Continuing Education: SRBD and the Use of
High Resolution Oximetry for Screening by Craig Pickerill
How to Use Potatoes
to Reduce Risk of OSA by Tara A. Clancy, MA
into Dental Sleep Medicine & Craniofacial Pain
SPRING 2019 | dentalsleeppractice.com PLUS
The Dentist and the Otolaryngologist Working Hard Together
Supporting Dentists Through PRACTICAL Sleep Apnea Education
an interview with Nicole Chenet, DDS, and Ryan Soose, MD
PATIENT SCREENING l BITE REGISTRATION l ORAL APPLIANCE SELECTION / FABRICATION
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ong have the pages of Dental Sleep Practice been devoted to helping the individual dentist navigate the uncertain path between traditional dentistry and specialized medical care. Between these two provider groups lie primary care, in all its forms and with various labels affixed to its practitioners such as family practice, advanced registered nurse practitioners, and various specialized medical providers not devoted strictly to sleep medicine. Leaders in medicine have called out the current state of health care where tens of millions of people lack diagnosis, let alone treatment or management, of serious airway-related disease. Trade groups associated with their particular constituents have mostly stuck with their mandate: look out for their own when it comes to defining practice while in more public pronouncements appearing to be interested in addressing the health care crisis of those tens of millions and their impact on the health care system, quality of life, and spending patterns in the community. The optimist in me notices the steps some organizations are taking to reach out to find novel solutions, address the crisis in new ways, bring more trained providers into the system. The inclusion of a committed, passionate, and sufficiently trained professional to the treatment team makes everyone more ‘productive,’ meaning able to impact more of the community via proper identification, diagnosis and treatment. What is happening in an increasingly common way is highly trained specialists accepting that they cannot see everyone with minor manifestations of ‘their’ disease – the sickest patients belong in their office with the less afflicted being seen by trusted professionals lacking their specific credentials. This is a two-way street. Any medical provider who wishes to be part of this team must commit to earning their way to the table. Proper education and demonstration of understanding the skills required is mandatory and should be supervised from the highest levels. Those occupying the lofty reaches of specialized knowledge must, in turn, reach out and provide opportunities for those non-specialists professionals to become valuable adjuncts to the main effort, reducing the number of undiagnosed symptomatic people in our community.
Steve Carstensen, DDS Diplomate, American Board of Dental Sleep Medicine
People are interested in better sleep. Editors of consumer publications choose stories based on what their audience wants – and it’s easy to notice many sleep-related themes online, in print, and on popular television. Gadgets to inform the wearer of sleep quality and snoring, address insomnia, and promote better sleep position are found in every electronic store and online retail outlet. It’s not difficult for anyone to order a boil-and-bite oral appliance, nasal breathing aid, positive air pressure system or even a custom mandibu- “If you don’t like change, lar advancement device, all without you’re going to like any professional oversight. Professionals who remain siloed irrelevance even less.” and turf-protective are going to stay – Eric Shinseki, US Army General busy, economically well-compensated, and reinforced by like-minded members of their group. Increasingly, however, they will become irrelevant as innovative ways of providing health care are demanded by consumers and less qualified professionals. Opening the way for increased participation by training other providers to do what they can to help is the way for all of us to meet consumer demand in a safe and medically sound manner. That is the path for better community health. DentalSleepPractice.com
A Journey into Dental Sleep Medicine and Craniofacial Pain Every professional must choose a path.
How to Use Potatoes to Reduce Risk of OSA
by Tara A. Clancy, MA Itâ€™s how you tell the story. Dr. Mayoor Patel (left), Clinical Director of Education, and Rose Nierman (right), CEO, of Nierman Practice Management
The Dentist and the Otolaryngologist â€“ Working Hard Together
an interview with Nicole Chenet, DDS and Ryan Soose, MD Patients benefit with two doctors on the team.
Sweet Dreams are Made of This by J.M. DeBord Quality of life is a vital part of therapy.
2 DSP | Spring 2019
Sleep Related Breathing Disorders and the Use of High Resolution Oximetry for Screening by Craig Pickerill Adding precision to therapy.
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No More Fingers: Tips for Digital Scanning Success by Susan Wingrove, BS, RDH Here’s a new tool to help.
In The Lab
Taking OSA Devices to the Next Level by Alex Buddemeyer, CDT Higher quality means better service.
4 DSP | Spring 2019
Publisher | Lisa Moler firstname.lastname@example.org Editor in Chief | Steve Carstensen, DDS email@example.com
46 Team Engagement with Team Focus
Functional Oral Appliances by Glennine Varga, AAS, RDA, CTA Families need you to help them.
HealthyStart® Online training for the whole dental team.
by Pat Mc Bride, MA, RDA, CCSH Books you need to read. Legal Ledger
Provision of Oral Appliances and Regulatory Compliance: Why Your Practice Should Have a Compliance Plan by Jayme R. Matchinski, Esq. Staying out of trouble by organizing your practice.
Managing Editor | Lou Shuman, DMD, CAGS firstname.lastname@example.org Editorial Advisors Steve Bender, DDS Ken Berley, DDS, JD Douglas L. Chenin, DDS Howard Hindin, DDS Ofer Jacobowitz, MD Christina LaJoie Steve Lamberg, DDS, DABDSM Dale Miles, DDS Amy Morgan Mayoor Patel, DDS, MS, RPSGT, D.ABDSM John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA
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©MedMark, LLC 2019. 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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How to Use
to Reduce Risk of OSA
by Tara A. Clancy, MA
SA is our greatest health risk, and yet we need only look at the low compliance rate of C-PAP users to see how a diagnosis of OSA can fail to motivate. But where does the problem lie? Could it be our marketing? Does OSA need rebranding? And how can potatoes help? Let’s consider the “marketing” of a disease like cancer. Who hasn’t been stopped cold in their tracks upon hearing the news that a loved one, a friend or a colleague has cancer. We know that cancer is progressive, and we know that it can kill you. It gets our attention. Despite cancer’s deadly reputation, I once had a friend tell me that a lesion on her leg was cancer. “I’ll have to get it removed,” she commented, as we lounged at the pool one warm, summer afternoon. CANCER, and yet there she was lounging at the pool instead of calling every dermatologist in the book for the next available. “It’s the slow-growing kind,” she went on to explain, “so there’s no rush.” What’s the takeaway? Even CANCER loses it motivating power when we water down the idea that it will hasten your death. And yet haven’t we done precisely that with OSA – watered it down and labeled it so that what is really going on is a mere backdrop. After all, we “brand” it from a mechanical perspective and get increasingly oblique: an obstruction, during sleep, that produces a Greek-sounding thing you’ll need to google unless you remember high school lessons
6 DSP | Spring 2019
that you, as a teenager, were probably too tired to learn. And let’s not forget that the main symptom of OSA is daytime sleepiness. Should we expect our OSA patients, still tired, to take in the health details we push on them? Would that pass any marketing test? To take the sleepiness one point further, we talk about the greatest impact of that sleepiness as an increased risk of auto accidents. Yet the SAVE study showed us that the lowest rate of C-PAP compliance was amongst the patients with minimal daytime symptoms. So that means they’re not at an increased risk of crashing their cars, but their brain cells are dying because of nightly airflow disruption while they sleep. In reality, our market is not getting the message, and so we’re wasting our breath on this breathing-related problem. And our patients suffer. But what if we called OSA what it is, something catchy like Breathing-based Brain Cell Death? It is a strong name, indeed, and potentially motivating. And yet we have to ask: would a name change even help? Is it truly possible to “rebrand” something that has been practically eschewed by segments of the public? The answer is a resounding yes – a name change would help, and we need only look to the potato to see how. In one of the most popular TED Talks, “Ad Man” Rory Sutherland tells about the successful rebranding of the potato. Frederick the Great of Prussia was having a problem getting peasants to grow it. In fact, people
MARKETING were literally being sentenced to death for refusing to grow the loathsome vegetable. In a stroke of marketing genius, Frederick the Great declared that the potato was for consumption by royalty only. With that, the formerly despised potato became an object that peasants would steal! With this story, Mr. Sutherland – who serves as the Executive Creative Director of OgilvyOne – proves this point: perspective is what gives something its value – and a simple “rebranding” can change everything. So taking the lesson from the potato, can we rebrand OSA? Specifically, can we market the perceived – and very real threat – of OSA? In fact, can we rebrand all forms of nighttime breathing problems? Yes, we can, and should. We need to start by giving sleep-disordered breathing an everyday name that tells it like it is. Think, for example, of the everyday name for mononucleosis: “kissing disease.” You get branded with that and no one is puckering up to you – or even sharing your cup – for fear of coming down with the virus. And that is why I like the name Breathing-based Brain Cell Death for everyday use. It captures what happens as airflow to the brain is repeatedly disrupted, right? (And it sounds kind of cool as an acronym, too: 3BCD.) So if we have a name that allows us to get the consequences of the disease to our market, then the next step is to tackle the degrees of the disease. The current “mild, moderate and severe” degrees of OSA are wholly inadequate. We need only think back to the example of my friend sitting poolside with her cancer lesion because it was the “slow-growing kind.” As an alternate to the “mild, moderate and severe” labels for OSA, I propose the following: Stages of Breathing-based Brain Cell Death: • Nasal Breathing – Typical Breathingbased Brain Cell Death • Mouth Breathing and SDB – Accelerated Breathing-based Brain Cell Death
Picture this scenario A new patient comes into your office showing all the signs of SDB: open mouth posture, elongated face, extracted teeth,
retruded mandible, and general craniofacial dystrophy. You: “There are two basic kinds of breathing-based brain cell death that happen to us as humans: typical and accelerated. Based on what I see, I am concerned that you are dealing with Accelerated Breathing-based Brain Cell Death. I would like you to schedule a sleep study as soon as possible. We need to know if your brain cell death is accelerated so we can get the right What if we called OSA treatment for you.” I don’t know about you, but I can’t something catchy like imagine that person lounging by the pool telling a friend she’ll have to get Breathing-based Brain a sleep study done…no rush. No, what Cell Death? I see is her reaching for her cellphone to call the sleep center – right then and there. And this would be excellent patient response because we know from Peter C. Farrell and Glenn Richards’ 2017 study, “…the recognition and treatment of SDB is vital for the continued health and wellbeing of individual patients with SDB (emphasis added).”1 In the current market, rebranding the insipid “sleep-disordered breathing” into Accelerated Breathing-based Brain Cell Death would make it like a potato – a very hot potato – that motivates the patient to act quickly. And it is through such rebranding that we can reach our market and truly help them maintain their health and wellbeing. 1.
Farrell, Peter C, Richards, Glenn: Recognition and treatment of sleep-disordered breathing: an important component of chronic disease management Journal of Translational Medicine 2017 15:114
Tara A. Clancy, MA, is an international speaker, breathing specialist, and sleep educator known for her unique insights and practical solutions. Since graduating from Columbia University over two decades ago, she has helped thousands of people feel better, look better, and perform better. It is Tara’s devotion to natural health, fascination with neuroscience, expertise in Buteyko Breathing and infinite desire to know why that allow her to help so many people improve their lives. Tara is committed to connecting the people who need airway health support with the professionals who provide it, and she is currently writing a book that will do just that. To learn more about Tara or to book her to speak at your next event, please visit www.o2tara.org.
into Dental Sleep Medicine & Craniofacial Pain
8 DSP | Spring 2019
e here at Dental Sleep Practice know that many of our readers have dreams of doing more sleep services in their practice, or even becoming a sleep-only practice someday. One thing that is universally true: if it’s been done, it’s possible. If you are one of those dentists, knowing how someone else came to that point might help you see the path for yourself.
was missing from my dental career. I began to question my limited education in dental school about the temporomandibular joint and became hungry for more. I started my journey into the field of Craniofacial Pain and TMJ disorders.
Mayoor Patel is a dentist many other professionals look up to as an expert – for very good reasons. He’s created the practice that takes the most advantage of his considerable talents. DSP sat down recently to ask him about how he put it all together.
Absolutely. During my first year, I traveled anywhere in the country to anyone giving a lecture on these topics. That was also the time in 2003 we changed the name of the practice to reflect that we were treating TMJ disorders. It didn’t take long for me to realize that many patients in pain also had a sleep issue that needed to be addressed, leading me down the path of dental sleep medicine CE. With a renewed look at dentistry and my career, I was inspired to learn more and do more. To prove to myself and my peers that I could navigate this new adventure, I began taking various board examinations. These allowed me to show that I understood what was expected of me to improve the health and well-being of my patients. I had the opportunity to work within a sleep medicine program in Atlanta where I provided dental appliances for their patients within their facility. I was also able to enroll in a three-year master’s program at Tufts University under the guidance of Dr. Noshir Mehta.
What was the beginning for you?
Have you ever had one of those moments where you thought “I can’t believe the answer was that simple”? In my early dental career, things were going well, but I always felt there was something missing. As a young dentist, I had a right side popping joint. At times, I also had ear and head pains of which the source was unknown. Because my father was a physician, I went to him for help. Neither he nor his colleagues were able to help me with the pain through high school, college, and even dental school. I learned to just live with my pain. It wasn’t until April 2003 when I took a course led by Dr. Harold Gelb in Chicago that there was a resolution. I approached him and described my symptoms. It was a moment of clarity. He told me it was my TMJ that had been causing me all this grief. I followed his recommendations, which resolved my pain issues, and I realized this was it – I had found what
All it took was one lecture to open a new and exciting world in the field of dentistry. Is this why continuing education became so vital in your career?
When did you transition into a dental sleep medicine and pain practice?
In 2012, we sold our dental practice and I started an exclusive full-time practice limited to pain and sleep. Luckily, two team members Sherry and Otilia, who worked with me
Dr. Mayoor Patel has a dental practice limited to sleep apnea and craniofacial pain in Atlanta, GA. He lectures in the United States, Canada, England, and Australia on dental sleep medicine and pain implementation. Dr. Patel has received over 15 credentials from major organizations related to orofacial pain and sleep apnea, including Diplomate status in the American Board of Orofacial Pain, Craniofacial Pain, Dental Sleep Medicine and Craniofacial Dental Sleep Medicine. Dr. Patel earned a Fellowship in the American Academy of Orofacial Pain, Craniofacial Pain, the International College of Craniomandibular Orthopedics, Pierre Fauchard Academy, and the Academy of General Dentistry. Additionally, Dr. Patel has published several chapters, numerous articles, as well as books educating the public on sleep apnea and craniofacial pain disorders.
COVERstory for many years, decided to come and take the gamble on the new startup practice. It was uncharted and uncertain times, but I am so happy we took that chance. To build referral networks with the medical community, we hosted lunch and learn events. We also hosted events at our office to expose the medical and dental community to what we were able to offer to their patients. We always send Offices that get their narrative SOAP reports to our patients’ other healthcare providers to keep them in comteam educated grow munication with their patient’s treatment and and do much better spread the word about our services. All of these things helped build our practice. than offices where We built it back up like a well-oiled only the dentist machine with such a great patient flow and systems, that we now have offices come comes to a program. and learn from our model, so as not to reinvent the wheel. Trust me, though, we made many mistakes before getting the systems in place. In my early years, there were no opportunities that existed to model a sleep or pain practice.
Let’s talk about how you became known as an educator.
I am so humbled by the guidance, education and support I have received from numerous individuals in our field. I feel it is only right to give back by doing the same in educating, supporting, mentoring, guiding and motivating others to do the same as I have. It’s my goal to challenge dentists to become the best providers they possibly can be for their patients. In 2014, I was provided an opportunity from Rose Nierman to lecture on dental sleep medicine. It is interesting how paths cross because I knew Rose Nierman from 2003 when I first licensed DentalWriter™ – their narrative
report writing & medical billing software. From then on, our relationship truly blossomed. I was fortunate to be given the responsibility of Clinical Director of Education for Nierman Practice Management (NPM) and take the role in ensuring our CE programs met the highest standards and were evidence-based. With Rose, Jon Nierman, and their team, we have been able to provide many new programs in the areas of dental sleep medicine, orofacial pain, TMJ disorders for sleep dentists, and, what they are so renowned for, medical billing for the dental office. It’s also been such a pleasure to work with NPM’s amazing caliber of faculty including Shouresh Charkhandeh, DDS; Terry Bennett, DMD; and other past and present speakers. What works so well at our courses is while I’m teaching the clinical team, Rose is nextdoor teaching the billing team (and even dentists) their roles in medical billing for sleep and TMD. Rose gives her cross-coding course, then comes to my class and trains the dentists on their role in medical billing. The combination of clinical and billing education creates the biggest impact for the implementation of TMD and sleep apnea.
What is it like collaborating with Rose Nierman?
I would consider ourselves a dynamic duo. Our programs provide a comprehensive experience for the entire dental team, enabling practices to acquire all of the pieces of the puzzle at once. Rose pioneered cross-coding in dentistry and celebrated Nierman Practice Management’s 30-year anniversary in 2018. It’s amazing to work with her because she has the most incredible work ethic and has stayed on the
From left: Dr. Patel’s team Sherry and Otilia, Rose Nierman and Dr. Patel celebrate Nierman Practice Management’s 30-year anniversary along with team members and sponsors
10 DSP | Spring 2019
Dr. Patel le
ssion of th
rmam, h h Rose Nie
forefront of innovation and medical billing knowledge over time. What I love about our courses and working with Rose is that she recognizes that when the practice is equipped with the medical billing knowledge and implementation blueprints, it removes the biggest hurdle many practices face when implementing DSM and TMD. Rose keeps me on my toes and when I’m teaching, I’ll hear the muffled sound of group laughter coming from her room next door. She makes medical billing training entertaining, thus I must keep coming up with ways to keep my room just as excited. It becomes somewhat of competition which makes us both better and keeps it fun.
How do you connect with dentists and team so well and provide a learning experience unique to them?
A combination of hands-on exercises, didactic review of principles, tangible application of evidence-based treatment modalities, Q & A and other educational styles are all part of my tool kit. We limit the size of our classes in order to provide a personalized experience. I try to have a thorough understanding of the many different backgrounds and philosophies that our attendees come from so that I am equipped to see things from their point of view and guide them with applying the information to their own unique practice. Based on the introductions from the students, I keep a mental note on the one thing they would like to take away from the courses. As I lecture and come onto a topic that someone had mentioned, I spend the time to make sure that student is clear before moving on. I love to engage with the class. Often when someone asks a question, I respond with my own relevant questions and get them to come
12 DSP | Spring 2019
r. Pa cy, and D
i-residen l sleep min
ard -Stack Aw
h the 20 nored wit
up with the answer. Working through different scenarios keeps them engaged and facilitates thinking in a logical manner.
Let’s talk about some of your recent accomplishments. You were the 2018 recipient of the Haden-Stack award for significant contributions to the advancement of knowledge and clinical practice in the diagnosis and treatment of Craniofacial Pain and TMD. What does that mean to you?
It was such an honor for me to receive this award, which was created by icons Dr. Jack Haden and Dr. Brendan Stack. I was in total shock when they announced my name, and it turns out I am actually the youngest recipient of the award. What is interesting is that this took place in Kansas City at the annual American Academy of Craniofacial Pain (AACP) meeting, and my first AACP meeting was in 2003 in Kansas City. Things have a way of coming back full circle, I suppose.
What are some final pearls of wisdom for dentists and team members that are looking to grow their practice with sleep apnea and craniofacial pain treatment?
The most important pearl I have is to start dedicating time in your busy schedule to see your pain and sleep patients. As those dedicated times start filling up then open up more and gradually grow your patient base. In addition, a solid understanding of the field is essential. Start taking some quality courses and look for a mentor. Another interesting observation I have seen is that offices that get their team educated grow and do much better than offices where only the dentist comes to a program. As Nike says “just do it” and that’s exactly what I would say. You need to start to feel more confident and keep educating yourself and your team.
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Sleep Related Breathing Disorders and the Use of High Resolution Oximetry for Screening by Craig Pickerill
Educational aims & objectives
Dental Sleep Practice subscribers can answer the CE questions on page 20 to earn 2 hours of CE from reading this article. Correctly answering the questions will exhibit the reader will: • Understand the difference between various subjective and objective screening modalities for sleep related breathing disorders • Recognize the difference between traditional pulse oximetry and high resolution pulse oximetry • Identify when and with which patients to use high resolution pulse oximetry to screen for sleep related breathing disorders • Recognize important indicators on high resolution pulse oximetry reports in order to identify which patients are appropriate to recommend potential sleep therapies
14 DSP | Spring 2019
leep related breathing disorders place a substantial monetary burden on the economy in the form of decreased productivity, work accidents, and health-related complications.1 Experts in dentistry, pre-surgical screening, cardiology, occupational health, and primary care find that their respective fields would benefit from screening, but polysomnography is often too expensive and impractical. However, recent technological advancements in high resolution pulse oximetry make it a straightforward, cost-effective tool, allowing more patients to be willingly evaluated.
Overnight pulse oximetry monitoring is also a cost effective and minimally invasive method for the dentist to adjust a dental device prior to a follow-up home sleep apnea test (HSAT) or facility-based polysomnography (PSG). While at least one follow-up HSAT or PSG is usually required, using oximetry reduces the likelihood that the patient will need to return for additional HSATs or PSGs.
Subjective vs. Objective Screening Tools
Overall, any health screener is used to indicate the next step – no treatment for those with no risk, more testing for people at high risk of having the disease being looked for. Screeners do not provide diagnosis – they are used
CONTINUING education to choose which people would benefit from increasingly sophisticated diagnostic tools. There are many subjective patient screening questionnaires for sleep related breathing disorders (SRBD) currently in use in various professional settings. These include the American Society of Anesthesiologist’s Checklist, the Berlin Questionnaire, STOP-BANG, STOP, and the Erlangen Questionnaire. These questionnaires are generally easy for patients to use and are low cost. However, the use of subjective questionnaires alone is problematic. The US Preventative Services Task Force found that validated questionnaires did not correctly identify who would benefit from sleep testing.2 They tend to have a high false positive rate, making patients and health care professionals believe everyone will screen positive. While some questionnaires have undergone rigorous validation, others have not been proven scientifically accurate. Also, there is no stratification of risk – all patients are shown to be at the same risk level, and they do not differentiate by cause of sleepiness, such as not getting enough sleep vs. SRBD. Finally, patients can falsely answer questions to match employment requirements, such as in the transportation industries. Because of the high false positive rate and other aforementioned factors, they poorly convert patients to get further testing and sleep therapy. For example, it was found in one study of Type II diabetics where only a screening questionnaire was used, while 90% were found to be at risk for sleep related breathing disorders, only 17% initiated therapy.2 Objective screenings can provide dentists with much more accurate and specific information when screening for SRBD. Physical exams, such as the Mallampati, can be utilized. The Mallampati test scores the distance from the tongue to the roof of the mouth into different classes; higher classes are associated with increased risk for SRBD.2 However,
the original intended use of the Mallampati was to predict difficulty of intubation, and some research has found it less effective for screening SRBD.3
High Resolution Pulse Oximetry is an Increasingly Used Technology for Sleep Related Breathing Disorders Screening
Pulse oximetry is increasingly being used as a screening tool for several reasons. It works by passing red and infrared lights through the tissue in the finger and analyzes how much light was absorbed by the red blood cells. The amount of oxygen in the blood can be measured, giving an oxygen saturation reading.6 It is widely available, most insurance plans cover it, it is relatively simple for patients to utilize, painless, and it is inexpensive when compared to polysomnography or home sleep studies. Further, oximetry results have been shown to provide similar predictive results as that of home sleep studies4 as well has having both high sensitivity and specificity for sleep related breathing disorders.8
Objective screenings can provide dentists with much more accurate and specific information when screening for SRBD.
The Role of High Resolution Pulse Oximetry (HRPO) in Screening for Sleep Related Breathing Disorders: High Resolution Pulse Oximetry vs. Traditional Pulse Oximetry
The accuracy of the results for the screening of SRBD can be affected by the type of pulse oximeter that is used. Advancements in technology have led to pulse oximeters that utilize faster, more accurate sampling rates and sophisticated motion artifact algorithms. These advancements can detect more respiratory events and compensate for patient movement. This in turn helps identify patients that are at high risk of having obstructive sleep apnea. When comparing pulse oximeters, the sampling rate, signal resolution and motion
Craig Pickerill is the CEO of Patient Safety, Inc. (www.patientsafetyinc.com). Patient Safety developed FDA approved SatScreen™ analysis for High Resolution Pulse Oximetry (HRPO). SatScreen’s Pulmonary Arrhythmia Pattern Analysis (PAPA) only works with elite HRPO oximeters which offer short averaging times and granular data storage to the tenth of a % SpO2, SatScreen stands in the gap of costeffective objective screening for sleep apnea and objective titration for Oral Appliance Therapy.
CONTINUING education algorithms can help determine the accuracy of the results. Traditional oximeters use a sampling rate that can be 4 seconds or more. The signal resolution is rounded to the nearest 1% SpO2. “High resolution” in pulse oximetry typically refers to one or both of the following: • Signal Resolution: Some HRPO’s include a signal resolution of 0.1% SpO2, which showed better detection of shorter apneas and improved reproducibility in 2010 comparison study.9 • Averaging Time: A shorter averaging time, or also known as weighted moving time, is important. This moving window averages data across time intervals during the test. Studies show that increasing the window length of an oximeter’s moving average causes underestimation of desaturation events. Although lengthening moving averages may artificially improve a pulse oximeter’s ability to hide unwanted noise, this may lead to the underestimation of the frequency of desaturation/resaturation events and extent of desaturations.9 • Sampling Rate: High Resolution pulse oximeters (HRPO) incorporate a sampling rate of >1 / second. Lower sampling rates can underestimate event amplitudes to apneas and miss events. This can cause an artificially low oxygen desaturation index (ODI).
Figure 1: Shows SpO2 values recorded for devices with low & high temporal resolutions10
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High resolution pulse oximeters, such as Minolta 300i and SleepSat, have a signal resolution of 0.1% and short averaging times, resulting in higher sensitivity and sensitivity. A study showed sensitivity was improved from 0.81 to 0.97 vs polysomnography (PSG) when HRPO changes were made. It is important to note a higher sampling rate doesn’t improve sensitivity unless it has a high signal resolution also. The results of this study suggest that the new algorithm with improved response to apnea/hypopnea events and higher oxygen saturation resolution is superior to the old algorithm.11 Comparison of the HRPO results to meta-analysis of HSAT shows the oximeter’s sensitivity outperforms HSATs when compared with polysomnography in the lab.10 In summary, high resolution pulse oximetry will be best suited to detect minor sleep related breathing disorders if it includes both storage of SpO2 to the tenth (.1%), AND data stored at 1 Hz (once per second).
Understanding High Resolution Pulse Oximetry Results
After receiving the results of HRPO, it is important to understand the results for the patient’s next step of care. Oximetry, home sleep apnea tests, and PSG software applications will typically report the number of desaturations per hour, and time recorded in defined oxygen saturation ranges. Profox oximetry software, for example, works with several oximetry devices and provides this type of summary data. Other device manufacturers, such as Nonin with PureSAT technology, have improved this type of reporting by enhancing the oximeter’s ability to record accurately during movement or low perfusion. This leads to a more accurate representation of desaturations per hour, minimum and maximum SpO2 and time spent in oxygen saturation ranges. Lastly, some software providers take advantage of the data collected by HRPO devices to provide advanced reporting features. SatScreen oximetry reporting software, for example, has developed baseline drift and severity indices to better stratify the type and severity of sleep-disordered breathing. In Figure 2, the overnight results are summarized in a set of bar graphs where green areas represent normal values and red areas represent moderate to severe values. It is
CONTINUING education generally recommended to obtain 4 or more hours of data. One of the indicators often used to screen for SRBD is the respiratory disturbance index (RDI). The RDI as defined herein as the average number of desaturations and respiratory effort related arousals (RERAs) per hour. A desaturation event is a breathing event with a 4% or more reduction in oxygen saturation. RERAs are events that are 10 seconds or more where upper airway resistance causes an arousal. It is adjusted for oximetry to represent mild desaturations with abrupt pulse rise and indicates the number of mild respiratory events which may be disruptive to sleep. In the example report above, the hourly index for minor desaturations associated with autonomic arousals is recorded on the left side of the bar graph. The hourly index of desaturations equal to or greater than 4% are recorded on the right side. The overall respiratory index is noted in the center. Normally, an RDI of 5-14 indicates risk of mild sleep apnea, 15-29 indicates risk of moderate sleep apnea, and 30 or more is at risk for severe apnea. A symptomatic patient who does not fulfill the diagnostic criteria for OSA might have Upper Airway Resistance Syndrome (UARS).12 The saturation baseline drift is an indicator for potential sleep hypoventilation. It is shown on the second bar graph with the highest baseline and the lowest baseline marked. This indicator represents the magnitude of decline from the highest to the lowest SPO2 baseline independent of acute respiratory events. A low baseline that falls in the red section of the indicator (≤88%) may be clinically significant. While the number of desaturations per hour is key to determining apnea risk and severity, oximetry reports including cycling time and cycling severity may provide additional insight into the patient’s disease state. The cycling time indicator represents the percentage of the total study time the SPO2 exhibits a cycling pattern of ventilatory instability. The cycling severity Index accounts for depth of the desaturation events, the duration of the desaturations, and the recovery time between events. Combined, these patterns can indicate milder forms of sleep-disordered breathing, possible presence of loopgain and diminished arousal threshold, as well as more severe cases of sleep apnea.
Figure 2: Example report showing possible OSA with normal arousal state12
Selecting Patients for Oral Appliance
Oral appliances are typically recommended for: • Patients with mild to moderate OSA • Patients who do not tolerate CPAP • Patients who request treatment of primary snoring (without obstructive sleep apnea)14 Obstructive sleep apnea pathogenesis is multifactorial (i.e., patients have OSA for different reasons). Several nonanatomic factors including inadequate upper-airway muscle function, a large ventilatory response to a respiratory disturbance (high loop gain), and low arousal threshold can occur in conjunction with compromised pharyngeal anatomy. A 2016 study by Edwards, et al found that some of these factors may impact the success of oral appliance therapy. Specifically, responders to therapy had a lower loop gain and less collapsible airway under passive conditions.15 Also, patients with a low arousal threshold (i.e., those who wake more easily in response to ventilatory instability) tend to respond poorly to CPAP therapy. The predictive success of oral appliance therapy depends on more factors than the number of desaturations per hour. Some oximetry reporting tools have looked at waveform patterns to indicate likelihood of low arousal threshold and high loop-gain, which may impact the patients’ likelihood of responding well to CPAP and oral appliance therapy. DentalSleepPractice.com
Figure 3: Explanation of High Loop Gain Report 12
OSA with Patients with severe ventilatory instability or high loop gain may experience less success with oral appliance therapy.16 Sleep, increased time delay, and increased tendency for the system to over respond (“underdamping”) are all known to promote an unstable breathing pattern though an increased systems response; “loop gain”.17 The increased time delay results in profound desaturations followed by late arousal and recovery in a recurrent pattern of ventilatory instability. In the example seen in Figure 3, characteristics of OSA with Severe Ventilatory Instability often include a clinically significant RDI, moderate to high Cycling Time, and high Cycling Severity.18 Conversely, patients with milder loop gain may respond well to oral appliance therapy as a first approach to treatment. In figure 4, characteristics of OSA with Hyper-Arousal often include a clinically significant RDI, moderate to high Cycling Time, and low Cycling Severity. As is shown in the figure to the left, the patient experiences an arousal due to minimal upper airway obstruction, takes a deep “Startle breath” (ventilation overshoot), which is followed by a compensatory drop in ventilation & airway tone (ventilation undershoot), resulting in another brief obstruction, causing arousal, perpetuating the cycle. Patients experiencing this type of hyper arousal associated with milder desaturations may have poor response to CPAP therapy and therefore, may achieve better adherence with oral appliance if CPAP fails.12 Once patients have been identified as potentially having sleep related breathing disorders, most insurance companies require diagnosis by a home sleep test or in lab sleep study. The dentist may wish to share the findings of oximetry testing with a sleep specialist to work with the patient to find the most suitable path for treatment. The American Academy of Sleep Medicine recommends oral appliances be used with patients with mild to moderate sleep related breathing disorders, especially those intolerant of PAP, as well as for use with primary snoring.14
Figure 4: OSA with Hyper Arousal Explanation
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Overall, any health screener is used to indicate the next step – which ranges from no treatment for those with no risk to the next test for people at high risk of having the disease being looked for. Choosing the correct
CONTINUING education pulse oximeter can better identify patients with sleep related breathing disorders. By correctly identifying these patients, the proper sleep therapies and treatment can be of1.
fered. High resolution pulse oximetry using technological advancements shows better detection in identifying these patients than using subjective screening alone.
Frost and Sullivan, "Hidden Health Crisis Costing America Billions," American Academy of Sleep Medicine, Mountain View, CA, 1996. 2. T. U. P. S. T. Force, "Screening for Obstructive Sleep Apnea in Adults," JAMA, vol. 317, no. 4, pp. 407-414, 2017. 3. L. M. A. P. M. R.Pateld, "The effectiveness of an obstructive sleep apnea screening and treatment program in patients with type 2 diabetes," Diabetes Research and Clinical Practice, vol. 134, pp. 145-152, 2017. 4. S. Mallampati, S. Gatt, L. Gugino, S. Desai, B. Waraksa, D. Freiberger and P. Liu, "A clinical sign to predict difficult tracheal intubation: a prospective study," Canadian Anaesthetists' Society Journal, vol. 32, no. 4, pp. 429-434, 1985. 5. C. Hukins, "Mallampati Class Is Not Useful in the Clinical Assessment of Sleep Clinic Patients," Journal of Clinical Sleep Medicine, vol. 6, no. 6, pp. 545-549, 2010. 6. John Hopkins Medicine, "Pulse Oximetry," https://www.hopkinsmedicine.org/healthlibrary/ test_procedures/pulmonary/pulse_oximetry_92,p07754, 2019. 7. R. T. L. R. M. G. S. L. A. D. L. D. F. K. L. E. K. Arthur Dawson, "Type III home sleep testing versus pulse oximetry: is the respiratory disturbance index better than the oxygen desaturation index to predict the apnoea-hypopnoea index measured during laboratory polysomnography?," BMJ Open, pp. 5:e007956. doi: 10.1136/bmjopen-2015-007956, 2015. 8. W. T. W. F. A. M. R. B. E. H. W. W. a. J. R. J. Vazquez, "Automated analysis of digital oximetry in the diagnosis of obstructive sleep apnoea," Thorax, vol. 55, no. 4, pp. 302-307, 2000. 9. B. S. S. E. T. P. W. B. N. Bohning, "Comparability of pulse oximeters used in sleep," Physical Measurement, vol. 31, pp. 875-888, 2010. 10. M. K.-R. A. I. R. W. B. T. B. J. Troy J. Cross, "The Impact of Averaging Window Length on the “Desaturation” Indexes Obtained Via Overnight Pulse Oximetry at High Altitude, Sleep," Sleep, vol. 38, no. 8, p. 1331–1334, 1 August 2015.
Business Trends in Dental Sleep Medicine April 5-6, 2019
11. "Comparability of pulse oximeters used in sleep medicine for the screening of OSA," Physiological Measurement, vol. 31, no. 7, pp. 875-888, 2010. 12. L.-A. T. M. T. S. P. L. P. M. Mohamed El Shayeb MD MSc, "Diagnostic accuracy of level 3 portable sleep tests versuslevel 1 polysomnography for sleep-disordered breathing:a systematic review and metanalysis," CMAJ, vol. 186, no. 1, pp. E25-E51, 2004. 13. Patient Safety, "Patient Safety," 2018. [Online]. Available: www.patientsafetyinc.com. [Accessed 19 January 2019]. 14. P. a. P. o. S. M. (. Edition, Principles and Practice of Sleep medicine, 5th ed., W.B. Saunders, 2011, pp. 1206-1218. 15. M. M. Kannan Ramar, D. Leslie C. Dort, D. Sheri G. Katz, M. Christopher J. Lettieri and M. Christopher G. Harrod, "Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015," Journal of Clinical Sleep Medicine, vol. 15, no. 1, 2015. 16. C. S. C. J. E. D. Osman AM, "Obstructive sleep apnea: current perspectives," Nature and Science of Sleep, vol. 2018, no. 10, pp. 21-34, 2018. 17. C. A. S. L. S. A. S. S. A. J. R. L. O. D. P. W. G. S. H. A. W. Bradley A. Edwards, "Upper-Airway Collapsibility and Loop Gain Predict the Response to Oral Appliance Therapy in Patients with Obstructive Sleep Apnea," Am J Respir Crit Care Med, vol. 194, no. 11, pp. 1413-1422, 2016. 18. M. Y. D. T. Kimgman Strohl, "Loope Gain and Sleep related breathing disorders," Current Respiratory Medicine Reviews, 2007. 19. D. Lawrence Lynn, "Occult Arousal Failure," in Ohio Sleep Doctors, Columbus, 2012. 20. Q. S. Aurora RN, "Quality measure for screening for adult obstructive sleep apnea by primary care physicians.," J Clin Sleep Med, vol. 12, no. 8, pp. 1185-1187, 2016. 21. F. B. Y. M. P. L. M. S. A. C. P. Frances Chung, "STOP Questionnaire," Anesthesiology, vol. 108, pp. 812-21, 2008.
Jonathan Lown, MD
Kent Smith, DDS
Arthur Feigenbaum, DDS
Jayme Matchinski, JD
Gy Yatros, DDS
Richard Monahan, DDS, MS, JD
Mark Murphy, DDS
John Viviano, DDS
Ellen Crean, DDS, PhD
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Sleep Related Breathing Disorders and the Use of High Resolution Oximetry for Screening by Craig Pickerill 1. Which of the following is NOT a commonly used sleep questionnaire? a. Anesthesiologist’s Checklist b. The Berlin Questionnaire c. PIQ-6 Questionnaire d. STOP
care or insurance companies c. It works by passing red and infrared lights through the tissue in the finger and analyzes how much light was absorbed by the red blood cells d. It is relatively easy for patients to use
2. Subjective questionnaires can be problematic due to which of the following reasons? a. They have a low positive rate. b. They correctly identify the patients that would benefit from sleep testing. c. There is no strati fication of risk. d. They can differentiate the cause of the patient’s sleepiness.
5. What is the typical signal resolution of a traditional oximeter? a. 1% SpO2 b. 0.1% SpO2 c. 4% SpO2 d. 2% SpO2
3. An example of objective screening for OSA is _________ . a. STOP –BANG b. Bronchoscopy c. X-ray d. Pulse oximetry 4. Which is not true about pulse oximetry: a. It is relatively inexpensive b. It is generally not covered by Medi-
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6. What is the typical sampling rate of a high resolution pulse oximeter? a. 4-5 seconds b. 10-11 seconds c. 3-4 seconds d. ≥1 second 7. High resolution pulse oximeters can help detect which type of event better than traditional oximeter? a. Long apneas b. Short apneas c. Long arousals d. Sinus Rhythms
8. Oral appliances are typically NOT recommended for ____________ . a. Patients with mild to moderate OSA b. Patients with narcolepsy c. Patients who do not tolerate CPAP d. Patients who request treatment of primary snoring (without obstructive sleep apnea) 9. Characteristics of OSA with hyperarousal include ____________ . a. moderate to high cycling time and low cycling severity b. low cycling time and high cycling severity c. RDI under 5 d. Total sleep time under two hours 10. Patients with OSA, severe ventilatory instability, or high loop gain tend to ________ . a. have more success with oral appliance therapy b. experience less success with oral appliance therapy c. never get insurance approval for oral appliances d. respond best to surgical options
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Using a Precision Milled, Continuous Advancement, Oral Appliance with Symmetric Titration to Treat All Severity Levels of Obstructive Sleep Apnea by Neal Seltzer, DMD, FAGD, D.AADSM, D.ACSDD, D.ASBA; Jeffrey S. Rein, DDS, FAGD, D.AADSM, D.ACSDD, D.ASBA; and Gina Pepitone-Mattiello RDH, C.ACSDD
or years it was thought that oral appliance therapy was limited to treating mild and moderate obstructive sleep apnea and was only to be considered as an alternative or secondary attempt to treat severe levels of OSA. In 2015, the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guidelines for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy noted: “Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. The purpose of this new guideline is to replace the previous, and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring.“1 Amongst many recommendations, the guidelines state “we recommended that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.”1 The guideline conclusion stated that, “The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs.”1 Although continuous positive airway pressure (CPAP) is a very reliable treatment for OSA, its history of poor compliance, difficulty of use in many circumstances (i.e. travel, lack of electricity), side effects, and
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in many cases, outright refusal of use by patients, many physicians have had difficulty considering oral appliance therapy as a viable alternative to treatment. As of now, the standard for successful treatment of OSA is based on reduction in apnea hypopnea index (AHI) to healthy levels. Severity levels of OSA can be quantified as follows: healthy = AHI less than 5 mild = AHI 5 To 15 moderate = AHI 15 to 30 severe = AHI 30 or higher Perhaps the best measurement of success in treating OSA is how effective the treatment is over time. Oral appliances have shown efficacy in treating all levels of OSA from mild to severe and additionally show compliance over time far superior to CPAP. This longer compliance combined with their efficacy results in an overall effectiveness with outcomes similar to CPAP.2 Our Dental Sleep Medicine practice, Long Island Dental Sleep Medicine, has been treating patients with oral appliance therapy for over 28 years. In that time, one of the more frustrating observations we have made is the length of time patients are forced to struggle with CPAP when an alternative and more patient-friendly therapy, such as with oral appliances, has been available. In addition, after CPAP failure, physicians rarely suggest alternative treatment such as oral appliance therapy. These patients, therefore, go untreated for long periods of time until they finally research alternatives themselves.
ProSomnus [CA] Sleep Device
Another clinical anecdote is that we have found that many patients with a severe AHI are assumed, by physicians, untreatable using oral appliance therapy. It is our clinical observation that AHI by itself is a poor predictor of success. Many patients we treat have the same AHI yet the breakdown of obstructions and hyponeas may vary proportionately and greatly affect the outcome of treatment. Other factors such as BMI, ODI, positional factors, age, and facial morphology must all be considered. When all aspects are considered, it is often that we have seen oral appliance therapy successfully treat patients with severe levels of OSA. One of the reasons patients cite for why they are more compliant with oral appliance therapy as a treatment option for OSA is the
obvious small size and comfort of oral appliances as compared to CPAP. The perfect oral appliance has yet to be developed. The variation in patient oral anatomy as well as consideration of minimizing potential side effects has produced a myriad of oral appliance designs. In our dental sleep medicine practice, we have used and abused just about every appliance ever developed in our quest to help improve patient outcomes. Recently, we have incorporated the ProSomnusÂŽ Continuous Advancement [CA] appliance into our armamentarium. Our decision to add this appliance to our list of choices was based on the precision milled platform that forms the basis of its unique design. Milled from a dense uniform acrylic, the ProSomnus [CA] is extremely hygienic, lingualess for increased tongue space, accurate in fit to reduce tooth movement, and engineered with symmetrical titration for comfortable, predictable results. Below are three recent case studies from our patient population ranging from mild to severe OSA utilizing the ProSomnus [CA] successfully.
It is our clinical observation that AHI by itself is a poor predictor of successful oral appliance therapy.
CASE #1 MILD Diagnostic AHI = 4.9 CC: Despite his low diagnostic AHI, the patient suffered with morning headaches, lack of dreaming, fatigue, and impaired cognitive function.
Dr. Neal Seltzer received his Doctor of Dental Medicine degree in 1982 from Tufts University, School of Dental Medicine. He is a Fellow of the Academy of General Dentistry. In addition to his general dental practice, he has focused on treating patients with obstructive sleep apnea since 1991. He is a diplomate of the ABDSM, the ACSDD, and the ASBA. Dr. Jeffrey S. Rein received his Doctor of Dental Surgery degree in 1982 from Loyola University, School of Dental Medicine. He is a Fellow of the Academy of General Dentistry. In addition to his general dental practice, he has focused on treating patients with obstructive sleep apnea since 1991. He is a diplomate of the ABDSM, the ACSDD, and the ASBA. Gina Pepitone-Mattiello is a Registered Dental Hygienist who obtained her dental sleep certification from the ACSDD. She is the creator of the only certification course for dental auxiliaries to become credentialed in dental sleep medicine. Her passion is to improve awareness and improve the lives of people suffering with sleep breathing disorders. At Long Island Dental Sleep Medicine, she works exclusively treating patients using oral devices to manage OSA. The authors can be reached at Long Island Dental Sleep Medicine â€“ www.lidentalsleepmedicine.com.
CASEreport Based on his symptoms, the patient was placed on CPAP therapy. For approximately one year the patient struggled with CPAP, unable to resolve his issues. Eventually at a follow up visit with his sleep physician, alternative treatment of oral appliance therapy was discussed, and the patient referred to our office. A ProSomnus [CA] appliance was inserted April 2018. Almost immediately, the patient stated that he felt better and all of his complaints had resolved. On 6/13/18 an efficacy study was done resulting in an AHI =1.4
Oral appliances continue to evolve and as they become more comfortable with less side effects there is better compliance.
CASE #2 MODERATE Diagnostic AHI = 16.5 CC: The patient reported that his family complained about loud snoring and occasional talking in his sleep. He stated that he had lack of focus and was tired all the time by day. He had a PSG 12/11/17 with an AHI = 16.5 He was placed on CPAP and immediately could not tolerate it because of claustrophobic factors. The patient was then referred to our office for oral appliance therapy. He was fitted for a ProSomnus [CA] appliance which was inserted February 2018. After several small titration visits over several months and subjective relief of all symptoms, except some slight occasional snoring, the patient was referred for an efficacy study. The study was done on 10/2/18. The AHI was 3.1
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CASE #3 SEVERE Diagnostic AHI = 67.3 CC: The patient was always tired; snoring and gasping in sleep as witnessed by his wife. The patient was put on CPAP therapy but struggled for years with ill fitting masks and pressures that were too high for him to tolerate. This resulted in him eventually discontinuing treatment. He then went untreated for months. It was then that he was eventually referred to our office for treatment. The patient was fitted for a ProSomnus [CA] appliance 3/2/18. Within weeks the patient reported he was feeling rested, was no longer snoring and stated, “this is much better than CPAP”. At that time he was referred for an efficacy study. Months went by and we did not hear from him regarding results of the study. We called the patient as he was coming due for his six month reevaluation visit. His response was “I am still using the appliance and feel great, so I did not go for the study”. We advised him, that despite his subjective results, he should quantify his results with a follow up study. It was not until 10/16/18 that the study was done, with very positive results showing an AHI = 13.4. After the efficacy study, the appliance was advanced 0.4 mm bilaterally and then he scheduled for another efficacy study. As of this writing, we do not have those results but are hopeful the patient’s AHI will continue to improve. In our practice, we have used the ProSomnus [CA] successfully to treat dozens of patients ranging in all levels of severity of OSA. It has been our experience that the unique features of this appliance help improve compliance, improve outcomes and ultimately improve effectiveness in reducing AHI. Oral appliances continue to evolve and as they become more comfortable with less side effects there is better compliance. Improved precision and engineering yields more reliable and predictable results allowing dentists to successfully treat a wider range of OSA severity.
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827. Sutherland K, Phillips CL, Cistulli PA. Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances. Journal of Dental Sleep Medicine 2015;2(4):175–181.
The Dentist and the Otolaryngologist – Working Hard Together
eople in Pittsburgh suffer as much from sleep related breathing disorders as any other part of the country, but they have one big advantage no other population enjoys. People in other cities can see a sleep doctor, an ENT, a dentist, and an orthodontist and put all that advice together to sort out their choices. Four doctors, four appointments – an unfortunate burden.
Nicole Chenet, DDS and Ryan Soose, MD
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In Pittsburgh, they can make one appointment and get advice from all four areas of expertise: they can see Nicole Chenet, DDS and Ryan Soose, MD and come away with all the information they need to choose how to address their sleep breathing problems. These two doctors did not fall together by accident. Each had a vision for changing the way sleep patients were cared for and put in the hard work to make their own practice a better solution path. When they discovered their interests-in-common, it became a natural fit. Dental Sleep Practice sat down with these innovative doctors to learn more.
DSP: How did you guys each discover sleep and airway as part of your patient care?
NC: I graduated from dental school in West Virginia in 2000 and bought my first practice a year later. During the next 15 years, I took several continuing education courses – I really enjoyed aspects of orthodontics. As I was learning orthodontic skills, airway problems kept popping up, and I got to thinking about how they could be impacting my regular dental patients. Soon, I enrolled in UCLA’s Mini-Residency with Dr. Dennis Bailey and went on to achieve Diplomate status with the American Board of Dental Sleep Medicine in 2015. RS: Fortunately for me, just as I was completing my residency in otolaryngology in 2007, the American Board of Medical Specialties certified Sleep Medicine as a subspecialty under Otolaryngology – Head and Neck Surgery. I saw that as a choice, then, right away. In early practice, I noticed how many airway patients were getting inade-
CLINICIANspotlight a CPAP, and then were sent elsewhere or lost to follow-up if that didn’t work. This one-sizefits-all approach commonly leaves patients inadequately treated – a new approach is needed that takes specific patient phenotypes into account and tailors treatment for the individual. There must be a dentist involved in that system, so when I met Nicole and felt her passion for the same kind of team approach, it became a natural fit. NC: In 2015, Allegheny Health Network, AGH Center for Sleep Medicine invited me to be their dental provider. After working hard at this for a few years, I saw it as a perfect fit to be part of a medical team who all understand what the goals are – what we are trying to do together. RS: I can’t really recall, to be honest, how we met and what my practice was like before we started working together – that’s how good a fit this is. It’s such a 2-way street – I and other MDs don’t look at dentists as technicians, like the old model, but as collaborators. quate treatment with a fragmented care model. People were shuffled around and often left on their own to manage their care. As I was learning new ENT-related treatments, I left otolaryngology as a sole focus and completed a sleep fellowship in 2010 – I think I was only the second person in the country to do so. Since I did all this at the University of Pittsburgh, I decided to stay in town and provide full diagnostic and management services for sleep, as well as sleep surgery, under one roof.
DSP: What made the connection, then?
NC: The Pittsburgh area has a small, but great, community of dentists that have worked hard to form relationships with the physicians in our area. When I started, there was really only one other ‘serious’ dentist but now there are five primarily dedicated to dental sleep medicine. My passion for this subject led me to reach out to MDs to ask how I could help solve their patient problems. I called them myself, asking about their ideas and thoughts for less fragmented care. I gave talks at health fairs and countless local doctor’s offices, trying to break down the barriers between our professions. The main message I tried to get across was that I was interested in patient care, not in pushing a high volume of appliances out the door. RS: I saw ENTs and Dentists in a similar predicament – part of a failing old model where patients saw the sleep physician specialist, got DentalSleepPractice.com
CLINICIANspotlight NC: And my patients with oral appliances sometimes are still symptomatic, so I know they need more help. Instead of that patient being lost to follow-up or given poor choices, our practice can address their needs in many ways and make the appropriate referrals to specialists if necessary. It’s not uncommon for a patient with severe OSA to be told PAP is their only option, but they end up with an oral appliance. While their quality of life is much better, perhaps Ryan and I put their SRBD is only better by half – instead of the sleep doctor telling them their OA isn’t our heads together working, Ryan and I put our heads togethto see what else er to see what else might be possible and work together to find the best solution for might be possible that patient. We find that common ground, and work together recognize that our patients need both of us, and we need each other to give that patient to find the best the best choices and build their confidence solution for in the care they are getting. RS: We think the profession should that patient. move away from the sole focus on AHI and more toward individual patient care – making a tailored multidisciplinary plan for each unique individual. Patients need to focus on the quality of life choices along with the objectives and the risk of each choice. When they have a team that is dedicated to patient education and a team approach, the treatment chosen seems to go better with fewer problems.
DSP: What else has been a key for success for you, Nicole?
NC: One aspect I know is important to our patients is being in network with medical payors in our area. We started out in 2013-14 with one of the biggest plans, and now I think we accept all of them. This has turned out to be a huge benefit for referring physicians, and it removes a big barrier for our patients. Treatment acceptance is better, which fits our vision for more successful treatment. It takes the right staff and excellent communications with them, the other doctors, and our patients to make it happen, but it works for us. Part of the hard work we’ve done to make this all happen is to get the medical billing part as solid as we can. Our practice created lots of written materials for our patients, too, to help them take in the information.
DSP: Do you guys do sleep testing in your office? RS: As a sleep physician, of course we
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do, both in the lab and, mostly, using home monitors. One thing I really like is having a white board in my exam rooms – I draw lots of pictures and link information from their treatment history, choices and sleep report together. Lots of our patients take pictures of the white boards. NC: Not us – we are committed to getting objective data, we always refer the patient back to the sleep lab / physician that referred the patient for follow up testing whether it be HST or in lab PSG. We talked with our sleep docs and worked out the language and protocols for the patients to return to them for testing.
DSP: There is a big interest in treating children’s airway problems now. How do you address this in your practice?
NC: Since 2015, my practice is limited to treating snoring and sleep apnea in adults. Prior to this in my general dental practice I would look for early signs of airway concerns in the pediatric patient, refer to ENT and initiate phase 1 orthodontic treatment when appropriate and within my scope of practice. I think about the ‘contents and the container.’ I do ask all my adult patients about their kids and their friend’s kids. My training, education, and clinical expertise lead me to refer to my orthodontic colleagues for collaboration as well. RS: Pediatric sleep-disordered breathing is an exciting frontier and one of the few opportunities for prevention rather than just treatment. For kids, it’s frequently about jaw structure, allergies, nasal congestion, tonsils, and adenoids. Early recognition and intervention is key.
DSP: This has been fantastic, Nicole and Ryan. I know many dentists reading this will be envious of what you guys have created, but I hope it inspires them to go out and make it happen in their town. What other message would you like to send our readers? NC: Do the work. Nothing takes the place of getting out there, knocking on doors, and making the relationships happen. Be sure you know what and why you are doing it, and get to work. RS: There’s common ground out there. ENT doctors want to know how to find the ‘right’ dentist to work with, and vice-versa. Collaboration is essential.
How We Do What We Do
I use a temporary device...
hoosing the device and following the therapy is the most important dental skill involved in oral appliance therapy. Let’s see how our readers see their role.
Appliance choice, I...
When the custom needs replacement or repair To prove that mandibular protrusion will be helpful first To allow my patients to ‘try out’ therapy before committing When a patient only wants a backup appliance For TMD or other non-airway focused therapy
show, explain choose the and give the device I think is patients the use both best suited choice approaches
How do I choose the device manufacturer...
Medicare / PDAC approves only a few designs and manufacturers for E0486
Lab details (delivery time, domestic or international)
Device features, advantages and benefits
What they allow is adequate for my clinical needs
Cost of the device
When presenting Medicare-covered patients, I only offer PDAC listed devices
Based on clinical evidence
Their list does not cover every patient’s best matched device
When presenting Medicare-covered patients, I discuss other appliances even though patients will pay out of pocket for them
More appliances should be added to the list
When presenting Medicare-covered patients, I provide the appliance I think best and submit to Medicare anyway
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Based on referral from a trusted colleague
Based on manufacturer sales and marketing
27% 40% 23% 10% 15%
Long term changes... Most patients have changes to their occlusion with OA wear I do not provide (or stopped providing) OAT because of bite changes Physicians warn my patients against OAT because of these changes I think bite changes are rare in my patients Long term changes are likely but medical necessity is more important
Are common but easily managed for most patients
11% Keep me from proposing OAT for my patients
10% Are common but I have a specialist to refer the patients to
61% My patients come to my office for device titration
My patients titrate their device on their own based on symptoms
I use only nontitratable devices
21% I provide a protocol sheet they are to follow to titrate according to a schedule
This is interesting data. Dentists choose devices for their patients, for the most part, but many bring the patient into the conversation. One would hope this is done with a thorough informed consent, based on the side effects noted in the survey. If you are one of the dentists who avoid OAT for your patients based on adverse events or side effects, look at how many of your colleagues carry on with this life-saving therapy, confident the medical benefits outweigh the dental changes. If your confidence needs a boost, noticing that successful therapies are happening all around you might point the way to addressing the source of your concerns. Oral appliance therapy can have an image problem if physicians tell their patients that the side effects are serious enough that OAT should be avoided. Part of what dentists can do to address SRBD in our population is to overcome this bias.
For morning repositioning, I...
fabricate and deliver a morning aligner with every appliance delivery
make and provide a morning aligner with some appliance deliveries
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6% provide a lab fabricated morning aligner with every appliance delivery
7% provide a lab fabricated morning aligner with some appliance deliveries
3% do not provide any aligner repositioning devices
CO2 Laser Functional Frenectomy by Cara Riek, DNP, RN, FNP-BC, IBCLC, DABLS; Stevanie Bahnerth, DC; and Peter Vitruk, PhD, MInstP, CPhys
he goal of frenectomy is to release the restricted frena (i.e., Tethered Oral Tissues or TOTs). The goal of a Functional Frenectomy1-3 in children, adolescents and adults is to release the restricted frena and to restore, with the help of mandatory pre- and post-frenectomy Oro-Myofunctional Therapy (OMT), the mobility and functionality of tongue and lips for optimal breathing, speech, chewing, swallow, and posture.1-3 A Functional Frenectomy involves, besides the surgeon, a team trained in myofunctional, physical, craniosacral, osteopathic, and chiropractic therapies.
Figure 1A: Dates from left: 5/8/2018, 7/31/2018, 10/24/2018, and 1/9/2019
Figure 1B: Dates from left: 5/8/2018, 7/31/2018, 10/24/2018, and 1/9/2019
This article reports clinical cases of a Functional Frenectomy with the CO2 laser and includes, in addition to pre- and post-frenectomy OMT, a pre- and post-surgical systematic bodywork performed by a chiropractor, to achieve long-lasting functional results. CO2 Laser Functional Frenectomy approach incorporates the following three parts: 1. Pre-surgical chiropractor assessment, bodywork and OMT exercises to strengthen and re-pattern tongue function; 2. CO2 laser frenectomy with real-time assessment of tongue and lip restrictions by the clinician to achieve ideal release for the optimal function; 3. Post-frenectomy chiropractor assessment, bodywork and OMT exercises to ensure long-lasting functional results. The compensations developed by the muscles can create muscle tension and tightness that need to be addressed before frenectomy, i.e., patient may require pre-frenectomy care to help begin to loosen and align the joints affected by the TOTs. Such collaboration between frenectomy provider and chiropractor may successfully resolve chronic pain, headaches, airway obstruction, and digestive problems.
The Functional Frenectomy approach to releasing oral restrictions is illustrated by the clinical cases in Figures 1-2.
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The 9 year-old female patient, presented with an open bite (Figure 1A), a narrow, high palate (Figure 1B) and limited range of mouth opening (Figure 1C). She wanted to eliminate the habit of persistent thumb
LASERfocus sucking that she found embarrassing. The patient was started on MyoBrace appliance and was undergoing chiropractic care. The patient was unable to keep the MyoBrace in most of the night. The patient’s mother attempted mouth taping, but the patient often pulled the tape off in her sleep. While the patient was improving, she hit a plateau and the progress slowed down. During that time the patient was diagnosed, by Dr. Riek, to have a posterior tongue-tie. After undergoing OMT, the patient’s lingual and labial (not pictured) restriction was released by Dr. Riek with a LightScalpel CO2 laser. A combination of topical and local anesthetic was used. Figure 1D shows immediate post-op image of the tongue – note lack of bleeding and clean surgical margins; no sutures were needed. Post-frenectomy, OMT continued and a much improved tongue mobility was achieved as tongue healed (Figures 1E and 1F: both at six months post revision. The tongue range of motion ratio (TRMR) has increased from 32/46 mm to 48/50 mm. Post-frenectomy, the patient now easily retains the MyoBrace appliance in the mouth without the need to tape. She no longer sucks on her thumb. Post-frenectomy, a significant progress was observed in both the palate shape and the bite – see sequences in Figures 1A and 1B.
The 28 y. o. female patient came to Dr. Riek’s office with complaints of headaches, neck pain, not getting restful night sleep, and digestive concerns. Upon examination, a tongue-tie was noted (figure 2A shows the limited range of tongue motion). Dr. Riek recommended OMT four weeks prior to the functional frenum release and the continuation of chiropractic care. After the pre-frenectomy care, the patient returned to Dr. Riek’s office for her tongue-tie release procedure. The local anesthesia was administered. The same LightScalpel CO2 laser settings were utilized as for Patient 1. Figure 2B shows the patient immediately after the laser release. No bleeding occurred intraoperatively or postoperatively. The wound, albeit deep, was left to heal by secondary intention. The surgical site healed without complications (figure 2C shows the wound healing five
Dr. Cara Riek graduated from Arizona State University of with Doctor of Nursing Practice degree. She is a board certified Family Nurse Practitioner in addition to having her IBCLC certification. Dr. Cara is also a diplomate of the American Board of Laser Surgery, specializing in Oral Surgery in Infants, Toddler, and Adults. Dr. Cara very much enjoys helping families reach their breastfeeding goals. She can be reached at email@example.com. Dr. Stevanie Bahnerth is a family chiropractor with more than 14 years of experience. She earned her Bachelor of Science degree from Purdue University and then attended Palmer College of Chiropractic in Davenport, Iowa. Her practice revolves around providing ongoing care and treatment for patients with TOTS – infants through adults. In her free time, Dr. Stevanie enjoys spending time with family and friends, yoga, and traveling. She can be reached at firstname.lastname@example.org. Peter Vitruk, PhD, MInstP, CPhys is a member of The Institute of Physics, UK, and a founder of the American Laser Study Club (www.americanlaserstudyclub.org), and LightScalpel, LLC (www.lightscalpel.com), both in the USA. Dr. Vitruk can be reached at 1-866-589-2722 or email@example.com.
LASERfocus days following laser frenectomy). In the absence of notable pain and swelling, the patient was able to perform her OMT exercises without difficulties. Nine months post laser frenectomy and ongoing OMT and chiropractic care, the patient has a much improved tongue range of motion: at the initial visit to Dr. Riek, the patient’s TRMR was Grade 2 (36/50); post-procedure the TRMR increased to 52/55) (Figure 2D). In addition, the lift of the tongue has significantly improved (Figure 2E). The initial symptoms have been resolved. The patient started mouth taping at night to achieve better sleep and reports no night time waking. Her headaches are minimal now. Neck pain was completely resolved, she is able to sleep 8 hours per night WITHOUT waking, and no longer experiences GERD (swallowing air, some reflux, burping).
Why CO2 laser?
Not all lasers are equally good at vaporizing (i.e., ablating or cutting) and coagulating soft tissue. Figure 3 demonstrates the difference in the absorption spectra for the main soft tissue chromophores for different laser wavelengths.4 The CO2 lasers offer the following benefits for oral soft tissue surgery: • Approximately 1,000 times greater photo-thermal cutting efficiency relative to dental diodes, and in approximately 10 times greater photo-thermal coagulation/hemostasis depth relative to erbium lasers; • Close match between the coagulation depth of the CO2 laser and the blood capillary diameters (Figure 3).4 This close match distinguishes CO2 from erbium lasers and provides instant hemostasis during high speed ablation or cutting. The CO2 laser ablates tissue while coagulating small blood and lymphatic vasculature. It provides improved visibility of the surgical field and therefore enables more precise and accurate tissue removal; • Minimal post-operative edema, pain and discomfort; due to the intraoperative closure of lymphatic vessels on the margins of the CO2 laser incision.4 With CO2 laser frenectomy, patients report less post-operative pain and discomfort than with the scalpel.
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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. Logarithmic scales are in use. Graph courtesy of LightScalpel LLC.
CO2 Laser Frenectomy Settings
For both clinical cases described above, the LightScalpel CO2 laser was set to 2 W Non-SuperPulse, and gated at 20 Hz, 40-60% duty cycle, 0.8-1.2 W average power; straight tipless handpiece with a 0.25 mm focal spot diameter was used to produce 0.3-0.4 mm deep shallow incisions at a 3-5 mm/sec hand speed. Such shallow incision depth, combined with shallow coagulation depth (0.1-0.2 mm4), allows for excellent and progressive visualization of larger diameter blood vessels. Also due to the shallow depth of incision, multiple laser passes are required to complete the required depth of incision in a safe and controlled fashion.
Achieving, with the help of OMT, the optimal breathing, speech, chewing, swallowing and posture is limited in the presence of restricted frena (i.e., Tethered Oral Tissues or TOTs).1-3 Such limitations are removed by a Functional Frenectomy, which includes mandatory pre- and post-frenectomy OMT. Pre- and post-frenectomy evaluation and bodywork by a chiropractor are beneficial additions to Functional Frenectomy as they help achieving truly long-lasting functional results. The use of CO2 laser for frenectomy results in a less painful surgical site, than the conventional procedure. The clinician can use either topical or small amounts of local anesthesia for functional tongue and lip assessments during the procedure. Acknowledgments: Authors greatly appreciate the help and contribution from Anna (Anya) Glazkova, PhD, in preparing this material for publication. 1. 2.
Fabbie P, Kundel L, Vitruk P. Tongue-Tie Functional Release. Dent Sleep Practice. Winter 2016: 40-45. Zaghi S, Valcu-Pinkerton S, Jabara M, Norouz-Knutsen L, Govardhan C; Moeller J, Sinkus V, Thorsen RS, Downing V, Camacho M, Yoon A, Hang WM, Hockel B, Guilleminault C, Liu SYC. Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. The Laryngoscope. 2019. Geis M, Kundel L, Vitruk P. Functional Frenectomy (Osteopathically Guided). Dent Sleep Practice. Summer 2018:30-32. Riek C, Vitruk P. Incision and Coagulation/Hemostasis Depth Control During a CO2 Laser Lingual Frenectomy. Dent Sleep Practice. Spring 2018:32-38.
I Gave You 10mm of Vertical... What do you mean it’s not enough? by Frank Madrigal, CDT, President, True Function Laboratory
ost of you have felt the pain of grinding down an occlusal guard or simply returning it to the lab because the bite was high in the posterior. Let’s contemplate the fact that most occlusal guards require a minimum of 1.5-2mm posterior thickness between cusp tips. Now consider that most sleep appliances require at least twice that clearance. Most of our clinicians try to be as conservative as possible when it comes to vertical. They tell us that this typically increases the chance of successful therapy due to more comfort, lip seal and other important reasons. Sharing clinical photos of the patient’s bite with the lab artist allows collaboration and problem-solving before the device is made. One of the most common challenges dental laboratories have is insufficient vertical clearance in the protrusive bite. Have you ever: • Had the upper and lower trays seat well individually but not when connected? • Delivered an appliance with a much more open bite than you expected? • Received a call from your lab requesting more vertical? • Found that the appliance only contacts in the most posterior area?
Possible causes for these issues could be: • Excessive Curve of Spee • Super-erupted molars • Anterior open bite • Steep mandibular plane angle • Insufficient vertical on bite registration Possible solutions: • Consult with lab about appliance choice • Reduce coverage over back teeth • Take bite at a higher vertical • Allow lab to increase vertical Considerations for your next bite registrations: • Patient’s oral anatomy • Patient’s occlusal scheme • Appliance selection specific for the patient’s anatomy • Taking a second bite registration while the patient is still in the chair
O M O
G N I F
! S R E
Success by Susan Wingrove, BS, RDH
igital scanning can change the way you practice – no more impressions to produce crowns, bridges, orthodontic retainers, and oral appliances for obstructive sleep apnea. Here are the key elements for intraoral digital scanning success, and some useful clinical tips. To capture the best quality for all scans, enhanced office systems, a new instrument, and more detailed clinical protocols are the improvement opportunities. Precision scans require excellent retraction and isolation to provide data that our top lab artists use to make accurate restorations and well fitted removable appliances.
Photos courtesy of Dr. Richard Martin using Trios
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Set up Scanning for the Day – Office Systems
• Assign one person to be the digital technology specialist. The scanner will need to be turned on in the morning, set up with the patients’ names for the day, and made ready to go so it can be brought to an operatory without delay. • Administrative team member or digital technology specialist reviews the schedule to identify the patients that are appointed for digital scans, and others who might be diagnosed that day. Include hygiene patients for possible orthodontic aligners, occlusal guards, or other removable appliances. • Organize a fully-stocked mobile cart set up to include: the warmed-up scanner, retraction cords or paste, and individually bagged, sterilized, scanning isolation / retraction instruments. The mobile cart makes the scanner ready to be wheeled into any operatory – having it in only one spot limits spontaneous choices. What if that operatory is occupied? Opportunity lost! Be scan ready! • Maintain digital scanner according to manufacturer’s instructions and keep the software up to date. Patience wears thin for technology problems.
TECHNOLOGY Scan What You Need, Retract the Rest!
Fast, clear scans benefit everyone – the patient, the digital workflow, the lab artist. What is the recommended clinical protocol and what are dental professionals using for retraction now? Fingers? A small metal mirror? A new professional bendable isolation retraction instrument, Scan-Mate,™ is now available to be your scanning partner. A product of Armor Dental, Scan-Mate retracts the patient’s lip, cheek and tongue comfortably. The Scan-Mate instrument is reusable, autoclavable, and includes a soft latex-free bendable tip with non-reflective black finish specifically intended to provide an isolated, optimal field during the scanning process for an error-free scan. “Scan-Mate gives trained auxiliaries the confidence to scan their patients with ease while drastically reducing their scan time” said Dona Schulz, Technology Trainer and Implementation Specialist. “As a result, we will be able to train more team members to scan, which will free up the doctor’s time and improve the practice’s digital workflow. A bonus is that Scan-Mate can be used for comfortable isolation throughout the patient’s entire appointment. Auxiliaries will love it and patients will, too!”
Tips for Successful Scanning – Clinician Protocol
• Identify the area that needs to be scanned. Visualize a clear scan path, from a single restoration to full arch scans. • Bend the non-reflecting Scan-Mate instrument to retract the lip, cheek and tongue. Glide the scanner effortlessly along the scan path. No more fingers in the way! • Complete the scan with patient comfort in mind. Fast, effectively, and without reflection or gloved fingers for a clear, clean scan.
Photos courtesy of Dr. Isaac Tawil
“Intra-oral scanning is here to stay, but that doesn’t mean it’s easy,” said Dr. Scott Ganz, DMD. “Getting the proper retraction is essential to insure proper image acquisition and quality.” Ganz continues: “mirrors are reflective and often uncomfortable for the patient. We shouldn’t be using fingers to retract for single teeth or full arch restorations. I have been very impressed with the recently introduced Scan-Mate’s fully adjustable and non-reflective instrument which definitively solves the problem. Scan-Mate allows me to quickly and clearly visualize the area to be scanned, helping to insure accurate, crisp, and clean images.” Digital technology enhances your patients’ dental experience with streamlined office and clinical protocol in place. Team up with a Technology Implementation Specialist who can train your dental team to confidently complete even the most challenging scans for crowns, bridges, full arch orthodontic aligners, occlusal guards, and oral appliances for obstructive sleep apnea. Scan-Mate, your new scanning partner, clearly eliminates the biggest problem with scanning: comfortable retraction for the patient. The scanner you invested in can obtain a high quality scan – and with proper isolation, you can take advantage of that technology! No more fingers! Scan-Mate is available through Benco, Henry Schein, JK Dental or Patterson. For more information, visit www.armor-dental.com.
Scan-Mate™ isolation/retraction instrument for scanning and surgical procedures by Armor Dental
Susan Wingrove, RDH, BS, is a dynamic innovator, writer, International speaker, instrument designer & 2016 Sunstar RDH Award of Distinction recipient. Susan is a member of the American Dental Hygienist’s Association, International Federation of Dental Hygienists, and Western Society of Periodontology. Published author for multiple journal articles, Scientific Panel for ACP Clinical Practice Guidelines, as well as Implant Maintenance Textbook: Peri-Implant Therapy for the Dental Hygienist: Clinical Guide to Maintenance and Disease Complications. She resides in Missoula, MT. She can be contacted at firstname.lastname@example.org or wingrovedynamics.com.
Taking OSA Devices to the Next Level by Alex Buddemeyer, CDT
hange is difficult but in most cases can be rewarding. You have to decide if you are going to change and adapt to keep improving yourself and your business, or fight change and hold onto what you have while you can. With the dental community being introduced to new digital 3D printers, milling machines, and intra-oral scanners, it is important to stay on the cutting edge of technology. This will ensure that you are always giving the best quality dental and medical devices that are available to your office and patients. Keeping up with these changes and successfully implementing them in your practice can make or break your business. DynaFlex is here to tell you that it can be easy and you don’t have to change anything in your practice that you’re currently doing for your sleep patients! Did I mention that you won’t have to invest thousands of dollars to take advantage of the technological advancements that DynaFlex can offer you and most importantly your patients? You can now give your patients a CAD/ CAM designed, precision milled, top of the line sleep device even if you don’t have a scanner or printer in your office. We take your stone models along with your bite and scan them which will create a digital (.stl) file in our 3D system. Once we create the digital file we will utilize our CAD/CAM software to design your selected sleep device and send it to one of our 5-Axis Milling Machines. Within a short time period, your sleep device is
Alex Buddemeyer is a Certified Dental Technician (CDT) and manager of the state-of-the-art Sleep Device Laboratory at DynaFlex. With a degree in Dental Technology and more than 9 years of experience in dental sleep medicine, Alex is able to advise the best way to handle even the most unique cases, as well as ensure your patients are receiving the highest quality sleep devices available on the market today.
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Figure 1: Milled adjustable Herbst
Figure 2: Milling machine
milled to perfection using a crystal clear preformed PMMA blank. This not only creates the perfect fitting device but also creates a much stronger, cleaner, and healthier device for your patients. With our new milled devices, your patients can rest assured, knowing it is covered by DynaFlex’s warranty for three years – versus the standard one year on most dental sleep devices. They will also benefit from approximately 30% less monomer in the device due to the use of a highly accurate and compressed pre-formed PMMA disc. Milled devices are 20% stronger, too – this means less breakage and revisits, allowing you to feel pride in your quality, service, see more patients, be more efficient and generate more revenue from happy, satisfied people. For questions and more information, please contact our Sleep Lab Manager Alex Buddemeyer at email@example.com.
Custom Milled Herbst® § Three Year Warranty
§ Smooth Diamond Finish
§ Medicare E0486 Verified
§ Thinner Design
§ Superior Strength
§ Maximum Tongue Space
With our new high precision 5 Axis milling machines, we can create an extremely accurate, crystal clear and impressively strong device. We utilize the newest CAD/CAM digital software and highly trained technicians to ensure an accurate fit and silky smooth finish to your milled devices. The new milled line of OSA devices are currently available in the Adjustable Herbst® and DynaFlex Dorsal® and includes a 3 Year Warranty. The Adjustable Herbst also has Medicare E0486 Verification for reimbursement.
800.489.4020 | www.dynaflex.com 120518 © 2018 DynaFlex® , St. Louis, MO 63074. All rights reserved.
Sweet Dreams Are Made of This
Using Dreams to Identify Breathing Issues by J.M. DeBord
he dreaming mind is a translator. It takes input received while dreaming and translates it into symbolic imagery. The type of input runs the gamut from memories, thoughts, and emotions to physical sensations and bodily messages. Include breathing on that list. Your body has a monitoring system that reports to your mind and makes your dreams part of the process. If your airway is obstructed from a condition such as sleep apnea, your dreaming mind will translate it into symbolic imagery. Here’s what to look for, beginning with my all-time favorite example. A woman who attended a lecture I gave at Canyon Ranch Spa in Tucson asked me why her husband has recurring dreams about being stuck upside down in a chimney. She said the dream is so common, they refer to it in shorthand as “the chimney dream.” “Does he have sleep apnea?” I asked in return. Her face lit up. Yes, he has sleep apnea. “Imagine you are the dreaming mind and you want to create imagery that symbolically represents an airway. A chimney is an airway. Now, how do you tell the story about an obstructed airway? One way is to stick your husband upside down in the chimney.” A house in a dream can symbolize the body -- it’s the place where your mind lives. The body’s “chimney” is the airway. Sleep apnea can manifest in dreams as anything that blocks the airway such as stran-
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gulation or choking while trying to swallow something large or sharp, or indirectly in scenes such as trying to breathe while in outer space or underwater, and even more indirectly in heavy symbolism such as a clogged pipe or broken elevator. It’s often accompanied by panic. Think about it: every cell in your body is hollering for more oxygen, or CO2 is building up in the bloodstream and the clock is ticking before serious harm happens. The dreaming mind is a clever storyteller. It has many ways of telling a story about sleep apnea and other issues related to breathing. Next, another example that I think is sleep apnea, but the dreamer only knows for sure that he’s never been diagnosed with it so there’s no saying for sure. I’m going to recount the dream in ﬁrstperson and in the words of the dreamer so you get the full impact. Imagine it’s your dream: Had a dream last night that I’m standing alone in a small room. Out of nowhere I pull a straw out from my pocket. I close one side of it with my hand, while the other I put in my mouth. Then I start to suck in all the air to try and suffocate myself. I did that a total of four times and felt my heart pounding and hurting because of a lack of oxygen. I woke up after the fourth time in a panic and my heart was pounding as though I was suffocating in my sleep, too. That sure looks to me like a dream about an obstructed airway. A straw can symbolize an airway, and in the dream the straw
ALTERNATIVEview is closed. You, as the dreamer, are a participant in the story and act out the symbolism. The dream-story has a script you follow subconsciously. When the dreamer closes off one end of the straw and tries to breathe through it, he’s acting out symbolism, and the most likely candidate for the meaning of the symbolism relates to breathing. With that in mind, look back at the main details of the dream: • I close one side of [the straw], while the other I put in my mouth. Then I start to suck in all the air to try and suffocate myself. • ...I felt my heart pounding and hurting because of lack of oxygen. • ...I was suffocating in my sleep. • Plus, he tries four times to breathe through the straw. That’s about as many unsuccessful breathing attempts in a row you can tolerate before panic sets in. He says as far as he knows he doesn’t have sleep apnea or sleep-related breathing issues, but his dream sure says otherwise. It’s possible the dream is symbolic of something else – he could be suffocating in the personal sense of being under too much pressure and stress. He could feel severely constrained, panicky, or weighed down by heavy expectations. The cause-and-effect relationship between the body and dream content is a twoway street. Dream content responds to what’s experienced by the body, and the body responds to dream content, such as when you dream about running and mimic the action while asleep. However, look at how his body reacts with symptoms such as elevated heart and breathing rate. There are other possibilities for why it responded this way. Your body can respond to dream imagery as if it’s actually happening. Heavy stress, embarrassment and powerfully-felt emotions such as fear or anger can cause a person to constrict their breathing while awake or asleep. After 25 years of interpreting dreams, though, I’ve developed my gut instinct and it says “this dream is about a constricted airway.” Whether it’s a one-time thing – for example, his tongue rolled back in his mouth, possibly creating a straw shape – or it’s an ongoing sleep-related breathing issue can’t be known after the fact, but it gives the person something to think about and watch out for.
Which raises a question: how do you know that your airway is constricted while you’re asleep, other than by recognizing the signs your dreams give you? Well, you could spend time in a sleep lab, but ﬁrst I suggest that you use a voice-activated recorder on your nightstand to monitor your sleep. The sounds of snoring or labored breathing should be loud enough to People with obstructive activate the recording device. I found sleep apnea (OSA) have several voice-activated recording apps less dream recall than for phones.1,2 A close member of my family is a people without OSA4 and heavy snorer and to hear it at its worst is worrisome. I remember well the ﬁrst report more unpleasant time I heard him experiencing serious dreams and less breathing diffculties while sleeping, 5 not just snoring but like a jackhammer emotional variation. pounding concrete. I went to his bedroom and listened to his breathing. Ten seconds elapsed and he didn’t breathe. Twenty seconds. Twenty-ﬁve seconds. Then “WHOA-ACKACK-ACK-ACK!” as he pulled in a powerful breath and forced air through his obstructed airway. Next, a few normal breaths, then a few labored ones along with snoring, then silence again. No breathing. Then the jackhammer. I woke him up (gently) and urged him to sleep on his side. Another way to tell if your airway is constricted while you’re asleep is by how you feel when you wake up. I snore if I sleep on my back, and when I do, I wake up with a headache. Hello, oxygen deprived brain (or more accurately, hello carbon dioxide saturated brain).3 When I wake up tired after a full night of sleep, it means I’m not getting the deep sleep I need to feel rested. Why? Airway obstruction, usually. When I sleep badly, I have less dream recall. My personal observations are born out by research into the dream lives of people with
J.M. DeBord is the author of Dreams 1-2-3: Remember, Interpret, and Live Your Dreams, and The Dream Interpretation Dictionary: Symbols, Signs, and Meanings. He’s a popular dream lecturer and interpreter who appears regularly in media and teaches dream interpretation. His work reaches millions of people worldwide. Online he’s known as “RadOwl” the reddit.com dream expert. Find him online at Dreams123.net.
ALTERNATIVEview sleep apnea compared with people without it. People with obstructive sleep apnea (OSA) have less dream recall than people without OSA4 and report more unpleasant dreams and less emotional variation.5 Interesting ﬁndings, wouldn’t you say? Even more interesting to me are the causes. I get asked frequently about sleep issues, or ﬁnd sleep issues at the heart of dreaming issues such as nightmares. Sleep apnea disrupts the normal rhythm of sleep. The person with OSA does not reach the deepest stages of sleep that provide the greatest beneﬁts in terms of rest and recuperation. Also, the most vivid and intense dreaming occurs during REM-stage sleep (rapid eye movement). REM is the pinnacle of sleep. Unless a person is sleep-deprived (in which case they can fall into REM sleep quickly after going to sleep), they won’t experience REM until the end of the ﬁrst sleep cycle. They won’t cycle through sleep stages normally unless the body sheds core heat and breathes in a long, shallow rhythm. Now imagine the dreaming mind, the translator of all input received including messages from the body, responding after a person hasn’t breathed for, oh, let’s say 30 seconds. And let’s say that airﬂow has been declining for, oh, ten minutes. Now you’re seriously oxygen-starved and CO2 is building up rapidly in your bloodstream. Soon it will be at poisoning level. You might even be turning blue. Can you imagine how that extreme panic would translate into dream imagery? It’s the most horrifying nightmare imaginable, which is how it’s been described to me by the few apnea patients I’ve worked with who remember what they were dreaming just before jolting awake. For many reasons, people want to forget those memories. Plus, they might experience apnea-induced nightmares and not know the cause. They jolt awake to breathe and don’t know they haven’t been breathing unless someone tells them or they recognize the symptoms such as elevated heart and breathing rate, headache, and gasping and choking. So then they don’t know that the nightmare is caused by sleep apnea and the condition ﬂies under the radar. [Specialists who diagnose sleep-related breathing issues would be wise to ask about a patient’s dreams. To my knowledge, it’s not a common practice in sleep medicine.]
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Obviously, sleep apnea disrupts the sleep cycle, which means that people who have it experience fewer and shorter REM stages. Which means less dreaming and less vividness. Which means fewer dreams to recall and less emotional variation to them. Keep in mind, snoring is a sign of a restricted airway and can produce similar symptoms and effects as mild apnea. How do you use this information to tell whether you have sleep apnea or other sleep-related breathing issues? One way is to ask yourself if you think you dream less, have less recall, or less emotional variation than you used to. Another way is to recognize and respond when you aren’t sleeping well. Your attention span is shorter. You’re more irritable and your temper is shorter. You have diffculty processing new information and recalling old information. Sometimes, though, I think that people avoid reaching that conclusion because there’s this idea in society that sleep issues are somehow less important than other medical issues. They aren’t even recognized as legit in some circles, and you’re perceived as weak if you express a need for something related to sleep such as more of it, or better quality. Disrupted sleep, a growing trend that now affecting hundreds of millions of people around the globe, has other causes such as excessive light and noise, stimulants, and the use of electronics immediately prior to sleep. A growing body of evidence suggests that we aren’t dreaming as well because we aren’t sleeping as well, and we aren’t sleeping as well because of a variety of factors that include not breathing as well. This trend needs to change. 1.
Dictaphone Voice Recorder iPhone app by Dorada App Software Ltd. https://itunes.apple.com/us/app/dictaphone-voiceactivated-recorder/id834938465?mt=8/ Smart Recorder – High-quality voice recorder Android app by SmartMob. https://play.google.com/store/apps/details?id=com. andrwq.recorder&hl=en/ Peters B. Morning Headaches May Be a Sign of Obstructive Sleep Apnea. Verywell Health. January 9, 2018. https://www.verywell. com/obstructive-sleep-apnea-am-headaches-3014738/ Fisher S, Lewis KE, Bartle I, Ghosal R, Davies L, and Blagrove M. Emotional Content of Dreams in Obstructive Sleep Apnea Hypopnea Syndrome Patients and Sleepy Snorers attending a Sleep-Disordered Breathing Clinic. J Clin Sleep Med. 2011;7(1):69–74. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3041622/ Ochman P. Do People with Sleep Apnea Dream? Sleep Apnea Treatment Centers of America. October 25, 2013. http://curemysleepapnea.com/sleepsource/2013/10/25/ people-sleep-apnea-dream/
Team Engagement with Functional Oral Appliances What is a functional oral appliance? How can we team support such therapies? by Glennine Varga, AAS, RDA, CTA Define and Educate
First, it’s important to define what a functional appliance is, and how the therapy fits within your practice. What is the difference between an occlusal guard and a functional oral appliance? The easiest way to understand this concept is an occlusal guard or night guard are fabricated to the patient’s habitual “everyday existing” bite – think of clenching, a ‘parafunctional’, or non-physiologic, movement or posture. The goal is to protect the structures from the excessive force and not allow changes, such as muscle pain or tooth wear. A functional oral appliance can be active, using normal movements like chewing, to use the muscle force with the intent to reposition the patient’s jaw, bite, teeth and muscles. Passive functional oral appliances include mandibular advancement devices for SRBD. This repositioning could be intended to be temporary or to make a more permanent change. Here are a couple of examples: Non-Functional Oral Appliance Functional Oral Appliance Occlusal Guard Oral device used to reduce upper airway collapsibility Orthopedic Expander Orthodontic Retainer
Hard Telescopic Sleep Herbst Image courtesy of Great Lakes Dental Technologies
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Oral appliances for sleep breathing disorders will reposition the mandible in a more forward position to support an open airway during sleep. This is a temporary change, which is why we supply our patients with morning exercises and aligners to recapture their habitual bite. However, an occlusal guard is fabricated to protect the teeth from dental forces during the night but not intended to anteriorly advance the mandible for airway patency and it is not considered a functional oral appliance. An orthopedic functional appliance will engage customized forces to change the shape and position of the bone which will change the position of the teeth, bite and muscles. However, an orthodontic retainer will hold the teeth in place to prevent a change in position therefore it also is not considered a functional oral appliance. Functional oral appliances for adults can be used for sleep breathing difficulties, night time clenching and bruxing habits, temporomandibular disorders, orthodontic and orthopedic issues. Some athletes will also use
a functional oral appliance during sports to reposition the mandible to gain the competitive edge similar to wearing nose strips or nose cones during sports. Functional oral appliances for children are geared toward making permanent orthopedic or orthodontic changes. Let’s take a look at team engagement with functional oral appliances and ways we can support it.
Evaluate and Plan
The responsibility of any dental team member is to understand the types of therapies provided and be able to answer simple questions regarding the necessity, procedure and outcomes. Team should keep all specifics up to their dentist to answer. However, once your patient commits to such therapies team responsibility becomes more involved in such actions as informed consent explanation, financial communications, medical insurance considerations, management of adjustments or use of appliance, documentation, home care instructions and promoting patient success. It is also important to know what the goal is for the treatment and document changes correctly. These processes can be completely different than what we are responsible for with dental procedures, but they can be very easily managed if you know what you should be saying. Once you identify what types of functional appliance therapy your office offers, now it’s time to help identify which patients would benefit from such therapies. Updating your existing medical history has proven to be the most effective way to screen every patient for airway deficiencies, headaches, facial pain etc. This will allow for every patient to answer questions regarding symptoms and habits. Helping our doctors by working with your practice management systems to understand how to update these medical histories is the first step you can take. If you are offering a
Print home care instructions and sleep hygiene tips. These go a long way with your patients.
Flat Occlusal Plane Splint Image courtesy of Great Lakes Dental Technologies
patient questionnaire focusing specifically on orthopedics, orthodontics, TMD or sleep breathing, work as a team to identify which patients should be introduced to this form. If possible, make it available on your website and include your office logo and contact information on any downloadable or printable form. You want your potential patients to have the opportunity to provide you with as much information as needed. When dealing with functional therapies there may be a medical component involved and obtaining a detailed medical history may be necessary for documentation. Taking measurements and documenting a changing position will require a new focus and level of awareness when it comes to the clinical aspects. Evaluate what you’re offering your patients moving forward with therapy. Functional oral appliances may have insurance benefit, if there is documentation of a medical necessity. Always remember there may be a deductible to consider. Therefore, preparing for the financial discussion should be a priority. To be ready to discuss a benefit from medical insurance for your patients, be prepared by understating the insurance policy and requirements. Decide which financial arrangement will be discussed. Assemble a packet of contents including a financial contract, informed consent, copy of sleep reports, physician letters and educational materials. Include your office contact information. Typically, functional appliance therapies require multiple adjustments, sometimes done by the patient. Make this process easy for them by providing a guide or a chart to follow. If the patient has an orthopedic device and is making adjustments at home, monitor and communicate with them often and celebrate his or her compliance. Ask them to take
Glennine Varga is a dental sleep medicine coach and a co-founder of Dental Sleep Apnea Team. She has been employed in dental education for 20 years. She is a member of the Academy of Dental Management Consultants (ADMC) and a professional member of the National Speakers Association (NSA). She is also a visiting faculty member of The Pankey Institute and Spear Education’s Dental Sleep Medicine courses. Glennine is an expanded duties dental assistant certified in TMD with the American Academy of Craniofacial Pain (AACP). www.dsatsleep.com • 877-217-2127 • firstname.lastname@example.org
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photos with their phone and email them to you for the chart – if they are receiving adjustments in the office take intra oral photos of the progress. Don’t forget to follow your HIPAA rules! Print home care instructions and sleep hygiene tips. These are all items that do not cost much but can go a long way with your patient and are easy to produce.
Promote, Promote, Promote!
Most dental offices offering airway therapies know it’s rough at first to shift from primary dental conversations to sleep breathing or head and facial pain. Patients expect to talk about decay, periodontal disease and restorative dentistry – instead, we bring up oxygen desaturation, apnea hypopnea scores and medical related conditions. It can be a lot to take in. So where do we start? Getting to know your patient is always best and personalize everything. Be specific with note taking and relaying information to each other. Find your best patient successes and ask for permission to share. Don’t forget to document their consent! You can get your first stories from your internal circle: teammates, bed partners, children, parents, brothers, sisters, uncles, aunts. It pays to treat a loved one at risk and experience benefits first hand. In my 13 years of assisting in a TMD, sleep breathing, functional orthopedic practice I can tell you it was the patient success stories and internal referrals that made the biggest impact. Specifically orthopedic cases showing before and after changes and improvements convinced parents and patients to commit to functional therapies. A sleep appliance for diagnosed sleep breathing disorders in my opinion is the easiest to influence patients to manage. When our patients are diagnosed with a sleep breathing disorder such as UARS, OSA or snoring, it is imperative we team communicate the importance of managing this and testify to other patient’s benefits. This promotion doesn’t have to be about the device, and, in fact, it should be much more about how we care significantly about our patients and their health aliments including damaging forces manifesting within their dentition. Helping patients breathe better during sleep with fabricated oral appliances will also protect dentition as a bonus. Helping patients orthopedically change bony structures to optimize function and airway support can also improve aesthetics – another bonus they can see and feel.
ealthyStart, a Comprehensive Pediatric Airway System, Announces New Online Training. Two free cases treated simultaneously.
Start young patients on the pathway to better health You have spent many hours attending classes, understanding the research and possibly treating adult OSA patients, but now you realize that the Pediatric patient is the next direction for treatment. You have questions and hesitancy, but HealthyStart, the top innovator of treatment for pediatric airway issues, provides the screening tools, the knowledge to identify the underlying root causes, and a 3D treatment plan incorporating oral appliances with built-in myofunctional therapy. The HealthyStart system is an “A” to “Z” solution that begins with a digital education class involving a six week series of extensive material covering how to identify, evaluate and treat the underlying pediatric issues, but will also provide “hands on” implementation of two complete cases that will be treated simultaneously. The HealthyStart digital series takes the quiz work and the initial hesitation out of the equation by providing a comprehensive clinical plan for every patient; collaboration with clinical advisors to assist in every step of the way and compliance monitoring of patient with the HealthyStart® App. The Digital Series provides a six-part series with two free cases that will be treated along side the education videos and study forums. Each week a video will be emailed on Monday with a Friday study forum conducted by expert providers giving an overview of the weekly material as well as discussing implementation of treatment into your practice, the selection of the two patients that you will treat, how to speak with a parent
HealthyStart Treatment Series of Appliances
CBCT image courtesy of W. Harrell, DMD
and patient, dental and medical insurance, treatment planning, etc. The course fee also includes the ability to attend a live course in the destination of your choice along with 4 staff members. To learn more about the HealthyStart® System, please attend an upcoming free medical webinar. Visit http://www.healthystart webinar.com/medical-webinar-presentations/ to register. DentalSleepPractice.com
Airway Health as a Food Choice by Pat Mc Bride, MA, RDA, CCSH The Circadian Code
Ask most people about their circadian clock and they will tell you it has “something to do with sleep.” As dental and sleep medicine clinicians we are increasingly tasked with educating our patients on the value of healthy lifestyle, eating, and sleeping habits. The negative impact of imbalanced systems in our environment and bodies now reaches far beyond the risks of periodontal disease and tooth decay to include overall functioning and sleep. In The Circadian Code, the science behind the 24 hour circadian cycle is revealed by illustrating how the timings of our day (when we eat, sleep, exercise, work) are more crucial to our overall health and longevity than we ever thought before. Dentists are often the one provider who spends more minutes per appointment with patients than just about any other medical practitioner. In that capacity, they become uniquely qualified to observe how a patient’s daily schedules may be out of sync with their circadian rhythms, which in turn affords him or her the opportunity to educate and help “fix” what may be wrong. The world of molecular and circadian science are delivered to the public in this very engaging and readable book by Satchin Panda, PhD, who emphasizes the importance of timing in our bodies and environment. He states simply that “everything in our bodies cannot happen at once.” The body was not designed to be awake and asleep at the same time and is set to operate on a 24 hour rhythm cycle. This has been the case for millennia, and modern culture has disrupted the body’s cycles and its rhythmic connection to the 24 hour day. The circadian rhythm, he explains, is controlled by clocks present in every cell Dentists are which tell the brain when to sleep, tell the gut to digest food optimally, and ultimately uniquely situated tell the heart to pump more or less blood to us alive. Every single cell in the human to influence their keep body, hormones, brain chemicals, digestive patients to improve enzymes etc., are pre-programmed genetically to peak at one point in the day and health, sleep, and trough (literally gas out) at another. Without wellbeing. this clock the business of sleep, which is tasked with resting and repairing all bodily systems, cannot function as it should. Poor sleep is much more than a bad headache for some people, it is actually contributing to the shortening of lifespan, reduced quality of life and exacerbation of serious disease processes including sleep apnea. Dr. Panda outlines in detail the circidian cycle, why it is important, how it works well, and ultimately how it fails to work properly as influenced by a host of factors such as food intake, lifestyle habits, no exercise or exercising at the wrong time of the day and social environmental factors
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such as exposure to too much light before bed or not enough during the day. While the book focuses heavily on weight gain issues caused by improper eating too late in the day, it lays out a program clinicians and hygienists can easily present during exam and hygiene appointments to patients who complain of weight gain, failed dieting or yo-yo swings in weight, fatigue, mood issues, and ultimately poor or fragmented sleep. Cracking the door into an individual’s daily cycle may help you save a life, or at the very least change one. Dr. Panda’s easy-to-implement lifestyle modifications, such as restricted eating times during the day and exercising in the morning, offer concrete examples of ways in which our patients can reverse ailments like diabetes, cancer, and dementia, as well as microbiome conditions we all associate with sleep apnea such as acid reflux, heartburn and irritable bowel disease. Something as simple as eating earlier in the day can align gut rhythms and improve overall health and wellbeing. As we look at sleep disorders in our patients we now have another educational tool to help them assess their own circadian cycles and individual habits so they can work to “reset their clocks.” You as their dental and sleep medicine provider are uniquely situated to influence and collaborate with your patients to improve their health, sleep, and wellbeing while empowering them to make small daily changes which lead to very big improvements in their lives.
BOOKreview The Dental Diet
I have to admit, another book about diet, any diet, usually leaves me cold. We all know that diet refers to weight loss in most people’s minds, but in reality diet is really about what, when and how we eat, not just weight loss. So, when a copy of Steve Lin’s The Dental Diet landed on my desk recently I thought – “must be more about sugar and decay”...I couldn’t have been more wrong! Every dental office in the country needs to have this book in the waiting room. The more I read, the more I realized that the general public is constantly fed volumes of inaccurate information about nutrition. The is no denying that 42% of all kids have tooth decay, and at least 50% of all adults have periodontal disease in this country. I would hazard to guess that these numbers are escalating with the current pandemic of type II diabetes, heart disease, periodontitis and sleep apnea. Deftly and without pretense, Dr. Lin teaches the reader that yes, in dental school he learned how to treat the issues of dental decay and periodontal disease but, it wasn’t until he came upon the seminal work of Weston A. Price that he realized the mouth is quite literally the “gateway to the entire body.” He could now prevent many of the issues he was treating people for. Lin explains quite simply that food choices literally shape our faces. Crooked teeth are not caused by genetics, but rather by poor nutrition. Epigenetics, the process of the way genes express themselves, makes much more of an impact on health than the genes themselves. The foods individuals consume produce the epigenetic influence, which changes the way the genes control body processes. Borrowing many of Price’s early research photographs from Nutrition and Physical Degeneration (1939), Lin goes into great detail regarding, for example, supplementation of K2 with vitamin D for teeth and bones and appropriately questions whether or not probiotics are actually helpful. He generously adds a comprehensive food plan for readers to better understand each food and how it either helps or hinders organ systems and overall health. This book is a beautiful read while being consummately
comprehensive, including a large swath of refereed literature (at least 300 citations) on general nutrition. Lin presents extensive and detailed information on all of the different food groups, revealing the sobering reality of modern grains verses the three ways grains were prepared in traditional cultures. There are more than a few “a ha” moments that help to debunk long held notions about what we have been sold commercially as healthy eating. An interesting chart with “healthy” foods on one side and dental diet recommendations on the other should be posted in your operatories. It’s an eye opener. Just talking about the list will entice patients to think differently about what they consider healthy eating for their dental as well as overall physical health. One of the most interesting sections dentists will discover in this book directly connects the development of jaw structures with breathing, revealing the damaging effects of 20th century extraction/retraction orthodontic practices. Couple that with poor nutrition and many of our patients can be recognized. The poignant take away here is that the growth of the jaw is no random toss of the dice but rather the result of the development of the muscles that let us breathe, chew and swallow. Lin has analyzed our ancestral traditions, epigenetics, gut health, and the microbiome in order to develop food-based principles for a literal top-down holistic health approach. By merging dental and nutritional science, his program can help ensure that your patients won’t need dental fillings or cholesterol medications – and give you and your team the resources to help parents to raise healthy kids who develop naturally straight teeth.
Pat Mc Bride, MA, RDA, CCSH, has spent 38 years as a full time clinician and educator in the fields of dentistry, respiratory medicine and dental sleep medicine. Her extensive experience in clinical, laboratory, research and educational arenas has led to the development of interdisciplinary care model delivery systems used by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. She sits on the Board of Directors for the American Academy of Physiological Medicine and Dentistry in New York. Pat continues to work hands on with patients while lecturing internationally on subjects relating to breathing and sleep medicine, dentistry and precision medicine systems to best benefit all patient populations. Serving the underserved and marginalized patient remains a passion and priority for her. She is a Ph.D. candidate at Fielding Graduate University. She has one grown daughter who shares her passion for social justice and education, serving as a fifth grade teacher in the inner city Oakland, CA.
Provision of Oral Appliances and Regulatory Compliance: Why Your Practice Should Have a Compliance Plan by Jayme R. Matchinski, Esq.
n recent years, there have been an increasing number of government and commercial insurance company audits and investigations related to durable medical equipment (DME) companies, dentists, and physicians providing Oral Appliances to patients who have been diagnosed with Obstructive Sleep Apnea (OSA). Most sleep disorder centers and DME companies have historically billed the Medicare and Medicaid programs and other third-party payors, including commercial insurance companies, for the provision of patient care, Oral Appliances, and related services and supplies. However, due to the rapid growth of Dental Sleep Medicine across the nation, collaboration between dentists and sleep physicians for the provision of Oral Appliances, and the related increased payment by third-party payors, including reimbursement by the Medicare program, Dental Sleep Medicine providers and suppliers are now on the radar of government agencies and third-party payors for regulatory compliance issues and related enforcement efforts. Additionally, the utilization of telemedicine by Dental Sleep Medicine providers and suppliers with multiple locations in different jurisdictions, and the availability of Oral Appliances for purchase on the Internet by individuals without a prescription or documented Polysomnography (sleep study) and diagnosis of OSA, has given rise to additional regulatory concerns and compliance issues.
Regulatory Environment and Compliance Issues
The current regulatory environment impacts how health care providers and suppliers provide Dental Sleep Medicine. Specifically, dentists, DME companies, sleep physicians, and sleep disorder centers have all been impacted by complex regulations in connection with the provision of Dental Sleep Medicine and Oral Appliances. An increasing number of audits and investigations are being conducted by government agencies and third-party payors, which have caused dentists, DME companies, sleep physicians, and sleep disorder centers, to revisit their regulatory compliance efforts and compliance programs. The national growth and expansion of Dental Sleep Medicine aligns with new and advancing technology and the evolving regulations and enforcement efforts. Compliance programs have become an effective tool to demonstrate regulatory compliance in the event of an audit, investigation or other enforcement activity. Dentists who provide Dental Sleep Medicine to their patients in conjunction with other health care providers and suppliers, including sleep disorder centers, sleep physicians, and DME companies should consider implementing a compliance program to demonstrate regulatory compliance, and as a preventative measure for risk management in the event of an audit or investigation. A compliance program is a system to ensure continuous compliance with all applicable laws, regulations, industry standards, organizational standards, governance principles, and community and ethical standards.
Dental Sleep Medicine and a Compliance Program
Corporate compliance is a term that is used in the health care industry to indicate that a provider or supplier runs a clean operation
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LEGALledger and does not commit fraud, waste or abuse of health care funds. Compliance programs increase staff awareness, demonstrate commitment to regulatory compliance, and may be a mitigating factor during an audit or investigation. Compliance programs for Dental Sleep Medicine should be designed, implemented, and enforced so that the program is effective in preventing and detecting fraud, and abuse and criminal conduct. Compliance plans may be required by law or contract. Third-party payor agreements may include a provision that the provider or supplier has to have a compliance program. The Office of Inspector General (OIG) has developed a series of compliance program guidance documents directed at various segments of the health care industry, including: hospitals, nursing homes, physician practices, hospices, home health agencies, clinical laboratories, third-party billers, and DME suppliers. These OIG model compliance programs encourage the development and use of internal controls to monitor adherence to applicable regulations, and program requirements. It should be noted that the OIG developed and published the compliance guidance in an effort to promote ethical and lawful conduct throughout the entire health care industry, and currently the OIG compliance guidance are not required by law. The OIG published the Compliance Program Guidance for the Durable Medical Equipment, Prosthetics, Orthotics and Supply Industry in the Federal Register, Volume 64, No. 128 (July 6, 1999). The OIG identified seven (7) fundamental elements applicable to an effective compliance program. These elements are: • Implementing written policies, procedures and standards of conduct; • Designating a compliance officer and compliance committee; • Conducting effective training and education; • Developing effective lines of communication; • Enforcing standards through well publicized disciplinary guidelines; • Conducting internal monitoring and auditing; and • Responding promptly to detected offenses and developing corrective action. (64 FR 36368) Using these seven (7) identified elements for an effective compliance program, the OIG has identified specific areas of the durable
medical equipment, prosthetic, orthotics and supply (DMEPOS) industry operations, which includes Oral Appliances, that may prove to be vulnerable to fraud and abuse. Like previously issued OIG compliance guidance for other health care providers and suppliers, the adoption of the Compliance Program Guidance for the DMEPOS industry is voluntary, and not mandated by federal regulation. The OIG’s compliance program guidance is intended to assist suppliers of DME, including Oral Appliances, and their agents and subcontractors with the development of effective internal controls that promote adherence to applicable state and federal regulations, and the program requirements of Compliance programs state, federal, and private health plans. increase staff The adoption and implementation of voluntary compliance programs awareness and may by dentists for the provision of Denbe a mitigating factor tal Sleep Medicine may prevent fraud, abuse, and waste in the health care during an audit or plans while providing quality patient care, the Oral Appliance, and related investigation. services. Compliance efforts should be designed to establish a culture within the Dental Sleep Medicine Program that promotes prevention, detection, and resolution of instances of conduct that does not conform with applicable state and federal regulations. The compliance program should effectively articulate and demonstrate the ethical and business policies of the dentist, DME company, sleep physician, sleep disorder center, and any other health care providers or suppliers involved in the provision of Dental Sleep Medicine. Benchmarks should be established by the dentists, and other Dental Sleep Medicine health care providers and suppliers, which demonstrate that implementation and achievements are essential for an effective compliance program. The compliance program is critical as an internal quality assurance control in the reim-
Jayme R. Matchinski is a health care attorney and Officer in the Chicago office of the law firm Greensfelder, Hemker & Gale, P.C. Jayme focuses her practice in health and corporate law, including helping health care providers and suppliers handle the complex regulatory and operation issues unique to the industry. She has significant experience in the area of Dental Sleep Medicine. She can be reached at email@example.com.
LEGALledger bursement and payment areas where claims and billing operations are often the source of fraud and abuse, and have been the focus of government regulation, and government and commercial insurance scrutiny, enforcement, and sanctions. Every compliance program implemented by dentists should require the development and distribution of written compliance policies, standards, and practices that identify specific areas of risk to the health care provider or supplier. These policies and procedures should be developed and drafted under the direction and supervision of the appointed compliance officer. Dentists and their staff, independent contractors, agents, representatives, designees, and any other individual who may impact billing deThe OIG has cisions, should be required to review identified certain the compliance program and attest and acknowledge that they understand and areas of concern for agree to comply with the compliance Dentists and dental practices DMEPOS suppliers. program. should require new hires to review their compliance program during orientation and sign an acknowledgement form that they agree to fully comply with the compliance program and the applicable state and federal regulations. The OIG has identified certain areas of concern for DMEPOS suppliers including, but not limited to: • Billing for items or services not provided; • Billing for services that the DMEPOS supplier believes may be denied; • Billing patients for denied charges without a signed written notice; • Duplicate billing which occurs when more than one claim for payment is submitted for the same patient for the same service, for the same date of service; • Billing for items or services not ordered; • Upcoding, which involves selecting a code to maximize reimbursement when such code is not the most appropriate descriptor of the service; • Unbundling items or supplies, which involves billing for individual components when a specific HCFA Common Procedure Coding System (HCPCS) code provides for the components to be billed as a unit; • Billing for new equipment and providing used equipment; • Resubmission of denied claims with different information in an attempt to be improperly reimbursed;
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• Refusing to submit a claim to the Center for Medicare & Medicaid Services (CMS) for which payment is made on a reasonable charge or fee schedule basis; • Providing or billing for substantially excessive amounts of DMEPOS items or supplies; • Failure to monitor medical necessity on an ongoing basis; • Delivering or billing for certain items or supplies prior to receiving a physician’s order and/or appropriate Certificate of Medical Necessity (CMN); and • Falsifying information on the claim form, CMN, and/or accompanying documentation. (64 FR 36373). These areas of concern identified by the OIG are a good roadmap for dentists to utilize when considering their collaboration with sleep physicians, documentation and provision of Dental Sleep Medicine, and billing and reimbursement for Oral Appliances. It is imperative that dentists, and other health care providers and suppliers providing Dental Sleep Medicine, conduct their own risk assessment to determine areas of concern and vulnerabilities specific to their operations and provision of patient care and Oral Appliances. Often, improper billing results from a lack of communication between different health care professionals who are providing services to the patient and improper coding and claims submission. Sleep disorder centers and DME companies have received denials for claims submission and reimbursement when medical necessity is not established and documented by the ordering physician or other health care providers who are authorized to order items or services which be paid by the Medicare or Medicaid programs. Dentists, DME companies, sleep physicians, and sleep disorder centers should take all steps to ensure that they are not submitting claims for services that are not covered, reasonable and necessary. DME companies should keep the treating physician’s or other authorized person’s signed and dated order or CMN on file for all DMEPOS items and services, including Oral Appliances. Upon a third-party payors request, the DME company should be able to provide documentation, such as physician orders, completed original CMNs, proof of delivery of the DME, written confirmation of verbal orders, and any other documentation to support the medical necessity of an item or service the DME company has provided and billed to a
LEGALledger federal health care program or commercial insurance company.
Potential Pitfalls and the False Claims Act
Health care providers and suppliers have a legal duty to ensure that there is no submission of false or inaccurate claims to government and private payors, including the Medicare and Medicaid programs, and commercial insurance companies. Health care fraud cases under the False Claims Act, 31 U.S.C. §3729 (FCA) have significantly increased in recent years. The FCA is the government’s primary civil remedy to redress false claims for federal money or property, including incorrectly billing for the provision of health care services. Most actions are filed under the FCA’s whistleblower, or qui tam provisions. Qui tam lawsuits are civil lawsuits brought by whistleblowers, also known as the relators, under the FCA. The FCA rewards whistleblowers if their qui tam cases recover funds for the government. Given the increasing number of qui tam lawsuits that are being filed, dentists, sleep physicians, DME companies, and sleep disorder centers need to ensure that their coding and billing practices and claims submissions are in compliance with the CMS regulations, coverage guidelines, and applicable National Coverage Decision and Local Coverage Decision guidelines for their Medicare Administrative Contractors (MACs) jurisdiction. Each state is assigned to a specific MAC jurisdiction and MAC. For example, Illinois is assigned to MAC 6 with National Government Services, Inc. designated as the MAC for this state.
Benefits of Implementing a Compliance Program
By voluntarily implementing a compliance program, dentist and other providers and suppliers involved in the provision of Dental Sleep Medicine, may realize the following benefits: • The formation of effective internal controls to ensure compliance with state and federal statues, rules, and regulations, and state, federal, and third-party payor health care program requirements and internal guidelines; • Improvement of the quality, efficiency, and consistency of providing services; • An increased likelihood of identification and prevention of criminal and unethical conduct; • The ability to obtain an assessment of
employee and contractor behavior relating to fraud and abuse; • A centralized source for distributing information on health care statutes, regulations, policies, and other program directives regarding fraud and abuse and related issues; • Procedures that require the prompt, thorough investigation of alleged misconduct by corporate officers, managers, representatives, employees, and independent contractors, consultant, clinicians, and other health care professionals; • Early detection and reporting, which may minimize the loss to the government from false claims, and thereby reducing the dentist’s and other Dental Sleep Medical provider and suppliers’ exposure to civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion; • Initiation of immediate and deliberate corrective action; and • Enhancement of the structure of the Dental Sleep Medicine Program’s operations and consistency between any related entities and service locations. While the implementation of a compliance program will not completely eliminate the potential for fraud and abuse, the development of a compliance program by dentists and other health care providers and suppliers involved in the provision of Dental Sleep Medicine, will demonstrate compliance with the applicable state and federal statutes, rules, and regulations and state, federal, and private payor health care program requirements, and will significantly reduce the risk of unlawful or improper conduct by the health care provider or supplier and reduce the risk of a potential audit, investigation, or other enforcement activity, including a qui tam action. A compliance program can be the foundation which enables a dentist and dental practice to build and develop the process necessary for an effective Dental Sleep Medicine Program that demonstrates compliance with the applicable regulations and requirements. An effective and well developed compliance program should incorporate the OIG’s identified seven (7) fundamental elements into a compliance program, and dentists and dental practices should strive to provide the highest level of patient care in the provision of Oral Appliances while reducing fraud, abuse, and waste to state, federal, and private health programs. DentalSleepPractice.com
2 7 6
5 2 5
For the solution, visit www.dentalsleeppractice.com.
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