, their respective spatial distributions need to be taken into account: • The 100-300 µm thin5 epithelium layer with its optical absorption dominated by melanin and water. Incisional laser applications are

never limited to just epithelium; therefore melanin concentration is not instrumental in understanding the mechanisms of photo-thermal cutting and coagulating with laser light. • The sub-epithelial medium (connective tissue, inclusive of lamina propria and submucosa5) with its optical absorption dominated by water and hemoglobin/oxyhemoglobin. 75% water content is assumed for convenience; adjusting water content within 70100% range does not significantly alter main

Cara Riek, DNP, RN, FNP-BC, IBCLC, DABLS is the co-owner of Arizona Breastfeeding Medicine and Wellness. She is a board-certified Family Nurse Practitioner with a background in research and education. Her practice focuses on TOT release for infants through adults. She is also a member of the American Laser Study Club and Sigma Theta Tau. Dr. Riek can be reached at drcara@bfmedaz.com. Peter Vitruk, PhD, MInstP, CPhys, DABLS is a founder of the American Laser Study Club, and LightScalpel, LLC. He is a Member of the Institute of Physics, UK and is Diplomate of and Director of Laser Physics and Safety Education at the American Board of Laser Surgery, USA. Dr Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com.

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CONTINUING education results and conclusions of this study. Optical absorption depth spectrum for sub-epithelial soft-tissue with 75% water and estimated 10% blood presence in the human soft tissue5 (containing hemoglobin (and/or oxyhemoglobin) at normal concentration of 150g/ L5 flowing inside the blood vessels) can be easily derived from absorption coefficient spectra (presented in Figure 3) for water3-6, hemoglobin and oxyhemoglobin3-6. During photo-thermal laser-tissue interaction, the laser beam energy is absorbed (by tissue’s main chromophores – absorption centers) and heats the tissue inside the irradiated volume, which can result in tissue ablation and coagulation. Figure 4 is a one-dimensional approximation of a laser beam irradiating the tissue surface

(is graphically represented as a thin slice of a laser beam directed at the thin slice of the tissue) from the left, assuming pulse duration is essentially shorter than Thermal Relaxation Time TRT discussed later. Incident laser beam intensity is exponentially attenuated inside the tissue: I = I0 Exp [-x/A], where 1/A is absorption coefficient from Figure 3 (or attenuation coefficient if light scattering is taken into account). Assuming that laser intensity I0 immediately below the surface is greater than the threshold intensity required (for a specific pulse duration) to ablate the tissue locally, the tissue ablation takes place in 0<x<xa referred to as “Ablation Zone” in Figure 4 for short pulse steady state ablation conditions ( xa <<A ).6 Immediately below the ablation zone the heat affected zone xa<x<xc is located, with the tissue temperature ranging from the very high Ta (ablation temperature) at xa all the way down to the coagulation threshold temperature Tc at xc (i.e. Ta = 100 ºC and Tc = 60 ºC). Coagulation depth H = xc – xa, in Figure 4 is defined by 60-100 ºC temperature range5 inside the heat affected zone.

Thermal Relaxation Time

Figure 4: Simplified graphical representation of laser beam intensity attenuated inside the soft tissue.

Figure 5: SuperPulse settings feature high peak power and short pulse, which maximizes soft tissue removal rate and limits the escape of heat from irradiated tissue.

34 DSP | Spring 2018

Soft tissue ablation and coagulation efficiencies are influenced not only by absorption/ attenuation spectra described in Figure 3, but also by laser pulse duration and tissue’ thermal conductivity. The rate of how fast the irradiated tissue diffuses the heat away is defined through the thermal diffusion time, or Thermal Relaxation Time (illustrated by Figure 5) as TRT = A2/K,5,6 where A is optical absorption (or Near-IR attenuation) depth discussed above. The physics behind thermal diffusivity process is similar to diffusion and Brownian motion first described by Einstein. Coefficient K is tissue’s thermal diffusivity; K = λ/(ϱ C) ≈ 0.155 (+/-0.007) mm2/ sec (derived from heat conductivity λ ≈ 6.2-6.8 mW/cm ºC ; specific heat capacity C ≈ 4.2 J/g ºC, and density ϱ ≈ 1 g/cm3 for liquid water for temperatures in 37-100ºC range5). The most efficient heating of the irradiated tissue takes place when laser pulse energy is high and its duration is much shorter than TRT, as illustrated in Figure 5. The most efficient cooling of the tissue adjacent to the ablated zone takes place if time duration between laser pulses is much greater than TRT, also illustrated in Figure 5. Short laser pulse allows for the most efficient ablation of the irradiated tissue with minimum coagulation and hemostasis underneath the ablated tissue. For instance, rapidly

CONTINUING education pulsed CO2 lasers are efficient at cutting with minimal coagulation in applications like charfree stage II implant uncovering, gingivectomy, frenectomy, biopsy, de-epithelization, fibroma excision, etc. The least efficient heating of the irradiated tissue takes place when laser pulse energy is low and its duration is much longer than TRT. The least efficient cooling of the tissue adjacent to the ablated zone takes place if time duration between laser pulses is much shorter than TRT. For instance, long pulse and continuous wave (CW) CO2 lasers are less efficient cutters but provide for greater depth of coagulation for excising/incising in highly vascular and inflamed tissues like hemangioma.

Photo-Thermal Ablation/Cutting Efficiency

Just because water is the most prevalent and the most concentrated soft-tissue chromophore (unlike Hb and HbO2, see Figure 3), the most efficient soft tissue photo-thermal ablation (or photovaporolysis3,4) is a process of vaporization of intra- and extra-cellular water.3-6 For a fixed laser beam diameter (or spot size), the volume of the tissue exposed to the laser beam is proportional to the optical absorption (or Near-IR attenuation5) depth. The shorter the absorption (or attenuation) depth – the less energy is required to ablate the tissue. The longer the optical penetration depth – the greater the volume of irradiated tissue and, therefore, more energy is required to ablate the tissue within the irradiated volume of tissue. The minimum energy density requirement to vaporize the irradiated soft tissue can be calculated from the spatial distribution of laser light intensity inside the irradiated tissue (see Figure 4) for different wavelengths that are relevant to practical soft tissue dental Near-IR Diode, MidIR Erbium and IR CO2 lasers, for the steady-state conditions6 that are the most suited for high efficiency photo-thermal ablation (pulse duration ≤ TRT) with minimum collateral damage to the surrounding tissue (pulse repetition rate << 1/TRT). The ablation threshold energy density ETH spectrum is indicated in Figure 3, where the Near-IR wavelengths 800-1,100 nm are characterized by 100s-1,000s times greater photo-thermal ablation threshold energy densities than Mid-IR and IR wavelengths because of weak Near-IR absorption by the soft tissue chromophores. Near-IR 800-1,100 nm wavelengths (dental diodes’ operating wavelengths) are poorly

absorbed by scarce melanin in epithelium and by low concentration hemoglobin and oxyhemoglobin in sub-epithelium connective tissue, which results in multi-millimeter depth of laser energy penetration into the oral soft tissue. Such multi-millimeter ambiguity in tissue removal spatial accuracy at Near-IR wavelengths (often cited3-6 as “poor scalpels” and as “not conducive to precise ablation”) increases the collateral damage risk of overheating both soft and hard dental structures (enamel, dentin, implants, and bone) underneath the connective soft tissue if photo-thermal ablation is attempted. Such risk is referred to in8 as “vital structures … may be heavily damaged before tissue ablation at the surface initiated”; the 810 nm soft tissue absorption coefficient of 0.7 1/cm in8 makes its observations highly relevant to the present analysis where 10% blood absorbs at the rate of approximately 0.4 1/cm at 810 nm (see Figure 3). Unlike Near-IR wavelengths, the Mid-IR wavelengths (Erbium lasers) and IR wavelengths (CO2 lasers) exhibit much shorter absorption depths, see Figure 3, which makes Mid-IR and IR lasers far more spatially precise and safer in soft-tissue ablative applications. The ablation threshold energy density5,6 ETH for 75% water-rich soft tissue is 3 J/cm2 at 10,600 nm CO2 laser wavelength, as indicated in Figure 3. The Near-IR 800-1,100 nm wavelengths of dental diode lasers are characterized by approximately 1,000 times greater photo-thermal ablation threshold energy densities, also indicated in Figure 3, which makes the Near-IR photo-thermal vaporization of the soft tissue unfeasible.

Depth of Laser Vaporization/ Ablation/Incision

Immediately after the tongue-tie release, the patient could open her mouth to 46 mm. Completely healed, the patient was able to open to 52 mm – a 16 mm improvement (44%) over pre-surgery measurement.

For a laser scalpel, e.g., CO2 or Erbium lasers, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a cold steel blade. Greater laser fluence (i.e., power density times the duration it applied to the target) results in greater depth and rate of soft tissue removal. For short pulse steady state ablation conditions (xa <<A , see Figure 4),2,5,6 the ablation depth is: A (E – Eth)/Eth, where A is the absorption depth and Eth is the ablation threshold fluence from Figure 3, and E is the fluence delivered to the tissue. For repetitive pulses that are scanned across the soft tissue, the depth of incision is proportional to laser average power, and is inversely proportional to focal spot diameter and the surgeon’s hand speed (see Figure 6). DentalSleepPractice.com

CONTINUING education Efficiency and Depth of Laser Coagulation/Hemostasis

Coagulation occurs as a denaturation of soft tissue proteins that takes place in the 60-100°C temperature range3-5 leading to a significant reduction in bleeding (and oozing of lymphatic fluids) on the margins of ablated tissue. Photo-thermal coagulation is also accompanied by hemostasis due to shrinkage of the walls of blood and lymphatic vessels due to collagen shrinkage at increased temperatures. Since blood is contained within and transported through the blood vessels, the diameter of blood vessels B (20-40 µm5) is a highly important spatial parameter in considering the efficiency of photo-thermal coagulation. During soft tissue laser vaporization with pulses that are comparable to or shorter that Thermal Relaxation Time TRT, the coagulation depth H is proportional to the absorption depth of light in the soft tissue5 and is also presented in Figure 3: For H<<B (see Erbium laser wavelengths), optical absorption and coagulation depths are significantly smaller than blood vessel diameters; coagulation takes place on relatively small spatial scale and cannot prevent bleeding from the blood vessels severed during tissue ablation. For H>>B (diode laser wavelengths), optical absorption (Near-IR attenuation) and coagulation depths are significantly greater than blood vessel diameters; coagulation takes place over extended volumes – far away from ablation site where no coagulation is required. Extended

Figure 6: Laser-tissue incision with focused (0.25 mm spot size) laser beam; incision depth is 0.30.4 mm for 2 W SP F1-6 at 3-4 mm/sec handspeed. Defocused beam (> 1-2 mm spot size) with reduced fluence does not incise, but coagulates the tissue. The handpiece is pen-sized, autoclavable and uses no disposables.

36 DSP | Spring 2018

thermal damage zones for Near-IR irradiated soft tissue are documented in8; the 810 nm soft tissue absorption coefficient 0.7 1/cm in8 makes its observations highly relevant to present analysis with absorption coefficient of approximately 0.4 1/cm at 810 nm (see Figure 3). For H ≥ B (CO2 laser wavelengths), sub 100-µm5,7 coagulation depths extend just deep enough into a severed blood vessel to stop the bleeding; the coagulation is more efficient then for diode (H>>B) and Erbium (H<<B) laser wavelengths.

Near-IR Diode Laser Soft Tissue Ablation and Coagulation

Near-IR diode laser light circa 1,000 nm is not used to optically ablate the oral soft tissue; instead, the diode laser optical energy is used to heat up the charred distal end of the fiber glass tip to 500-900ºC,9 which then heats up the soft tissue through heat conduction from hot glass tip: soft tissue is burned off on contact with the hot charred glass tip, while the margins of the burn are coagulated. Unlike non-contact surgical lasers (such as CO2 or Erbium), the soft tissue ablative diodes are contact thermal non-laser wavelength-independent devices.9

Case Study

The patient, a 51-year-old female, came to Dr. Riek for a revision of the tongue-tie which had been unsuccessfully released with a hot tip dental diode, similar to another recently published case study.10 Patient reported tongue biting; choking that woke her up at night; tongue getting caught in the lower teeth due to tonguetie, difficulty brushing teeth, and chronic neck/ back pain. She had a history of significant tooth decay, speech therapy for 2 years as a child (with no noted improvement), braces at the age of fifteen years old with head gear, and oral myofunctional therapy for tongue thrust. She wore a night guard due to clicking and chronic teeth grinding. She had broken several dental appliances due to excessive grinding. She specifically sought Dr. Riek’s practice because Dr. Riek uses a CO2 laser for tongue tie releases. The patient had hoped to have an increase in the jaw range of motion and improve her other symptoms (jaw pain, airway issues, continued bruxism and moderate sleep apnea, diagnosed with a sleep study). Previous Unsuccessful Treatments: The patient had initial tongue tie release two years before, with a diode hot tip (technically not a laser

CONTINUING education procedure) and the tongue restriction returned with the bunching scar tissue. A year after the diode frenectomy, she had an arthrocentesis of the TMJ by an oral surgeon due to pain and damage of the joint. She reported that the minimal relief from the procedure did not last long. The surgeon encouraged continued stretching to keep the jaw opening at 44 mm. Since the procedure, she continued stretching and noted the ongoing reduction in the jaw range of motion; and at the time of the tongue-tie release in Dr. Riek’s office, the jaw opening measurement10 was at 36 mm. CO2 Laser Frenectomy Settings are schematically illustrated in Figure 6. The LightScalpel CO2 laser was set to 2 W SuperPulse, and gated with F1-6 Repeat Mode (20 Hz, 60% duty cycle, 1.2 W average power); straight tipless handpiece with 0.25 mm focal spot diameter was used. Anesthesia: Only topical anesthetic was utilized (a combination of lidocaine, tetracaine, and prilocaine was applied three minutes before procedure). Laser tongue tie release: The entire laser procedure took approximately 20 seconds with a few stops. There was no bleeding, despite the fact that the area is heavily vascularized. With the above stated laser settings, the incision with 0.25 mm diameter focused laser beam is only 0.3 mm – 0.4 mm deep, as indicated in Figure 6. Such shallow incision depth, combined with sub-100-µm5,7 coagulation depth, allows for excellent and progressive visualization of larger diameter blood vessels, as shown in Figure 1. Due to the shallow depth of incision, multiple laser passes are needed to complete the required depth of the incision in a safe and controlled fashion. Post-Operative Care: Immediately after the tongue-tie release, the patient could open her mouth to 46 mm. She took 600 mg of ibuprofen every 6 hours for first 48 hours. She also used 30c arnica every 4 hours for the first week post-procedure. Post-operative OMT exercises included manual tongue stretching, lift and hold (held for 3-5 seconds) every 4 hours for the first week, 6 hours for the next second week, and every 8 hours for the third week. The patient additionally sought out chiropractic care and CST work from a trained professional. Figure 2 demonstrates the healed surgical site four weeks after the frenectomy procedure. By that time, the patient had undergone additional OMT work and was able to open to 52 mm. Her

Mallampati score changed from II/III (pre-release) to I/II (post-release followed by OMT).

Summary

A combination of the CO2 laser wavelength, and SuperPulse settings, and tightly focused laser beam allows for: • a char-free and bloodless surgery (i.e., approximately 1,000 times more photo-thermal cutting efficiency than dental diodes, and for approximately 10 times more photo-thermal coagulating efficiency than erbium lasers; • Sub-100 µm coagulation/hemostasis depth, which closely matches the blood capillary diameters.5 It allows, unlike with erbium lasers, for an instant hemostasis during high speed ablation/cutting. It affords the clinician with the improved visibility of the surgical field and therefore allows for more precise and accurate tissue removal;7 • Highly controllable speed and depth of incision with dynamic range from micrometers to millimeters. The depth is proportional to laser power and inversely proportional to laser beam diameter and hand speed;1,2,11 • Minimal post-operative pain, discomfort, and swelling, significantly reduced post-surgery production of myofibroblasts, diminished wound contraction and scarring.1,2,11 As observed in our surgeries, healing with the CO2 laser is markedly different from the other surgical modalities, it is uncomplicated and predictable.

Acknowledgments

Authors greatly appreciate the help and contribution from Anna (Anya) Glazkova, PhD, in preparing this material for publication. Fabbie P, Kundel L, Vitruk P. Tongue-Tie Functional Release. Dent Sleep Practice. Winter 2016: 40-45. Convissar R, Hazelbaker A, Kaplan M, Vitruk P. Color Atlas of Infant Tongue-Tie and Lip-Tie Laser Frenectomy. PanSophia Press, 2017. 3. Fisher JC. Basic laser physics and interaction of laser light with soft tissue. In: Shapshay SM. ed. Endoscopic laser Surgery Handbook, New York, NY: Marcel Dekker. 1987:96-125. 4. Fisher JC. Qualitative and quantitative tissue effects of light from important surgical lasers. In: Wright CV, Fisher JC, ed. Laser surgery in gynecology: a clinical guide. Philadelphia, PA: Saunders. 1993:58-81. 5. Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Practice US. 2014: 7:6. pp. 19-27. 6. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003:103:2. pp. 577-644. 7. Wilder-Smith P, Arrastia AM, Liaw LH, Berns M. Incision properties and thermal effects of three CO2 lasers in soft tissue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):685-91. 8. Willems PWA, Vandertop WP, Verdaasdonk RM, van Swol CFP, Jansen GH. Contact laser-assisted neuroendoscopy can be performed safely by using pretreated ‘black’ fibre tips: Experimental data. Lasers in Surgery and Medicine. 2001;28(4):324-9. 9. Vitruk P. Laser Education, Science and Safety – A review of dental laser education standards. Dentaltown. 2017 June;17(6):62-67. 10. Wuertz K, Vitruk P. Superpulse 10,600 nm CO2 Laser Revision of Lingual Frenum Previously Released with a Diode Hot Glass Tip. Dent Sleep Practice. Winter 2017:40-42. 11. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004:48(4):861-888. 1. 2.

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Incision and Coagulation/Hemostasis Depths Control during a CO2 Laser Lingual Frenectomy by Cara Riek, DNP, RN, FNP-BC, IBCLC, DABLS and Peter Vitruk, PhD, MInstP, CPhys, DABLS 1. Oral soft tissue absorption coefficient is lowest around this wavelength _______ a. 1,000 nm b. 3,000 nm c. 10,000nm d. none of the above 2. Oral soft tissue blood vessel capillary diameters are ______ a. > 1 mm b. < 0.01 mm c. Approx 0.02 - 0.04 mm d. none of the above 3. Oral soft tissue depth of photo-thermal coagulation is greatest around this wavelength ________ a. 1,000 nm b. 3,000 nm c. 10,000 nm d. none of the above 4. Oral soft tissue depth of photo-thermal coagulation is shortest around this wavelength ________ a. 1,000 nm b. 3,000 nm c. 10,000 nm d. none of the above

38 DSP | Spring 2018

5. Which of the below statements is true? a. CO2 laser wavelength is 1,000+ more efficient for soft tissue cutting than dental diode wavelength b. Erbium and infrared CO2 laser wavelengths are efficient and spatially accurate ablation tools c. A and B d. none of the above

8. The advantage of the CO2 laser for soft tissue surgery is _______ a. ability to cut radiantly (non-contact) with simultaneous hemostasis and coagulation b. post-operative swelling c. weak light absorption in soft tissue d. strong light scattering in soft tissue

6. Which of the below statements is false? a. CO2 laser wavelength is far more efficient for soft tissue coagulation than Erbium laser wavelength 2,940 nm b. the Nd:YAG laser 1,064-nm wavelength is an efficient scalpel but a poor coagulator c. A and B d. all of the above

9. Which of the below statements is true? a. CO2 laser wavelength is 1,000+ more efficient for soft tissue cutting than dental diode wavelength. b. all lasers are efficient at both coagulating and cutting c. Erbium wavelength is 10+ efficient for soft tissue coagulation/hemostasis than CO2 laser wavelength. d. none of the above

7. Which of the below statements is true? a. Near-IR diodes are non-laser thermal tools for soft tissue cutting b. In Near-IR diodes, laser optical energy is used to heat up the charred distal end of the glass tip c. Near-IR diodes are efficient coagulators d. all of the above

10. Identify true statements about SuperPulse CO2 laser: a. It provides pulses of high peak-power density and high fluence. b. It minimizes thermal damage to adjacent tissue. c. It maximizes hemostasis. d. A and B

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FUN

TEAMfocus

opportunities to awaken DSM in your practice! by Glennine Varga, AAS, RDA, CTA

et’s face it – it’s not always fun and games when wearing oral appliances to improve sleep breathing but on the other hand there are some fun things we team can do to enhance our patient’s experience.

It amazes me how fast the sleep industry is growing and producing some really cool wearables, apps and sleep hygiene products. Let’s use them! My great mentor, Dr. Dick Barnes, is fond of saying: “It’s time.” The time is now my dental sleep friends – IT’S TIME to discuss sleep breathing with everyone we know! This is going to take a lot of educating and evaluating each person, where they are in their therapy, and what they are ready to hear. You may be thinking, “that sounds hard” – and you’d be right, it is. Precisely the reason we should make it FUN! Ideally, your practice is set up for two types of sleep patients – the diagnosed and un-diagnosed. For the undiagnosed patient our goal is to educate the patient on the importance of good sleep and how bad breathing can affect it. Our goal is to help them obtain a diagnosis. Depending on the patient’s medical insurance policy (if you will be using that) you can recommend or help facilitate either a sleep evaluation by a physician to order a test or a diagnostic entity

40 DSP | Spring 2018

that will administer a home sleep apnea test (HSAT). We team can make this process fun. Yes, FUN I say… Think of your practice as a wheat field that goes for miles and miles. You’re not sure how it became this huge wheat field, but it did. Your dentist is not a farmer, nor do you know anything about wheat – how to manage it, sell it and you’re not quite sure what to do with it. There are some farmers close to your wheat field that are losing their farms because the way they set up their farms isn’t working any more. They can’t get paid for growing wheat according to new standards and most are having to do a complete restart. The wheat market is strong in your community. What do you think can be done in this situation? In your dental practice your current un-diagnosed sleep patients are the wheat field and the farmers are local diagnostic sleep physicians setup for polysomnography (PSG) studies. Most medical insurance policies require an HSAT before PSG which has thrown a wrench in the system. Sleep physicians are retiring, selling or restructuring their businesses. Seek out your local diagnostic entities, aka your local farmers, that would welcome your undiagnosed patients. FUN opportunity #1 - Once you’ve established a relationship with a local diagnostic entity, plan a fun event for your team and invite them to the party. Bowling, gaming facilities, rent out a night of painting and wine events – anything that will bring both offices together. Make it airway themed get to know each other. Invite a few patients you have in common, especially if we team think they’ll have a good time. If no one shows from your diagnostic entity keep inviting them. Who knows, this could spark more awareness within your community. Always think local and organic – the majority of your patients will come from within 30 miles of your practice.

TEAMfocus For the diagnosed patient, if they are ready to move forward with therapy (whether they qualify for medical insurance benefit or not), they first decide if they like and trust you. They must value their health and your therapy more than their money. How is this different from the dentistry you provide? It’s different because oral appliances save lives and can dramatically improve a patient’s quality of life and health. Don’t get me wrong – I believe dentistry can do the same, but airway therapy is more urgent because of the masses of people that suffer with un-diagnosed sleep disordered breathing. It’s your job to provide information to your patients about your therapy. You’ve got this! You do this every day in dentistry. The big difference is, in dentistry we have tons of educational tools, videos and hundreds of years of passed along information to explain to patients what a crown is or how to manage periodontal disease. Dental sleep medicine is barely going on 26 years of only about 1% of dentists explaining sleep breathing to patients. We have an uphill battle! The good news is with today’s technology and social media interactions we can lean on some fun ways to educate, manage and follow up with our patients. FUN opportunity #2 introduce your patients to some apps like sleep cycle to monitor duration and quality of sleep or Pzizz, an app that helps users slip into sleep using a combination of music, words and sounds. I like the sleeplog app. It allows the patient to provide notes regarding their sleep and graphs the information provided. SnoreLab is another popular app. This is great for subjective information for your follow up visits and to monitor compliance. Keep in mind none of these apps or devices are HSATs but a fun way to monitor success. Create games in the office with your patients and reward them sleep goodies, like eye masks, nose cones, positional pillows or team up with local retail that sell anything sleep related. Get creative and again think organic! FUN opportunity #3: work with the oral appliances themselves! Most patients who commit to oral appliance therapy become attached to their appliances. Wearing and cleaning them is a daily/nightly occurrence. When possible personalize your patient’s oral devices. Get with your dental labs and find out if anything can be done to personalize them, different acrylic colors or adding your favorite sports team logo. You never know

what your labs can do, they are remarkable! Keep in mind some of the appliances are patented to be a certain color or made in a specific way. As we look to the future of dental sleep medicine more and more patients will become aware of this great therapy and will seek out your services. As we navigate medical insurance and deal with high deductibles and lower benefit allowances some patients may bring up the value question or even consider it elective treatment. Build value not only in the medical benefits, but why not make the appliances as attractive as possible? Brighten up your patient’s oral appliance experience. Here are some examples: Create a home care package with a fun info-gram on sleep hygiene or recommendations for better sleep. Provide your patients and referring physicians with easy-to-read progress reports that demonstrate success. Most patients would love to get something from you mid treatment expressing enthusiasm for their progress. Once Maximum Medical Improvement (MMI) is achieved, work on a success story with your patient’s permission. For long term follow up patients create a recall system similar to your hygiene recall system to keep them in your practice. Oral appliances need to be repaired and replaced from time to time. Always remember life is short, have some fun. Your patients will have choices when it comes to therapy, get creative so they choose you!

Fun Opps 1. Plan a fun event for your team and invite your local diagnostic entity to the party. 2. Introduce your patients to some sleep apps. 3. Work with the oral appliances themselves!

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@MedMarkMedia.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 team, business development and sleep coach for Arrowhead Dental Laboratory. She has been a TMD and dental sleep medicine trainer and speaker with an emphasis on medical billing and documentation for over 15 years. She is a member of the Academy of Dental Management Consultants (ADMC) and a professional member of the National Speakers Association (NSA). Glennine was an expanded duties dental assistant, certified in TMD with the American Academy of Craniofacial Pain. She is a visiting faculty at University of Tennessee’s DSM mini-residency, The Pankey Institute and Spear Education’s dental sleep medicine courses. Glennine currently teaches Total Team training and co-teaches Airway Management and Dentistry for the Dr. Dick Barnes Group seminars.

DentalSleepPractice.com

PRACTICEgrowth

Marketing From a Culture of Innovation by Chris Bez, opportunity engineer

here’s a buzz in larger corporations today about nurturing a culture of innovation, and in the dental sleep medicine field, it appears the idea of getting seriously innovative is being forced upon us. At one point (long ago and far away) there were few ABDSM Diplomates, medical insurance was looked at in a completely different light than it is today, and DME suppliers did their job and dentists did theirs. Today, there are over 3,000 members of the AADSM and approximately 10% of them have achieved Diplomate status, with more offices setting their sights to achieve accreditation status. The insurance companies have managed to create enough smoke and mirrors connected with networks and allowable fees, codes and peripheral criteria that to be responsible as a business entity while simul-

Sales, marketing and the development of the enhanced communication skills that support both of those efforts, has been the focus of Chris Bez’s career since inception. From a start as a Sales Manager for a national manufacturing company, she became an award-winning Marketing and Advertising Executive, a Professional Executive and Team Coach and a national speaker on marketing and promotions. Today she focuses her attention on niche marketing for dentists – specifically for those practices that have incorporated Dental Sleep Medicine into their patient offering. She writes and advocates on the imperative of consulting versus selling, and the development of individuals and teams. For more information, contact Chris at cbez@chrisbez.com.

42 DSP | Spring 2018

taneously welcoming to potential patients seeking covered treatment pretty much takes an act of God. And there is of course, for now, a shortage of qualified, available clinical assistants, which makes the challenge of staying on schedule formidable for all but the most efficient, Diplomate-wielding dentist, operating in an accredited facility, with a full-time insurance specialist on staff. Now we have added to the mix the challenge of vendors becoming providers. In some circles, the discussion has turned from one of marketing to grow the dental sleep practice to an often angry one about survival – and I’d like to suggest that we are reacting in completely the wrong direction. Enter the idea of an innovative culture. In concept, the idea of innovation is generally met with enthusiasm. New ideas, solutions instead of problems – that’s the fun part. Until we get to the place of turning thoughts into actions. New action requires change, and assuming responsibility for change is like putting a target on your back. The culture in most practices reflects the comfort of standardized procedures and routine; ideas that in the dental practice model are essential to the health and well being of schedules, patient care and production. The dental sleep practice requires fully customized appliances applied to unique individuals with specific stories – nothing standard there! And yet, here we are. Snoring and sleep apnea sufferers want our solutions but it feels like it’s getting harder with each passing day to pull it

PRACTICEmanagement all together for them. How do we market this exciting, in-demand service when we feel overwhelmed? From a marketing perspective, innovation provides the spark we need. Being able to identify what sets a practice apart and gives the patient benefit is the stuff that wildly successful campaigns are made of. There is brilliance in practices where innovation cultures exist. These practices have created an environment where they have taken on the challenge of finding the best amid the chaos. They have simplified, become models of efficiency, and do what benefits the practice, the patients and the people who make up the staff. They don’t wait until a crisis arises, rather they live in an awareness and take competition on before it arises. It is our nature as individuals to be attracted to “new.” The idea that we can be the ‘new’ is one that must start at the top, with the practice leader. Teams overcome challenges and get to the

other side with consistent attention and support from strong leaders. Simply put, it takes innovative leadership to get to an innovative culture. Granting committed team members the license to give voice to insight, moving that insight into actionable ideas and giving those actions support – that’s the kind of culture that is marketable and gains traction. It is a big shift from how practices were once run, but 30 years ago, social media marketing didn’t exist, either. Change is seldom pretty. As the adage goes, “the only one who likes change is a wet baby!” But dental sleep medicine is a creation of change. It is the place where what was once the bastion of CPAP machines and surgeons collides with dentists and a completely different approach to sleep apnea and snoring. With that as our pedigree, we can hardly dismiss the potential that sits on the horizon, waiting for the same innovation that got us here to rally us into action.

To Continue Growing,

There is brilliance in practices where innovation cultures exist.

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STARTINGearly

How Children Breathe Sets the Stage for Life by Daniel S. Bruce, DDS, D,ABDSM and Bethany A. Bewley, RDH, MS

hen adult patients with sleep-related breathing disorders come into my office for treatment, they often ask me why they developed sleep apnea in the first place. After all, it makes sense that natural selection should eliminate unfavorable traits, (such as choking in your sleep) and therefore, the genes that allow you to choke in your sleep should not exist. This apparent contradiction can be explained by delving a little deeper into the unique environment of modern man. Physical form is dictated not only by our genetic code, but also by the pressures of our environment. When the environment changes, the physical human form can change. This is the classic nature versus nurture discussion. Also, the benefits of a certain characteristic may outweigh the drawbacks. For example, the ability to communicate through speech is highly valuable to humans despite the necessity of a collapsible airway to do so. I was first introduced to the concept of Darwinian medicine in college while reading the book “Why We Get Sick.” One aspect of the theory is that our bodies are suited to ideally develop in conditions similar to those of Paleolithic times. Humans ate large quantities of raw, unprocessed

44 DSP | Spring 2018

food unfortified with nutrients and very little sugar. They had to deal with infections, bacteria and parasites on a daily basis. Paleolithic humans lived in an environment with different types of stressors and different types of toxicities. Our bodies are designed to function in the Paleolithic environment. This concept was applied to the world of dentistry by Dr. Kevin Boyd in his article on Darwinian Dentistry in 2012.2 He noted that the raw, hard food humans ate before the advent of agriculture created wide, more protrusive dental arches with a more balanced posture and thus a larger airway less prone to collapse. Reading this article was an “aha” moment for me that helped me understand the role our environment plays in the development of the human airway. Does this make you curious about ideal growth and development? It should! Understanding the topic helps dentists assess where things can go wrong, why they went wrong, and what environmental and functional roadblocks can be removed to allow full expression of our growth potential. With this in mind, here are a few risk factors kids have for developing sleep apnea as a child or later on as an adult.

STARTINGearly Tongue-Tie

A “tongue-tie” or “tethered oral tissue” or “ankyloglossia” occurs when a band of tissue tethers the tongue to the floor of the mouth. This situation can result in problems breast feeding, swallowing, and speaking. Very simply put, the tongue is a very good (actually the most ideal!) orthodontic expansion device. An ideal tongue posture occurs when the mouth is closed and the tongue is between the arches sitting fully on the palate. An ideal swallow occurs when the tongue pushes food to the roof of the mouth after chewing and peristaltically moves the food down the throat. The action of chewing and a tongue-to-roof-of-mouth swallow helps to develop the maxilla and mandible in three dimensions. A tongue-tie restricts the ability of the tongue to support the maxillary arch. This often results in an underdeveloped maxilla and can affect the ability of the mandible to develop normally. The solution for a patient with a tongue-tie is a lingual frenectomy. However, this needs to be performed in conjunction with myofunctional therapy in order to re-train the tongue to function ideally. If this sounds like hard work, it is! However, it is necessary to restore function in most cases. Just because the tongue now has the ability to function ideally, does not mean it will forget the old swallow patterns. A myofunctional therapist is a hygienist or speech therapist with additional training in the function of the tongue. Finding and partnering with a trained therapist greatly enhances any effort to shape ideal growth.

Mouth Breathing

Mouth breathing is incredibly common in children. Allergies, low muscle tone, tonsil and adenoid hypertrophy, and even tonguetie can cause mouth breathing. When a child breathes through his or her mouth, the tongue cannot sit between and develop the arches. The result is retrusion and collapse of the maxilla and often the mandible. Screening for mouth breathing is as easy as observing the child at rest. Also, crowded teeth or lack of space in the primary dentition are big red flags. Often kids that mouth breathe have heavy plaque levels, gingivitis (especially in the anterior teeth), and may have high caries rates due to xerostomia. Treatment involves referring for a sleep study

if risk factors for sleep apnea are present or to an ENT to assess the reason for nasal congestion. The local myofunctional therapist can also be of assistance by teaching the patient exercises to change the resting posture of the tongue and aid in nasal breathing.

Adenotonsillar Hypertrophy

Hypertrophic adenotonsillar tissue has a direct correlation with sleep apnea in children. The benefits of removing the tonsils and/or adenoids can be seen dramatically and immediately. Improvement in school performance has been shown, as well as improvement in sleep disordered breathing.3 However, it is extremely important to realize sleep-related breathing disorder symptoms can recur in some patients and tonsillectomy may not be the first line therapy for all patients. Myofunctional therapy can improve outcomes after surgery and reduce the risk of relapse later in life.4 In addition, orthodontic expansion has been shown to be helpful in necessary cases. Reasons for adenotonsillar hypertrophy are complex and having a team treatment approach is necessary for persistent results.

Case Study

The following photos are of a six-yearold female patient who presents with mouth

Dr. Dan Bruce has a passion for treating patients with sleep-related breathing disorders and an even greater passion for helping children develop beautiful and functional airways. He enjoys creating interdisciplinary relationships with the health care community in order to provide the best outcomes for patients. Dr. Bruce practices in Boise, Idaho and is a Diplomate with the American Board of Dental Sleep Medicine. He has lectured on the topic of dental sleep medicine. Outside the office, Dr. Bruce spends his time exploring the Idaho outdoors with his wife and 3 children. Bethany A. Bewley, RDH, BA, MS, is a full time mom and part time Director of Marketing for a private general dental practice in Boise, Idaho. While working as a clinical dental hygienist, she received her Master of Science in Dental Hygiene degree from Idaho State University. Her thesis research on incorporating sleep apnea screenings into dental hygiene appointments won an award as part of the DENTSPLY/ADHA Graduate Student Clinicians Program.

DentalSleepPractice.com

STARTINGearly

Figure 1: Tongue tie in a 6 year old

The lethargic kids who snore and gasp for air at night are easier to identify, but you have to look beyond the teeth and at the whole patient.

Figure 2: Unilateral crossbite, likely a result of low tongue posture secondary to a tongue tie

breathing, adenotonsillar hypertrophy, tongue-tie, and maxillary crossbite. However, the parents do not report fatigue, snoring, or other issues associated with pediatric SRBDs. Since not all patients with risk factors have disease, we focused on dental arch development and removing barriers to ideal growth and development. The treatment plan therefore included orthodontic expansion, a lingual frenectomy, and myofunctional therapy. Pediatrician or pediatric ENT evaluation of tonsils was also recommended. Finally, the patient was referred to a pediatric functional medicine physician to assess environmental, food-related, or other interactions that might cause hypertrophy of the tonsils and adenoid tissue. Without parental observations of SRBD, we didn’t push for a sleep diagnosis, but focused on that ideal growth and development. I’m happy to report that she is currently in treatment – we felt that insisting on a sleep study might have delayed treatment, and it wasn’t necessary for this treatment plan.

Where to go from here

The risk factors for developing a sleeprelated breathing disorder in kids are often complex. Every child responds to resistance of the airway differently. The lethargic kids who snore and gasp for air at night are easier to identify, but you have to look beyond the teeth and at the whole patient. It is also 1. 2. 3. 4. 5.

46 DSP | Spring 2018

Figure 3: Hypertrophic tonsils. Note the red and chapped lips, a common finding in mouth breathing children.

important to remember every kid responds differently to airway stress. OSA may contribute to ADHD symptomatology, with these symptoms improving with ADHD treatment in a subset of patients.5 There are likely genetic, epigenetic, environmental, nutritional, digestive system, immune system, physiologic and other factors at play. A holistic approach is helpful in getting kids on the best treatment path. I have found help in navigating this journey through the American Sleep and Breathing Association, the American Association or Gnathologic Orthopedics, the American Academy of Dental Sleep Medicine, and the American Academy of Physiologic Medicine and Dentistry, to name a few. SRBDs in children are a huge problem and appear to be getting worse, setting them up for life-altering challenges as adults. I hope to see the pattern of increased attention, research, and openminded thought in this area continue. The best thing we can do as dentists is educate ourselves on treatment options, help educate parents about the problem so they can take ownership in finding solutions, and develop a comprehensive referral network. This is a complex problem in which the solutions may or may not be simple. However, I believe a truly integrative dental practice needs to have at least a baseline knowledge of the role of the airway in human development and the risk factors that can put our patients at risk for airway disorders.

Nesse, R. M., & Williams, G. C. (1994). Why we get sick: The new science of Darwinian medicine. New York: Times Books. Boyd, Kevin. (2011). Darwinian Dentistry: An Evolutionary Perspective on Malocclusion, Part I. Journal of the American Orthodontic Society, Nov/Dec, 34-39. Gozal, D. (1998). Sleep-disordered breathing and school performance in children. Pediatrics, 102, 616–620. Camacho, M., Certal, V., Abdullatif, J., Zaghi, S., Ruoff, C.M., & Capasso, R. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep, 38(5), 669–675. doi: 10.5665/sleep.4652 Is obstructive sleep apnea associated with ADHD? Youssef NA, Ege M, Angly SS, Strauss JL, Marx CE. Ann Clin Psychiatry. 2011 Aug;23(3):213-24. Review.

Do you ever wonder what other dentists think? ...How they practice?

...What ideas they

have for treating sleepy patients?

Keep an eye out for a special request in your INBOX! DSP is surveying thousands of dental sleep professionals this spring on Industry Trends, Clinical Management, Education and The Business side of all this. This seminal report will help you navigate our profession with current information that keeps you â&#x20AC;&#x153;In The Knowâ&#x20AC;?. Your colleagues are curious about your opinion and some other important metrics about you, too. Be sure to click on the link when it comes. Plus, thanks to our co-sponsor ProSomnus Sleep Technologies, the first 500 respondents will get paid to have their voices heard!

www.dentalsleeppractice.com

ADVANCEDtreatment

Combination Therapy by Ronald S. Prehn, ThM, DDS

hat therapeutic options does a sleep dentist have when Oral Appliance (OA) monotherapy fails? Since most dental sleep patients choose OAT (oral appliance therapy) because they have already rejected CPAP (continuous airway pressure) or are CPAP intolerant, what can be done? They can’t go back to CPAP! OAT is not resolving their sleep breathing issues. What is next? What can the sleep dentist do? Where can these patients go?

FCM side view

48 DSP | Spring 2018

Consider using these two therapies at once. Combining CPAP therapy and OAT is indicated when both therapeutic options fail. Using two devices at once takes advantage of the best of both strategies, while eliminating the disadvantages of each. The best of OAT is mandibular stabilization, supporting the airway by maintaining the jaw in a forward posture, resulting in increased airway patency. The best of CPAP is that the positive airway pressure supports the flexible oropharynx during pressure changes of respiration. The worst of OAT is that the more the mandible is advanced, the more side effects occur. Some airways collapse no matter how much one brings the jaw forward, and the OSA continues. With combination therapy, the jaw does not have to be advanced as much, usually just 3mm. Side effects of OAT are typically eliminated. The worst of CPAP are the head

straps, leakage of the mask caused by high CPAP pressures and instability of the mask on the face. With combination therapy, the pressures can be reduced and, with the jaw stabilized, mask leaking is also minimized. There are two types of combination therapy. Type one is called “Dual Therapy.” This is when an OA is used at the same time as the CPAP. There is no integration of the OA and the CPAP, they are just both on the patient at the same time. This does not take any special training by the sleep dentist. Any sleep dentist who does OAT can offer this combination therapeutic option to the patient and to the sleep physician as a solution to failed OAT and CPAP. The oral appliances that are most effective do not allow the lower jaw to open passively. Type two combination therapy is called “Integrated Therapy.” The CPAP is actually attached to the oral device, eliminating the head straps while providing mandibular stabilization. This option requires additional special training by the sleep dentist (www. FusionCustomMask.com). At this time, there are two types of devices that can apply integrated combination therapy. The first type attaches a nasal pillow CPAP mask to an oral appliance such as a TAP. Examples include TAP-PAP CS and CPAP-Pro. These work well for CPAP pressures less than 15cm H2O. For patients needing higher CPAP pressures, the second type of device is the Fusion Custom

ADVANCEDtreatment Mask (FCM). The FCM is custom fabricated from an impression of the patientâ&#x20AC;&#x2122;s face and is tightened to a post that protrudes from the mouth that is attached to an oral appliance called the Fusion Monoblock (FMB). The FMB is an upper and lower dual laminate shell that is luted together to secure the mandible in a 3mm forward position. The FCM features a stable and efficient CPAP interface, providing stabilization of the mandible and the airway. The FCM has no straps to cause mask dislodgment during sleep movements, increasing patient comfort. In addition, the FCM is firmly attached to the cranium through the fit of the FMB element to the maxillary teeth. The patient who suffers from obstructive sleep apnea, and the sleep dentist who is trying to treat OSA, no longer have to abandon oral appliance therapy when it fails to resolve the problem. Combination therapy allows the sleep dentist the ability to treat the entire scope of sleep breathing disorders and provide hope to people desperately in need of better health.

2. 3.

Prehn RS, Swick T. A descriptive report of combination therapy (custom face mask for CPAP integrated with a mandibular advancement splint) for long-term treatment of OSA with literature review. Journal of Dental Sleep Medicine. In Print. Prehn RS, Colquitt T. Fabrication technique for a custom face mask for the treatment of obstructive sleep apnea. JProsthet Dent, 2016;115:551-55. Prehn RS. Sleep and Breathing, 19th Annual Meeting of the American Academy of Dental Sleep Medicine, San Antonio, Texas. 4â&#x20AC;&#x201C;6 June 2010;14(4):283.

Ronald S. Prehn, ThM, DDS, is a third generation dentist who focuses his practice on complex medical management of Facial Pain conditions (TMD and Headache) and Sleep Disordered Breathing. He received his degree at Marquette School of Dentistry in 1981 and post graduate education at the Parker Mahan Facial Pain Center at the University of Florida and the LD Pankey Institute in the years to follow. He is a Board-Certified Diplomat of both the American Board of Orofacial Pain and American Board of Dental Sleep Medicine, of which he is president-elect. While being an adjunct professor at the University of Texas Dental School in Houston, he is published in several journals on the subject of combination therapy for the treatment of obstructive sleep apnea. He is a sought-after speaker on this subject at the national level. He currently limits his practice to management of complex sleep breathing disorders at the Koala Sleep Center in Wausau, Wisconsin while enjoying with his wife, Linda, the outdoor life style and people of North Central Wisconsin. He can be contacted at rprehn@tmjtexas.com.

DentalSleepPractice.com

LEGALledger

ADA Policy Statement on Sleep Disordered Breathing From a Lawyer’s Perspective by Ken Berley, DDS, JD, DABDSM

DA policy statements have historically guided the evolution of our dental standards of care. The ADA House of Delegates adopted a policy on Sleep Disordered Breathing recently. Whenever the ADA publishes a policy statement, it is quickly discovered by plaintiff’s attorneys and becomes a resource for litigation. Therefore, it is vitally important for all dentists to understand the legal ramifications of the ADA policy statement and adopt in-office protocols and procedures to ensure compliance. There are eleven points in the whole document. Two issues, screening and use of home apnea testing by dentists, are getting the most attention, so I’ll give you my thoughts on them. Before we delve into this subject, you should know that I am not opposed to this policy statement. I completely support the actions of the ADA and overall, I like the content of this policy statement. Dental sleep medicine has been the subject of significant controversy for too long regarding the use of home sleep testing equipment and the dentist’s role in the diagnosis of obstructive sleep apnea and sleep disordered breathing. The ADA policy statement on SDB seems to settle many of these questions. For you to understand the implications of the ADA policy statement, you must also un-

50 DSP | Spring 2018

derstand the legal concept of a “learned treatise.” A Learned Treatise is a document that is universally accepted within a profession and considered authoritative, as Evidence of the Standard of Care. When a document is recognized as a “learned treatise” in court, that document can be easily introduced into evidence and can be used during the trial to prove your case. For example, courts throughout the country have universally recognized Gray’s Anatomy textbook as a learned treatise, therefore, all plaintiff and defense attorneys have a copy which can be introduced in any trial where it is needed. An example of a learned treatise is 2010’s policy statement on screening for oral cancer. That document can be introduced in court and used against you if you find yourself defending a charge of malpractice for failure to screen for oral cancer. That brings us to the new ADA Policy Statement on Sleep Disordered Breathing.

Can a Dentist Dispense an HSAT for the Diagnosis of Sleep Disordered Breathing?

I have been concerned at the number of dentists who are either treating “snoring” patients without diagnostic testing or are dispensing HSTs out of their offices for the diagnosis of OSA without a face-to-face exam-

LEGALledger ination by a sleep physician. While I agree that not every patient needs an overnight PSG to diagnose sleep disordered breathing, personally I would like to see a local Sleep Physician on your team, to provide the face to face examination and diagnosis. This cooperation between dentists and sleep physicians provides for the best patient care and you can legally share liability with that sleep physician. ADA Policy Statement: 1. Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertension. These patients should be referred, as needed, to the appropriate physicians for proper diagnosis. The ADA policy statement does not include any statement that could be construed as giving dentists the authority to dispense type 3 or type 4 patient monitoring for diagnosis of Sleep Disordered Breathing. As I write this I am anticipating the emails that I will receive from dentists who don’t want to refer to sleep physicians because they will not get their patients back to treat. You should be aware that there is a legal cause of action for “negligent failure to refer.” You can be sued for failing to refer a patient for care when the standard of care dictates that a referral is indicated. The diagnosing physician will prescribe the therapy she/he feels is best for the patient; the dentist’s disappointment for not being first line treatment is not a reason to withhold the referral. Every dentist treating Sleep Disordered Breathing should develop relationships with local sleep physicians to share liability.

HSAT/Pulse Ox Usage for MAD Titration

The American Academy of Sleep Medicine has repeatedly stated that dentists are inadequately trained and therefore, unqualified to use type 3 or type 4 testing equipment for any purpose. The AASM has even gone so far as to state that it is criminal for a dentist to even own home sleep testing equipment. This is particularly troubling given that research has repeatedly shown that oral appliance therapy is most effective when

the appliance is titrated as a result of testing. It is my personal opinion that some level of overnight testing during the titration process improves patient outcomes. The ADA seems to agree with this position and has included a provision for testing during the titration of a mandibular advancement device. The ADA Policy statement states as follows: 7. Dentists who provide OAT to patients should monitor and adjust the Oral Appliance (OA) for treatment efficacy as needed, or at least annually. As titration of OAs has been shown to affect the final treatment outcome and overall OA success, the use of unattended cardiorespiratory (Type 3) or (Type 4) portable monitors may be used by the dentist to help define the optimal target position of the mandible. A dentist trained in the use of these portable monitoring devices may assess the objective interim results for the purposes of OA titration. With the publication of this statement, dentists are now authorized to possess home testing equipment and to utilize those devices for the titration of Mandibular Advancement Devices. The interesting thing is that New Jersey, North Carolina and Georgia have statutes or board opinions which are in direct conflict with this paragraph. This issue will need to be resolved. If you practice in a state that refuses to allow you to utilize type 3 or type 4 portable monitors, I would petition the state board for a review of the state statute in light of the ADA Policy Statement on Sleep Disordered breathing.

Cooperation between dentists and sleep physicians provides for the best patient care.

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.

DentalSleepPractice.com

LEGALledger Duty to Screen for SDB

ADA policy statement includes these paragraphs addressing this issue for adults and children: 1. Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertension. These patients should be referred, as needed, to the appropriate physicians for proper diagnosis. 2. In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern. For a dentist to be considered negligent and therefore, guilty of malpractice, a plaintiff’s attorney must establish that the dentist owed a “duty” to the patient to practice in a particular way and the dentist failed to do so, which resulted in injuries to the patient. (Duty, Breach, Proximate Cause and Damages) Here, the Policy Statement proclaims that all dentists are “encouraged” to screen each patient for SDB. In other words, “A Reasonable and Prudent Dentist in the same or similar circumstance would have screened for Sleep Disordered Breathing.” Therefore, if a dentist fails to screen for SDB, this policy statement could be introduced into evidence as a learned treatise to establish screening as his standard of care. Once the duty to screen is established and breach of that duty shown, the dentist will be legally responsible for any damages which are directly and proximally caused by the breach. As a hypothetical, let’s assume that an elderly male obese patient presents to his dentist for a checkup. He has a history for refractory high blood pressure, coronary artery disease and diabetes. Oral examination reveals significant signs of bruxism with an enlarged and scalloped tongue. The patient falls asleep during the dental examination. The examining dentist does not record any

52 DSP | Spring 2018

finding of sleep disordered breathing and is unable to prove that routine screening for sleep disordered breathing occurs within his practice. If that dental patient falls asleep while driving, could the dentist be held liable for “Negligent Failure to Screen for Sleep Disordered Breathing”? The good news is that no such lawsuit has occurred to date. However, with the adoption of the ADA policy statement on SDB, this type of suit is theoretically possible. It is projected that approximately 10% of all children have sleep disordered breathing. Some of these children are easy to identify due to very enlarged tonsils or chronic mouth breathing habits. They may present with signs of excessive wear on their baby teeth or a diagnosis of ADHD. Each dental office must become familiar with the typical signs and symptoms of pediatric SDB and develop a protocol for screening these young patients. You should be aware that the law does not require that you successfully screen and identify every patient in your practice that has an airway problem. That would be unreasonable! However, with the adoption of the ADA statement, the law will require that you systematically attempt to identify patients with airway problems. If you miss a patient who has SDB, you will not be found to be negligent if you routinely performed a reasonable screening. Just make sure you screen.

Screening Protocol

What constitutes a reasonable screening protocol? In my opinion every dental office should incorporate questions which might expose SDB into their health history. Here are some important questions – there are others: 1. Do you ever wake up during the night gasping for breath? 2. Has anyone ever said that you stop breathing when you are asleep? 3. Do you snore? 4. Has anyone ever complained about your snoring? 5. Have you been diagnosed with Sleep Apnea? 6. Have you ever worn a CPAP (Continuous Positive Airway Pressure) device? 7. Are you sleepy during the day? 8. Do you feel the need to nap to make it through your day? Additionally, it would be ideal if all patients were asked to complete an Epworth

LEGALledger

With the millions of undiagnosed patients, dentists are in a unique position to positively affect the health and longevity of these patients.

Sleepiness Scale and/or a STOP-BANG Questionnaire on a yearly basis. If these screening steps were taken, many patients at risk for SDB within any dental practice would be identified. These actions would easily satisfy the legal requirements for screening. If you are one of the many dentists who are scratching your head at this point trying to figure out what I am talking about, you need to find a course on screening and treating Sleep Disordered Breathing. Obviously in a short article, I cannot cover all the techniques and methods of screening for this serious condition. I would encourage you to make education in this area a priority. The treatment of adult OSA with oral appliance therapy is the fastest growing area of dentistry. Become part of the solution for these patients. In conclusion, sleep disordered breathing is now considered to be within the scope of practice of all dentists. As a matter of law, we are required to screen for any disease or condition that falls within our scope of practice. We are not required to treat all conditions that fall within our scope, but we are required to recognize the condition and provide appropriate treatment or referral. With the millions of undiagnosed patients who routinely receive dental care, we are in a unique position to positively affect the health and longevity of these patients. Go screen your patients and save lives!

The final version of the ADA Policy Statement

Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders Sleep related breathing disorders (SRBD) are disorders characterized by disruptions in normal breathing patterns. SRBDs are potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms. Common SRBDs include snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA). OSA has been associated with metabolic, cardiovascular, respiratory, dental and other diseases. In children, undiagnosed and/or untreated OSA can be associated with cardiovascular problems, impaired growth as well as learning and behavioral problems. Dentists can and do play an essential role in the multidisciplinary care of patients with

54 DSP | Spring 2018

certain sleep related breathing disorders and are well positioned to identify patients at greater risk of SRBD. SRBD can be caused by a number of multifactorial medical issues and are therefore best treated through a collaborative model. Working in conjunction with our colleagues in medicine, dentists have various methods of mitigating these disorders. In children, the dentistâ&#x20AC;&#x2122;s recognition of suboptimal early craniofacial growth and development or other risk factors may lead to medical referral or orthodontic/orthopedic intervention to treat and/or prevent SRBD. Various surgical modalities exist to treat SRBD. Oral appliances, specifically custom-made, titratable devices can improve SRBD in adult patients compared to no therapy or placebo devices. Oral appliance therapy (OAT) can improve OSA in adult patients, especially those who are intolerant of continuous positive airway pressure (CPAP). Dentists are the only health care provider with the knowledge and expertise to provide OAT. The dentistâ&#x20AC;&#x2122;s role in the treatment of SRBDs includes the following: 1. Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertension. These patients should be referred, as needed, to the appropriate physicians for proper diagnosis. 2. In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern. 3. Oral appliance therapy is an appropriate treatment for mild and moderate sleep apnea, and for severe sleep apnea when a CPAP is not tolerated by the patient. 4. When oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient

LEGALledger with obstructive sleep apnea, a dentist should evaluate the patient for the appropriateness of fabricating a suitable oral appliance. If deemed appropriate, a dentist should fabricate an oral appliance. 5. Dentists should obtain appropriate patient consent for treatment that reviews the treatment plan and any potential side effects of using OAT and expected appliance longevity. 6. Dentists treating SRBD with OAT should be capable of recognizing and managing the potential side effects through treatment or proper referral. 7. Dentists who provide OAT to patients should monitor and adjust the Oral Appliance (OA) for treatment efficacy as needed, or at least annually. As titration of OAs has been shown to affect the final treatment outcome and overall OA success, the use of unattended cardiorespiratory (Type 3) or (Type 4) portable monitors may be used by the dentist to help define the optimal target position of the mandible. A dentist trained in the use of these portable

monitoring devices may assess the objective interim results for the purposes of OA titration. 8. Surgical procedures may be considered as a secondary treatment for OSA when CPAP or OAT is inadequate or not tolerated. In selected cases, such as patients with concomitant dentofacial deformities, surgical intervention may be considered as a primary treatment. 9. Dentists treating SRBD should continually update their knowledge and training of dental sleep medicine with related continuing education. 10. Dentists should maintain regular communications with the patientâ&#x20AC;&#x2122;s referring physician and other healthcare providers to the patientâ&#x20AC;&#x2122;s treatment progress and any recommended follow up treatment. 11. Follow-up sleep testing by a physician should be conducted to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.

DentalSleepPractice.com

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56 DSP | Spring 2018

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