Dental Sleep Practice Spring 2020

Page 1

Time to Go In-network with Medical Insurance?

by Randy Curran and Kyle Curran


Continuing Education

Bruxism & Sleep Disturbed Breathing by Barry Glassman, DMD, and Don Malizia, DDS

Introducing the Medley, a Three-in-One Appliance by Robert R. Rogers, DMD, D.ABDSM

SPRING 2020 |

Supporting Dentists Through PRACTICAL Sleep Apnea Education

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What Is a Dental Sleep Practice?


hat is a Dental Sleep Practice? Sure, it’s the name of the esteemed publication you’re holding in your hands right now. But what else? What are the criteria for a dental office to be deemed a Dental Sleep Practice? Is it about the volume of patients you treat with Oral Appliance Therapy (OAT) each month? Is it the number of sleep CE hours you’ve acquired? Does it have something to do with proficiency or accreditation, academia, podium time, which appliances you use, or how much sleep production is generated in your office? Over the past 14 years, I’ve encountered dentists that return to the office after a weekend course and immediately start screening their patients, practices that treat several dozen patients monthly, and esteemed thought leaders that only provide OAT to a couple patients each month. So, back to my question; what is a Dental Sleep Practice? It is all of the above, and this publication is intended to provoke thought, dialogue, and new perspectives for all these Dental Sleep Practices. This magazine aims to give value to the polarities and everyone in between. It is what you make of it. Your contributions, insight, and effort make your Dental Sleep Practice the one you and your patients deserve. It is pragmatism, practicality, academia, case studies, and innovative product spotlights. This publication is your Dental Sleep Practice. Now, let me ask you, what is a successful Dental Sleep Practice? A successful Dental Sleep Practice has an educated practitioner at the helm. These clini-

cians are informed, experienced, and draw on a wide range of knowledge. In every successful Dental Sleep Practice, the dentist has a strong team to support and execute her vision. Practices with disengaged team memJason Tierney bers are frequently unsuccessful. With this axiom in mind, you will see more content relevant to the team’s role in a Dental Sleep Practice. A successful Dental Sleep Practice also requires you to leverage innovative products and proven tools. We strive to provide you with exposure to these products and services so you can stay abreast of the This publication is ever-evolving field. You may have noticed that I am intended to provoke not Dr. Steve Carstensen. This is my first issue as Editor in Chief of Dental thought, dialogue, Sleep Practice. Dr. Carstensen did a and new perspectives Herculean job establishing DSP as the for all these Dental canonical industry journal. I’m honored and humbled to continue build- Sleep Practices. ing upon the foundation laid by Dr. Carstensen and DSP’s Publisher, Lisa Moler, and I look forward to taking the baton and running with it. From our Dental Sleep Practice to your Dental Sleep Practice, let’s grow together and improve the health of our profession, your patients, practices, and our communities. Let’s make it happen…

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing questions about the article “Bruxism & Sleep Disturbed Breathing: A Guide to Critical Thinking about Empiricism, Science, Bruxism, and Sleep” by Barry Glassman, DMD, and Don Malizia, DDS, which starts on page 44. The CE quiz can be submitted online at or via mail. Sponsored by MedMark, LLC, and CE Zoom, LLC.



10 Cover Story

Introducing the Medley, a Three-in-One Appliance


by Robert R. Rogers, DMD, D.ABDSM No single appliance is indicated for every patient? The Medley may have you singing a different tune.

Technology & Innovation

Successful Oral Appliance Therapy Should Not Be a Guessing Game

by Dr. John E. Remmers Reduce chairtime and arbitrary titration while improving efficiency and efficacy of OAT.

Dr. Robert R. Rogers with the Medley Appliances


Choosing Appliances

The 3 Most Common Mistakes with Oral Appliance Selection


by Jamison Spencer, DMD, MS Avoid these 3 mistakes and become a better DSM practitioner.

Billing Blocks

Time to Go In-network with Medical Insurance? by Randy Curran and Kyle Curran In-Network vs Out-of-Network; What Works for Your Practice?

2 DSP | Spring 2020

Continuing Education


Bruxism & Sleep Disturbed Breathing: A Guide to Critical Thinking about Empiricism, Science, Bruxism, and Sleep by Barry Glassman, DMD, and Don Malizia, DDS Rethink your assumptions about the relationships between bruxism and sleep disordered breathing while earning CE credits.



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Publisher’s Perspective

Resolution or Resolve? Time to Take Positive Action in 2020! by Lisa Moler, Founder/CEO, MedMark Media

16 Practice Management

Join the Movement for CrossCoding and Airway Health by Rose Nierman, Founder & CEO, Nierman Practice Management CrossCoding is key to your practice.

40 Book Review

Book Review: The Shift by Pat Mc Bride, PhD, CCSH Add wellness to your life and your practice.

42 Product Spotlight

Spring 2020

Should your practice be “laser focused?”

Publisher | Lisa Moler

52 Product Spotlight

Editor in Chief | Jason Tierney

Fotona LightWalker® and NightLase®

Effective Oral Appliances; By Definition and Design

You Treat “The Silent Killer,” But Are You Aware of the Silent Killer of Your Sleep Practice?

by Mark T. Murphy, DDS, D.ABDSM Practical insights into the AADSM’s new definition of an effective oral appliance.

by Greg Kamyszek, President, BioRESEARCH, Inc. Gather data to improve patient outcomes.

20 Expert View

54 Medical Insight

Which appliances are these prolific providers using most often?

The Athlete’s Secret Ingredient: The Power of Nasal Breathing

18 Product Focus

In Your Own Words

26 Choosing Appliances

The Clinician and Patient Benefits of Midline Devices by Patrick Tessier, MBA Understand the differences between midline and bilateral titration mechanisms.

34 Education Spotlight

Confidence in the American Board of Dental Sleep Medicine Certification Process by Jennifer Le, DMD, D.ABDSM, and Ronald Prehn, DDS, D.ABDSM The real value of DSM professional credentialing begins with its exams.

36 Team Effort

Dental Hygienists Becoming Myofunctional Therapists: Part of the Dental Team by Joy L. Moeller, BS, RDH RDH’s can play a crucial role in your Dental Sleep Practice.

4 DSP | Spring 2020

Managing Editor | Lou Shuman, DMD, CAGS

Editorial Advisors Jagdeep Bijwadia, MD Scott Craig Randy Curran Barry Glassman, DMD Elias Kalantzis Steve Lamberg, DDS, D.ABDSM Mayoor Patel, DDS, MS, RPSGT, D.ABDSM Mark Murphy, DDS John Viviano, DDS

by Michael Flanell, RDH, MBA Breathing and athletic performance.

58 Product Spotlight

When Disaster Strikes; A Call to Action by William L. Tycoliz, Jr., DDS A devastating natural disaster was the impetus for one dentist to help his patients sleep better.

60 Legal Ledger

The Provision of Oral Appliances and Regulatory Compliance by Jayme R. Matchinski, Esq. Documentation, appliance selection, and proper coding – how to stay compliant.

64 Sleep Humor

...The Lighter Side of Sleep Apnea

National Account Manager Celeste Scarfi-Tellez | Manager – Client Services/Sales Support Adrienne Good | Creative Director/Production Manager Amanda Culver | Front Office Administrator Melissa Minnick |

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

©MedMark, LLC 2020. 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.


Resolution or Resolve? Time to Take Positive Action in 2020!


Lisa Moler Founder/CEO, MedMark Media

he New Year is a time for resolutions — which has led me to think of the true meaning of that word. Resolution is defined as “a firm decision not to do something.” That doesn’t sound so positive to me. I am more invested in the word resolve, defined as to “decide firmly on a course of action.” That’s more like it! As leader of the MedMark team, our vision and our goals for 2020 are positive — we don’t want to “not do something;” we are going to take action on many exciting innovative, creative projects for our readers and advertisers. This year, on our media side, we continue to inform and educate through DocTalk videos and podcasts. We are especially excited about our new dental sleep medicine ZZZ Pack Podcast, which will bring news and views from some of the most knowledgeable sleep-focused dentists in the niche. Also, Dr. Rich Mounce will feature many of our most popular authors on his Dental Clinical Companion Podcast. In the past few years, I have been fortunate to help motivate our audience by interviewing some phenomenally inspiring people — Shaquille O’Neal, Tony Robbins, Simon Sinek, and Dr. Oz, and I will continue to connect you with those who can encourage you to expand your horizons.

Our print and digital articles continue to keep you on the cutting edge of clinical and practice management ideas and information. In this issue, our CE by Drs. Barry Glassman and Don Malizia provides critical thinking on bruxism and sleep-disturbed breathing. Both science and experience must be included in the diagnostic equation for appropriate patient evaluation and subsequent treatment. Randy and Kyle Curran explore the risks and rewards of whether to contract and become in-network with medical insurance payers or remain out-of-network. Read this article to help determine the best options for you, your patients, and your practice. Dr. Robert R. Rogers has designed a universal appliance that offers three different design features on the same platform. Read about how the interchangeability of the Medley

6 DSP | Spring 2020

appliance brings a quick, easy, and economical advantage to dental sleep appliance design. 2020 has just started, and the opportunities to expand your practice potential are endless! Along with our constant resolve to inform you through the written word of the most current technologies, products, services, and techniques, keep watching for us online and in person at major dental meetings and events across the United States. Please continue to contact us with your article ideas or if you want to take part in one of our online chats or podcasts. This year, “resolve” along with us to “embrace the exceptional.” Start the decade as we have — deciding firmly on a course of positive action based on solid science, facts, and innovation. To your best success in 2020!


Successful Oral Appliance Therapy Should Not Be a Guessing Game by Dr. John E. Remmers


s a life-long physiologist, physician, and innovator in sleep medicine, I find the recent statistics from the Lancet deeply troubling. With close to one billion people worldwide1 suffering from mild to extreme obstructive sleep apnea (OSA), it is our job, as sleep practitioners, to step in and help these people sleep and breathe.

“Sleep apnea… remains the most undiagnosed deadly problem in medicine”. – Dr. William C. Dement

8 DSP | Spring 2020

Over the past 20 years, we’ve seen the exponential rise of oral appliance therapy (OAT) for treating OSA. As a sleep physician, I often prescribe oral appliance therapy as the first line of treatment. Why? Most patients tend to prefer a simple oral appliance over CPAP. We’ve determined that patients are more accepting and compliant with treatment when their inputs and preferences are considered while prescribing treatment. Many dentists agree that offering dental sleep medicine can be immensely beneficial to a practice. Treating sleep disordered

breathing illness improves the patient’s connection with the practice, provides incremental practice revenue, and is often a highly profitable treatment. Unfortunately, I believe that as more dentists begin to implement sleep in their practice, they’re learning outdated techniques and workflows and not providing the best quality healthcare or patient experience. Just as I would only send my patients to respiratory therapists and CPAP providers using the most current products, training and titration technology, I will only send my patients to dentists who are well trained and are using the most current appliances and titration technology. While sleep appliances are often preferred by my patients, they aren’t always as efficacious as PAP therapy. In approximately 38% of cases2, OAT does not treat the illness to an acceptable standard. Further, determining where to set the appliance’s therapeutic protrusive position is a key unknown param-

TECHNOLOGY&innovation eter. These two unknowns can make it difficult for a sleep physician to confidently send a patient to a dentist for treatment and as a result, many of my colleagues continue to rely on CPAP as a preferred treatment. New technology rigorously tested and approved by the FDA has been developed to determine: I. OSA patient response to OAT treatment; and, II. Therapeutic protrusive position This technology is available with the MATRx plus™, a medical device, now installed in over 350 dental clinics in the USA. By using MATRx plus, dentists and their teams can eliminate guesswork and provide a fast and effective way to treat my patients. In comparing the MATRx plus workflow to the traditional titration process, 87% of patients who use the MATRx plus do not require subsequent appliance adjustment visits3. This saves time for clinicians and patients while improving therapeutic predictability. These dentists, who are using the MATRx plus, are true dental sleep medicine innovators. They are confident in the treatment outcome; they are eliminating OAT failures, prescribing optimally titrated appliances, and delivering the highest quality patient satisfaction. Sadly, there seems to be resistance to integrating this clinically proven technology into dental clinic workflows. I’ve attended numerous conferences over the years, and many industry leaders continue to teach outdated sleep techniques that aren’t established in clinical research. I fear the leaders in the dental sleep community are doing a disservice to the dentists interested in starting a sleep practice by not teaching progressive and innovative technology. Treating sleep doesn’t have to be complicated, it can be quite simple when you use the right technology. The MATRx plus is that technology; it is designed to make all dentists successful in sleep. Evidence supports this innovative workflow. Why does the field adhere to outmoded processes with little supportive data? My passion and life’s work have been investigating and developing technologies for diagnosing and treating sleep apnea, and I am dismayed by the industry’s slow acceptance of this clinically proven technology. Let’s stop subjecting our patients to guesswork, uncertainty, and out-of-date clinical

practice. I believe the MATRx plus is the only way to confidently prescribe OAT to patients, therefore, I refer patients exclusively to practitioners who use the MATRx plus. As this innovation reaches the tipping point, I’m certain the future will see that many sleep physicians will do the same.


Benjafield, A.V., Ayas, N.T., Eastwood, P.R., et al, “Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis”, Lancet Respir Med 2019, pp 1-12, published online July 9, 2019, Copyright 2019 Elsevier Ltd. 2. Bartolucci, M., Bortolotti, F., Raffaelli, E., et al, “The effectiveness of different mandibular advancement amounts in OSA patients: a systematic review and meta-regression analysis”, Sleep Breath (2016) 20:911-919, Copyright 2016 Springer-Verlag Berlin Heidelberg 3. Hambrook, D., & Cataford, P. (2019). Comparison of MATRxplus protocol to naïve oral appliance adjustment protocols. Internal Zephyr Sleep Technologies report: unpublished. TM Trademark of Zephyr Sleep Technologies


of patients who use the MATRx plus do not require subsequent appliance adjustment visits

Dr. John E. Remmers is a well-known figure in sleep medicine, having contributed importantly to understanding of the pathogenesis of obstructive sleep apnea. He is an inventor of modern CPAP and home sleep recorder technologies. Dr. Remmers has been active in the field of sleep dentistry for 15 years where his principal contribution has been the invention and development of the remotely controlled mandibular positioner, now available as the product MATRx. He works full time for Zephyr Sleep Technologies as their Chief Medical Officer.



Introducing the Medley, a Three-in-One Appliance by Robert R. Rogers, DMD, D.ABDSM


y first experience with a sleep appliance was in 1990 when I journeyed from Pittsburgh to San Antonio to hear the late Dr. Thomas Meade speak about his breakthrough boil and bite Snore Guard appliance. My success with this rudimentary method of stabilizing the mandible during sleep changed the course of my career and the lives of thousands of patients. Over time, the concept proved valid and the appliances became customized and more sophisticated. Today, there are more than 150 designs from which we may choose. The concept of mandibular stabilization remains rather constant while the application of varying hardware designs to accomplish this has proliferated. Even so, there are only a few variations of the basic theme. Very early on, as appliances began to offer protrusive adjustability, the Herbst rod/sleeve design was observed to be effective and continues to enjoy great popularity today. Eventually, orthodontic expansion screws were utilized in various ways to advance the mandible. At the same time, anterior hooks, rigid and elastomeric straps were effectively utilized. Recently, wings or fins are effectively employed to accomplish our purpose.

A common question from novice practitioners is, “What appliance design should I utilize?” Indeed, seasoned veterans are also concerned with which appliance design matches the needs of different patients. Further complicating matters, Medicare and other insurance carriers dictate the use of certain designs and prohibit the use of others. Personally, I am approaching 30 years practicing dental sleep medicine and have fabricated over 10,000 appliances. I have “been around the track” as they say and have utilized most of the designs available today. I have experienced great success with many of them and at the same time have had more than my share of frustrations. Over time it became apparent to me that no single appliance design is effective for every patient. Anatomic considerations and patient response varied significantly from case to case and became confounding factors to the routine use of my “favorite” appliance. Experienced dental sleep medicine practitioners now understand that some patients accommodate and respond better to certain appliance designs over others and it is necessary to ultimately fit the patient with the most comfortable, effective appliance possible.

Robert R. Rogers, DMD, D.ABDSM, has had a special interest in the treatment of sleep-disordered breathing since 1990 and treats patients in conjunction with many regional sleep centers. Presently, he is Chief Dental Officer for Pittsburgh Dental Sleep Medicine, Inc. and limits his practice to dental sleep medicine. Dr. Rogers is the founding president of the American Academy of Dental Sleep Medicine (AADSM) and served again as president in 1995 and 1999. In addition to being a long-term member of the Board of Directors, he has participated in committee work on a consistent basis. Dr. Rogers is a Diplomate of the American Board of Dental Sleep Medicine and is the recipient of the AADSM Distinguished Service Award. Dr. Rogers was a member of the task force for the revision of the American Academy of Sleep Medicine Position Paper and Practice Parameters on Oral Appliance Therapy. He also co-authored the American Academy of Sleep Medicine Guidelines for the Evaluation, Management and Long-term Care of Adult Obstructive Sleep Apnea. In addition, he is a consultant for the National Institutes of Health regarding oral appliances as related to the treatment of sleep-disordered breathing. Dr. Rogers has presented lectures on oral appliance therapy to physicians, dentists, and patient groups throughout the United States and Europe.

10 DSP | Spring 2020


Dr. Robert R. Rogers with the Medley Appliances


COVERstory With this reality in mind, I sat down with some design engineers and created a “universal” appliance that offers three different design features on the same platform. Hence, the name Medley. In less than a minute, the Medley appliance (FDA cleared and Medicare PDAC approved) can transform from a rigid nylon link, similar to a Narval or Panthera, to an elastomeric strap in the style of the EMA appliance. And in another minute can take advantage of the Herbst rod/sleeve mechanism if indicated. The variable Medley design offers dentists and patients a quick, easy, and economical way to utilize 3 different oral appliance designs without having to incur additional lab expense or waste valuable treatment

Medley Rigid Nylon Links Sleep Appliance

Medley Elastomeric Sleep Appliance

Medley Rod Sleeve Sleep Appliance

12 DSP | Spring 2020

time. Each of the 3 different design applications is quickly interchangeable on the same appliance platform at chairside by the dentist or assistant in less than a minute. The 3 different designs are predicated on well-known, commonly used advancement mechanisms that have been in use for years. The breakthrough represented by the Medley appliance is the interchangeability of these 3 protrusive mechanisms. • The rigid nylon link application employs a mandibular “pulling” force which provides a rigid, firm advancement feel and will not deform with prolonged use. Six different lengths are available for jaw advancement and by simple movement of an anchor screw can offer another 6 advancement positions for a total of 12 mm of protrusion. In my practice, this has proven to be a very effective and comfortable approach with over 2,000 appliances delivered. • The elastomeric strap application similarly employs a “pulling” force but offers a softer feel to the patient. I find this most effective for certain patients who may have tender temporomandibular joints, slightly mobile teeth, or simply prefer the softer feel. The slight stretch of the elastomeric straps acts as a shock absorber and can be used temporarily to settle down a hot joint or be used permanently if desired. Unlike other elastomeric strap designs, the attachment screws will not dislodge from the platform and are much easier to place and remove. • The Herbst rod/sleeve application employs a “pushing” force, delivers firm jaw positioning, and is accepted by Medicare PDAC and other insurers who follow Medicare guidelines. Great Lakes Dental Technologies is the exclusive distributor of the Medley appliance. The interchangeable protrusive mechanisms can be placed on any base material platform that Great Lakes offers such as Durasoft bi-laminate, Biocryl with Thermacryl, or hard acrylic. Ball clasps can be included for retention if desired. A demonstration video is available on the Great Lakes Dental Technologies website:



The unique Medley Appliance features a platform with dual configuration options that can accommodate different advancement mechanisms; rigid nylon links, elastomeric straps, or Telescopic Herbst® arms (Rod Sleeve).

Three Different Design Applications




THE MEDLEY ROD SLEEVE SLEEP APPLIANCE utilizes a “pushing” force. The Telescopic Herbst Rod Sleeve mechanism offers superior strength and firmer jaw positioning. PDAC-approved.

THE MEDLEY RIGID NYLON LINKS SLEEP APPLIANCE, ideal for the majority of qualified patients, utilizes a mandibular “pulling” force. The nylon link material provides a more rigid, firmer advancement feel and won’t deform.

THE MEDLEY ELASTOMERIC SLEEP APPLIANCE utilizes a mandibular “pulling” force. The subtle stretching characteristic of the elastomeric (EMA) straps allows maximum comfort during advancement. Ideal for patients with tender joints or loose teeth.

* Herbst is a registered trademark of Dentaurum, Inc.

“The Medley sleep appliance gives me the ability to address specific patient needs and circumstances without delay or multiple appliances.” —Robert Rogers, DMD, DABDSM, Inventor of the Medley


Learn more at or call 800.828.7626

COVERstory Case Study #1

The variable Medley design offers three different oral appliance design features on the same platform and is quickly interchangeable chairside by the dentist or assistant in less than a minute.

Bill W., 58 years old with a history of Parkinson’s disease, had been a 5 year user of a traditional Herbst appliance originally made by another dentist. He came to our office requesting a new appliance of the same design, and we fabricated a Medley utilizing the Herbst rod/sleeve mechanism. As he titrated the appliance over several weeks to manage his subjective symptoms, he mentioned that the adjusting mechanism was becoming more difficult for him due to his advancing condition. We demonstrated the rigid nylon link mechanism and he felt that it would suit his particular circumstance better. In less than a minute, my assistant transformed the original Herbst rod/sleeve mechanism to the nylon link, and he has accommodated well to the easy placement and removal of the links.

Case Study #2

Margaret L., 38 years old, was initially placed in a Medley nylon link application. Within 10 days, her subjective symptomatol-

ogy was improved significantly. However, she complained of bilateral TMJ tenderness that lasted throughout the day. She had no history of TMD and the appliance fit well, had good midline relation, and reasonable vertical dimension. Her dental intercuspation was unaltered. We asked her to cease using the appliance for a few days until the sensitivity resolved and then resume use. She did so, but the joint tenderness recurred in several days. At this juncture the rigid nylon links were replaced with the elastomeric straps by the assistant. After several days of use, the joint tenderness resolved and did not return. At her 6-month evaluation visit, she asked if the nylon links could be put back on, since the elastomeric straps had to be replaced every several weeks due to stretching. The assistant then replaced the straps with the nylon links for a trial with the understanding that we could easily return to the elastomeric straps as needed. As is generally the case in my experience, she then accommodated well to the nylon links.

Parts Management

Since the Medley offers three variations of protrusive mechanisms, there are a few different parts that need to be coordinated. Great Lakes offers a very handy Medley Configuration Kit to help keep track of the screws, links, straps and rod/sleeve arms. The kit is a one-time purchase and affords the dentist an easy way to manage parts inventory so that protrusive mechanisms can be quickly interchanged as needed or replaced if damaged.

Platform Configuration

Two platform configurations are available: The “Complete” Platform has attachment locations to accept all 3 design variations while the “Basic“ Platform has attachment locations for the nylon link and elastomeric strap applications only.

14 DSP | Spring 2020

Two platform configurations are available. The “Complete” Platform has attachment locations to accept all 3 design variations previously discussed. It can accommodate the nylon link, elastomeric strap, and the Herbst rod/sleeve arms. For cases where the dentist is certain that the Herbst rod/sleeve arms are not needed, the “Basic” Platform can be ordered. It features attachment locations for the nylon link and elastomeric strap applications only and carries a lesser lab fee. The Great Lakes Dental Technologies website has a comprehensive video tutorial on Medley construction and utilization: http://


Join the Movement for CrossCoding and Airway Health by Rose Nierman, Founder & CEO, Nierman Practice Management


reat news for dental practices! The average allowed amount that clients of Nierman Practice Management’s (NPM) medical billing service saw in 2019 for a custom-made oral appliance for OSA (Code E0486) was approximately $3,000. Some insurers pay more, some less, but all of them have one thing in common; prior to providing reimbursement, the insurer wants to ensure that the services meet their guidelines for medical necessity.

Many insurers now require a SOAP report generated from the delivery appointment, in addition to the exam. Implement a system for documentation of medical necessity for each oral appliance visit.

So, what are the guidelines for medical necessity of a custom-made oral appliance for OSA? The requirements vary per insurer, but there is a common denominator – a narrative report from the dentist’s oral exam in the SOAP format. Insurers require these narrative reports, “the clinicals”, during preauthorization of an oral appliance. The SOAP report includes subjective symptoms and comorbidities, objective exam findings, assessment (with ICD-10 codes), and the plan, including follow-up. Convert to a medical practice model by doing the following: 1. Many insurers now require a SOAP report generated from the delivery appointment, in addition to the exam. Implement a system for documentation of medical necessity for each oral appliance visit.

Rose Nierman is a leading expert in cross-coding and medical billing in dentistry. Rose’s mission is to help dentists implement dental sleep medicine and TMD services. A major innovator in narrative and medical billing software, DentalWriter, Rose developed Dental Sleep Medicine and TMD Questionnaire and Exam forms to help establish medical necessity. Nierman Practice Management provides CrossCoding and medical billing seminars along with clinical dental sleep medicine and TMD courses. Contact Nierman Practice Management at or 1-800-879-6468.

16 DSP | Spring 2020

2. When a pre-authorization is required for an oral appliance, submit the documentation of medical necessity and await an approval prior to delivering the appliance to the patient. 3. Include the sleep study, a prescription from the treating physician and documentation of CPAP refusal or intolerance. 4. Provide documentation of hypertension, excessive daytime time sleepiness and other comorbidities of OSA. 5. Be prepared to request the clinical notes from the physician who saw the patient prior to a sleep test. 6. If you would like to provide oral appliance therapy for Medicare beneficiaries, you must become a DME supplier. Review Medicare documentation guidelines and know when to execute a signed waiver of financial liability for situations such as when there is previous CPAP use. 7. If your facility is not a DME supplier and you are providing oral appliance therapy to a Medicare beneficiary, a signed waiver of financial liability informing the patient that Medicare will not reimburse is required. Join the movements for airway health and Cross-Coding to transform your office into the medical model and a comprehensive wellness office. Nierman Practice Management strives to stay abreast of changes in medical billing for dentists relating to dental sleep medicine, oral surgeries, TMD, CBCT, and other procedures. We’re happy to help you with any questions and review proven, repeatable strategies that many DSM dentists have applied to be successful.


Effective Oral Appliances; By Definition and Design by Mark T. Murphy, DDS, D.ABDSM


he American Academy of Dental Sleep Medicine (AADSM) recently issued an important update to their 2013 definition that helps shape Oral Appliance Therapy (OAT) use for Dental Sleep Medicine (DSM) providers, “Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: An Update for 2019”.1 The paper states that “An Oral Appliance can be an effective treatment option for those with OSA and snoring.” The key word in the title that makes this so vital to practitioners is “Effective.” To promote consistency and best treatment practices, the AADSM has updated its definition of an effective oral appliance to reflect current scholarly literature and clinical practice. The new generation of devices is demonstrating greater effectiveness and efficiency than older artisanal products have enjoyed. As dental sleep technology and materials rapidly change, new and effective appliances have emerged. As further updates in science, technology, and practice develop, future edits to this definition may be necessitated. The recommendations provide an excellent matrix for helping providers decide what is the best appliance for each patient. One of the key components of the definition is that an effective oral appliance stabilizes the mandible. What does this mean in clinical practice? Do devices with elastomeric straps or fulcrum wires adequately

Milled PMMA

18 DSP | Spring 2020

Soft Liner

Lab Cured PMMA

stabilize the mandible? Or do those styles of devices introduce too much play to satisfy the definition of stabilize? That’s a decision the prescriber ought to consider. Another key component of the definition is that the device protrudes the mandible. What does this mean for devices that might lose their protrusive setting as the jaw opens? The definition states that devices ought to be made from biocompatible materials. Though all devices are made with materials that are cleared by the FDA, clinical practice and research alike have demonstrated the different types of material are associated with different degrees of staining and biomass buildup. The electron micrographs below show the relative porosity of common materials still used today compared to precision milled, control cured, medical grade, PMMA. As material science, manufacturing methods, and precision engineering design continue to evolve, so should our selection

Printed Nylon

PRODUCTfocus criteria. One would be remiss if they chose a mono-block, non-adjustable device when adjustable choices abound. When biocompatible materials are readily available, they should be preferred. Precision designs and components are more favorable than devices that do not hold the mandible in the prescribed position. With well over one hundred FDA approved devices, loosely fitting into a few design categories (Herbst, Dorsal, Anterior Hinge, Iterative, Fulcrum Strap, Bilateral Strap, etc.) the material and manufacturing have a much greater impact today. FDA clearance alone, does not connote “best choice” for the patient. One of the most recent device designs with a counter balancing titration strap, stretches up to 3.0mm.2 That is not consistent with the definition of an acceptable, effective device in the AADSM update. Kudos are due to the AADSM for defining designs, materials, conditions and use for OAT that is more patient centric and effective. Efficacy and compliance combine to create the patient experience. One of my DSM mentors told me that, “the best therapy for each patient is the one that they will use that helps their condition.” Not considered on this discussion are additional design attributes that impact side effects. During the OAT selection process, consideration should also be given to tooth movement, bilateral symmetry, tongue space, hygienic nature of materials, and overall profile size. Today’s modern engineering and manufacturing of precision medical devices has allowed great improvements over previous generations of appliances. Below are some truisms that you should weigh when evaluating your next patient for an effective OAT. • Milled devices are less porous, easier to clean and accumulate much less biogunk. • A study done by the University of Alberta and the University of the Pacific using control cured PMMA platforms have been shown to not allow for tooth movement.3 • Device designs today, should wrap the distal molars and prevent drifting and open contacts. • Precision engineered symmetry that CAD embraces can be designed to prevent TMD issues.

“Choices are the Hinges of Destiny” – Edwin Markham

Precision Engineered and Milled ProSomnus® [IA]

• The size advantages of milled materials increase tongue space without compromising strength. Patient experiences and physician expectations are strengthened when effectiveness is prioritized and side-effects are minimized. Today’s innovative materials, design, and manufacturing processes are delivering robust improvements to these device characteristics.


2. 3.

Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: An Update for 2019 Kenneth Mogell, DMD, D. ABDSM (Chair) 1 ; Norman Blumenstock, DDS, D. ABDSM ; Erika Mason, DDS, D. ABDSM, D. ACSDD ; Rosemarie Rohatgi, DMD, D. ABDSM ; Srujal Shah, DDS, D. ABDSM ; David Schwartz, DDS, D. ABDSM (Board Liaison). Short-Term Results on a Novel Duo-Block Custom Made Titratable Mandibular Advancement Device Using a Flexible Counter-Balancing Titration Mechanism: Braem MJA, Dieltjens M, Beyers J, Vanderveken OM. Tooth movement and bite changes for a hard-acrylic sleep appliance; 2-year results using the ProSomnus® Sleep Appliance, Nikola Vranjes, DDS, Gene Santucci, DDS, David Kuhns, PhD.

Mark T. Murphy, DDS, D.ABDSM, has practiced in the Rochester area for over 35 years He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of Funktional Sleep, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and as a Regular Presenter at the Pankey Institute. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion.



In Your Own Words


he number of appliances FDA cleared for the treatment of Obstructive Sleep Apnea is more than double the number of pages in this issue of Dental Sleep Practice. Marketing claims abound. We want to bring you practical information about which appliances your peers are using most often, why they select them, and what advice they have for a first-time user of the respective appliances.

We asked numerous Dental Sleep Practitioners across the US and Canada for their insight. These are their answers to the following questions “In Your Own Words” 1. What device do you use most often in your practice? 2. What appeals to you/your patients about this device? 3. What is one tip you’d give to another clinician using this device for the first time?

John Carollo, DMD Florham Park, NJ 1. Milled PMMA and 3D printed nylon devices, namely the ProSomnus [IA], [CA] [LP], Precision Herbst & IA Select, and Panthera D-SAD 2. Light, thin, non-porous, less bacteria forming on the device, less bulk, and great patient compliance. 3. Try each arch on the model first. If the fit is too tight on the model, adjust before trying in on the patient. Then, separately put one arch in at a time to adjust before putting both arches together.

Richard Drake, DDS San Antonio, TX I’m a raving fan of several different devices, but if I must pick one for you today: 1. Prosomnus Precision Herbst [PH] 2. What I like about it, translating to what a patient might like: a. Low profile making it easy to wear b. Ability to add or subtract from lingual as necessary for retention c. Can add an anterior opening d. Option to add an anterior discluder

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e. Comfort bumps for anterior part of the adjustment arm 3. Can I give more than just one tip? a. Start with perfect scans or impressions. This is true for any device. b. Ensure the midlines are where you want them on your bite. This is a BIG deal. We draw lines on the teeth (lower line on anteriors that matches to max midline) c. Evaluate retention issues: very short, straight teeth, then you MUST cover lingual completely, for both arches d. Evaluate nasal patency; if an issue with patient, then add an anterior opening e. Evaluate sleep bruxism; if severe, then add an anterior discluder, keeping it as thin as possible, as low as possible, and make sure that it is long enough anterior to posterior to allow for maximum protrusion (otherwise you can advance too far, and then get “off” the discluder)

Jay Neuhaus, DDS New York, NY 1. For Medicare patients, I love the SomnoDent Herbst Advance with soft liner. It’s reasonably priced and fits perfectly. I just started using the ProSomnus Precision Herbst [PH], which has a smaller footprint and also a perfect fit. I do wish it came with a soft liner to accommodate patients with lots of porcelain teeth. For non-Medicare, I love the ProSomnus MicrO2, as well as the Somnomed Avant, 2. I’m a fan of both ProSomnus and SomnoMed as companies because their devices have precision fit and hardly ever require remakes. In particular, I love the measurement scale on the SomnoDent Herbst Advance. It makes it easy to see the amount of titration. Patients love them because of their low profiles and comfort.

EXPERT view 3. Take a very accurate standard-type impression or digital impression. I use a putty/wash combo for standard impressions, and Trios scanner for digital impressions.

John Tucker, DMD Erie, PA

1. Herbst 2. Herbsts are FDA-cleared and Medicareapproved appliances. It does not splint the mandible to the maxilla, providing full range of movement in lateral excursions and protrusive for the patient. This makes them TMJ friendly. They’re great for patients with parafunction. No hardware in the midline to inhibit the tongue from moving anteriorly to clear the airway. Low profile to maximize oral cavity volume. Extremely durable appliance. 3. Make certain you have recorded any midline discrepancy when you take your protrusive bite registration. Honor any midline shift.

Stacey Layman, DDS Phoenix, AZ

1. I use both the SomnoDent Herbst Advance and the SomnoDent Avant equally. 2. The Herbst is nice because it’s low profile and the soft liner is very comfortable. The Avant is appealing because it’s low profile, it’s a metal-free option, and has a soft liner. 3. The Herbst Advance and Avant are very simple and usually require no adjustments. Always advise patients that at first it will feel bulky and tight. Review the homecare instructions with them, set a timer for 5 minutes, and then reevaluate. They’ll usually acclimate to the device in that few minutes. Try not to adjust the fit unless absolutely necessary.

Marc Newman, DDS Indianapolis, IN

1. I try not to be a one trick pony, however, I’ve been stuck on nylon-12 devices whether it be hinge or dorsal designs. Lately I’ve been making more DDDO’s (Diamond Digital Dorsal Orthotic) and Panthera D-SAD devices. 2. The appeal for me is the combination of

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thin design, durability, and ease of delivery. I also like how it’s CAD/CAM so there’s some play with design features to help accommodate for patient anatomy. 3. My tip for first timers on any nylon-12 device is to talk to your local sales rep about the device and they’ll likely get you connected with a lab they have confidence in.

Arthur Feigenbaum, DMD Forest Hills, NY

1. SomnoDent Avant 2. The biggest appeal of the device is its comfort due to its minimal size and soft lining. Its innovative strap design allows tremendous flexibility making midlines unimportant while minimizing the effects of deviations and deflections. This makes adjustments very rare, minimizing chair time. A happy patient is a comfortable patient. A happy dentist is one with happy patients. Presently, it is the most comfortable appliance available. 3. My advice for first time users would be to totally understand the strap design which differs from most others. Understand how the straps are changed and the advantages of using them.

John Viviano, DDS Ontario, Canada

1. The device that is best suited to the patient’s presentation. Factors considered are condition and health of dentition and periodontium, retention capabilities of dentition, edentulous areas, size of arch and mouth, pre-existing TMD (range of motion issues), level and type of bruxism, existence of positional sleep apnea, manual dexterity of patient if contemplating home calibration, severity if looking for active advancement beyond what is available passively, and Medicare status if applicable. I always consider patient preference and like to offer two appliances so the patient has a choice whenever possible. If there is one BEST appliance, then I present that one and explain why. 2. The fact that it is the appliance best suited to their particular needs! 3. Spend time evaluating which appliance is best suited for your patient and it will save both you and the patient a lot of grief.

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The 3 Most Common


with Oral Appliance Selection by Jamison Spencer, DMD, MS


lmost every week I get an email from someone asking “Jamison, what’s your favorite appliance?”

“What is your favorite dental bur?”

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I get this question almost EVERY time I lecture. Sometimes, if I’m feeling particularly rude, I’ll answer their question with a question. “What is your favorite dental bur?” “Or your favorite endo file?” If this exchange occurs in person they will then look at me confused, and then answer back, “well, I guess that depends on the situation.” Right! There is no one best appliance. There is the best appliance for the specific patient, based on what’s going on with them currently. In other words, the “best appliance” might even change over time! Here are the 3 most common mistakes I see good dentists making when it comes to appliance selection. Note that I said “good dentists.” Only good dentists care. Bad dentists will just use whatever they learned at some manufacturer’s course, or whatever is cheapest, or whatever they saw an ad for. And they’ll use it on EVERY PATIENT. I’ll assume that’s not you (or not you anymore), and give you a few simple things to look for when deciding which appliance design is likely to perform the best.

Mistake #1: Choosing an appliance that does NOT allow adequate lateral movement for a patient with evidence of historical lateral bruxism.

This is by far the most common mistake I see. A dentist chooses an appliance that does not allow for lateral motion, or very little lateral motion, and the patient clearly has evidence of historical lateral bruxism as witnessed by their worn dentition. While it’s true that some patients may have reduced bruxism activity once their airway is protected, this is unfortunately not universal. I always “plan for the worst, and hope for the best.” So, I choose an appliance in such cases that will allow the patient to continue the mandibular movements that they have done in the past (again, based on their historical wear patterns). In general, in such a case you’ll want to avoid what I refer to as “interlocking” appliances or “mono-block” appliances. While this isn’t always intuitively obvious, the question to ask is “will this appliance design allow this specific patient the lateral movement that they may need?”

Mistake #2: Choosing the appliance that you think will be the hardest for the patient to break.

This one I can totally forgive. We’ve been trained to look for materials that are super strong and unlikely to fracture or even wear. We see ads for materials that are said to be

CHOOSINGappliances indestructible, and have lab guys challenge us to break the material using pliers… and we can’t. We think to ourselves, “Wow! That dude with the huge masseters will never be able to break this stuff!” And that’s probably true. But sometimes I wonder if we shouldn’t be asking a different question. Rather than asking “what can I make this out of that the patient can’t break?” perhaps we should ask “why is the patient trying to break this in the first place?” With a single crown, having an indestructible material probably isn’t that big of a deal, and I think we understand that using the diamond hard material is not stopping the patient from “trying to break it.” But when we are fitting something to all the teeth, and connecting the upper and lower jaws, using an unbreakable appliance for sure does not stop the patient from moving their jaw in a way that may have historically resulted in damage. So the question is, which would you rather have break? The patient, or the appliance? Since there is no such thing as an appliance that can stop the patient from trying to “parafunction,” where do the forces go? If the appliance is so strong as to not break, where do those forces get transferred? Answer: to the teeth, restorations and periodontium. Personally… if I’m in a car crash, I’d rather have the car be destroyed and me walk away from the accident. If I’m wearing an oral appliance and I am putting excessive pressures on the appliance for some reason, I’d rather have the appliance be the weak link.

Mistake #3: “n of 1 syndrome.”

I hear about this all the time. Someone comes up to me and says “I tried X appliance and it was garbage.” I ask some follow up questions, and usually find out that the dentist… usually a good dentist… tried a specific appliance from a specific lab one time with a specific patient, and that one experience wasn’t very good. Maybe the appliance was too tight. Or too loose. Or too bulky. Or the patient didn’t like it. Or it didn’t seem to work that well (which is a whole other article as to what that even means). Or it didn’t last as long as they thought it should.

I had a prosthodontic professor that used to say, “you have to earn the respect of the material.” It took me a long time to figure out what that meant. My interpretation of that statement, applied crassly to dental sleep, is “just because you suck doesn’t mean the appliance sucks.” I opened this article by saying that it’s inappropriate to think there is one best appliance that you can use all the time for every patient. However, I know that there are many really, really, really good dentists who ALWAYS use the same appliance for virtually all of their patients. Often this dentist is using an appliance that they either invented, is named after them, or both. And they get great results! Why? Because they are masters with that appliance, and they’ve figured out what to do when various things happen, through lots and lots of experience. So whatever appliance you don’t like, I’ll bet you anything there is someone out there who has fantastic results with it. They’re just better at using it than you are. You see, it’s not about the plastic (or nylon). It’s about our skill and expertise in using the plastic. I can buy my paint brushes at the same store that Rembrandt buys his, but that doesn’t mean I can do the same thing with them. So be careful with the “n of 1” syndrome. Remember back in dental school where it took time to “gain the respect of the material.” It takes time to gain the respect of the appliance, and to learn what to do when and why… and perhaps more importantly, when not to do anything… which we’ll discuss some other time.

Dr. Jamison Spencer is the director of the Centers for Sleep Apnea and TMJ in Boise, Idaho and Salt Lake City, Utah. He is an invited lecturer on the topics of dental sleep and TMD around the world. His “Spencer Study Club” is the premier, members only, education and mentoring forum for smart and ethical dentists looking to implement sleep and TMD in their practices effectively and profitably.



The Clinician and Patient Benefits of Midline Devices by Patrick Tessier, MBA


ppliance selection is one of the most important decisions a clinician makes when treating a patient with Sleep Disordered Breathing (SDB). Breaking down the academic, clinical, and financial benefits of the two major advancement categories can provide clarity on the overall effectiveness of appliances.

Effectiveness = Efficacy x Compliance

Mandibular Advancement Devices (MAD) are generally segmented into two advancement mechanism categories, midline traction (MT) and bilateral thrust (BTh). • MT devices have a single point of midline adjustment in the anterior of the device. The most popular and recognizable midline device is the TAP Custom Appliance. • BTh devices have two points of adjustment; one on each side of the arch. The two most common devices in that category are the Herbst and Dorsal Fin appliance. The easiest way to differentiate between the two categories is “push vs. pull”. The midline device pulls the mandible forward while bilateral devices push the mandible forward.


In 2015, the American Academy of Sleep Medicine (AASM), updated their clinical

Practical image to serve as analogy of two different basic adjustment mechanisms. Image courtesy of Airway Management, Inc.

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guidelines to include a literature review comparing the effectiveness of various devices against CPAP and Oral Appliance criteria. The literature review found that: Midline devices • 100% met the Oral Appliance criteria • 50% met the CPAP criteria Bilateral devices • 20% met the Oral Appliance criteria • 0% met the CPAP criteria Based on these peer reviewed studies, data supports the efficacy of midline traction devices.


Both comfort and compliance are key to clinical success. Concerns about comfort are the most common reason cited for CPAP noncompliance. An effective treatment modality must also be comfortable for the patient to use which usually equates to higher levels of treatment compliance. Comfort: While anecdotal and not the experience of every patient, let me share my first experience with a bilateral device. After the appliance was delivered, I instantly stopped snoring. My wife loved it. However, after just a few nights, I started to notice jaw pain in the morning. After a week, I could barely open my mouth in the morning. Finally, I called the dentist to complain.





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CHOOSINGappliances cess. By giving them an adjustment key with a titration schedule, it becomes “their treatment�. Bilateral devices are generally more complicated as patients may inadvertently turn one of the screws the wrong way and cause additional pain. The literature is also quite clear that if the mandible falls open, soft tissue is more likely to obstruct the airway. With bilateral devices, many clinicians address this issue by adding clasps and orthodontic rubber bands. This increases the complexity of the treatment and reduces compliance. With single point midline adjustment, the advancement mechanism does this by design. The hook in the anterior prevents the jaw from dropping down and eliminates the need for clasps or bands. He asked if it hurt on one side or both sides. It was just on one side. He said that the midline was off and had me move the screw on one side to compensate. Bilateral devices require two independent adjustment mechanisms requiring modification. This can lead to an issue whose origin can be found when the initial protrusive bite is taken. If the patient inadvertently bites to one side, even slightly, the device can be manufactured with an offset midline. This causes the device to stretch the muscles and ligaments on one side and induces pain. With midline devices this problem does not exist as there is only a single point adjustment that allows for lateral movement. Compliance: If patients don’t wear their devices, their SDB will remain untreated. One of the most effective methods clinicians can use to increase compliance is patient engagement. When a patient is engaged and takes some measure of ownership, they are much more likely to feel empowered in their treatment and overcome short-term obstacles to wearing the device. Single point adjustment is so simple, the patient can be involved in the titration proPatrick Tessier, MBA, is a mechanical engineer, a dental laboratory veteran, and serial entrepreneur specializing in treatments for sleep disordered breathing. He serves as the Director of Dental Business Development for Airway Management, the leader in OAT. He also founded SnoreMart. com, Modern Dental Laboratory USA, and Northwest Laboratories. Patrick can be reached at

28 DSP | Spring 2020

Financial Implications

Medicare is the most restrictive payor and allows reimbursement for only TAP, Herbst, and Snorehook oral appliances. Dorsal fin devices and all others are not covered by Medicare. Private insurance companies, seeking to reduce their liability, are beginning to restrict approved appliances to only those that are PDAC approved. The conservative approach, advocated by many third-party billers, is to use a PDAC approved device to avoid potential reimbursement issues. The profitability of a DSM procedure is largely determined by the chair time required to complete the treatment. If the patient returns several times for adjustment or advancement, the profit margin for that procedure decreases. This is where the simple adjustment mechanism of the single point device shines. The patient advances the device on their own; following the titration schedule limiting the amount of advancement per day. Cases that are treated with single point mechanisms are more likely to be profitable than those cases requiring chair time for every 0.5mm advancement.


Whether evaluating academic, clinical or financial implications, midline adjustment devices are the extremely effective. More than 500,000 TAP appliances have been delivered. These MT devices are PDAC approved and a litany of research has demonstrated their effectiveness for the normalization of AHI.

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Time to Go In-network with Medical Insurance? by Randy Curran and Kyle Curran


s a dentist treating Obstructive Sleep Apnea, is it in your best interest to contract and become in-network with medical insurance payors? This is a common question for providers across the full spectrum of experience levels; from those new to dental sleep to expert-level practitioners that are solidly established in the industry. This inquiry arises now more than ever, as a growing volume of providers are recognizing an industry-wide shift. No longer an emerging treatment modality, Oral Appliance Therapy (OAT) is gaining traction among dentists, oral surgeons, and even ENT providers. OAT has reached a pivotal point in its life cycle. The influx of dentists who are beginning to treat sleep coupled with the litany of research demonstrating OAT’s efficacy, has resulted in a rising number of contracts insurance payors will give dental sleep medicine providers. These contracts typically offer rates ranging from $1,800 - $2,100. The question is, should you take advantage of this or remain out-of-network? Undoubtedly, you should closely analyze the pros and cons of in/out-of-network options. For many years, the downside of contracting with medical insurance far outweighed the upside. Until recently, large

30 DSP | Spring 2020

out-of-network allowed amounts and easily obtainable gap exceptions have offset the time and effort necessary for in-network contracting. A shift is occurring though, and you need to know about it. Contracting with medical insurance can result in less time dedicated to obtaining approvals, increased accuracy regarding patient out of pocket quotes, faster processing times for claims, consistent reimbursement across all billed codes, and better relationships with referring physicians. One of the most challenging aspects as an out-of-network provider is contending with the unpredictability of the allowed amounts. This variability can lead to a highly volatile, labor-intensive process to approximate the patient’s out of pocket cost. A gap exception denial can potentially render the initial quote useless and increase the patient’s cost. This undesirable cascade of events frequently results in the patient declining needed treatment. For an in-network provider, that guessing game ceases to exist. In-network providers have a predetermined amount they know the payor will allow for the appliance. Once the patient’s specific benefits have been verified, you can confidently quote patients their out of pocket cost. This simplifies the process

BILLINGblocks Along with better rates of acceptance, becoming an in-network provider should also reduce the time spent obtaining approvals and processing claims.

for both the practice and the patient and increases patient acceptance for OAT. Along with better rates of acceptance, becoming an in-network provider should also reduce the time spent obtaining approvals and processing claims. As an out-of-network provider, there are usually two approvals that must be obtained prior to treatment: a gap exception and a prior authorization. Both approvals require comparable amounts of time for processing, but a gap exception is more prone to denial. These denials aren’t just caused by the growing number of in-network providers who treat sleep with OAT although that is a common reason. When a prior authorization is strictly based on medical necessity, a gap exception is conducted by a sole reviewer which increases the likelihood of an incorrect denial. These incorrect denials have the potential to delay treatment by up to 90 days. Gap exceptions can also cause delays in the claim process, as it isn’t uncommon for a payor to incorrectly process a claim as out-of-network, when a gap

Randy Curran is the founder and CEO of Pristine Medical Billing. During the past 12 years, Randy has committed his life to helping those with sleep related breathing disorders obtain prior authorizations for coverage while ensuring providers receive fair compensation for care. Randy has been involved in the treatment of more than 38,000 patients while collecting over $85,000,000 for providers from insurance carriers through both contracting and claim submissions. Kyle Curran has been active in the Dental Sleep Medicine industry for nearly four years and is currently a Senior Account Manager at Pristine Medical Billing. During this time, Kyle has managed medical billing processes, training, and coaching for more than 50 dental practices across the country. He stays abreast of the ever-changing field by participating in continuing education, practical experience, and coursework at California State University in San Marcos.

32 DSP | Spring 2020

exception is on file. By eliminating the need for gap exceptions, providers should find that it requires less time to move patients into treatment and payment processing is expedited. There are many benefits to being in-network, but the authors do not wish to create a false narrative by giving the impression that unicorns will be frolicking with leprechauns in your practice while your team sings ditties from The Sound of Music. The obstacles of contracting may include: a lengthy credentialing and negotiating process, lower contracted fee schedules than what you may be accustomed to, and a vital emphasis on compliance with contractual requirements. Many practices decide not to contract with medical insurance because of at least one of these reasons. Unfortunately, the process to contract with a medical insurance as a dentist is neither simple nor easy, and it can take as long as a year to complete. There isn’t a magic pathway or secret handshake to bypass the paperwork, phone calls, and emails that are necessary to secure a fair contract. However, once through the initial contracting process, the insurance will be more apt to offer you a new contract every cycle. The process is heavily front-end loaded, but once complete you should be set for the lifetime of your practice. Though the current “Wild West” style of billing in the Dental Sleep profession has been somewhat successful to date, a dramatic shift is likely on the horizon. As awareness builds across the country about the importance of quality healthy sleep, more non-dentist providers will begin proffering OAT therapy. We will likely see a sizable increase in the number of oral surgeons and ENTs opting to bring dentists into their practices for the sole purpose of delivering oral appliances. Many of these providers already possess medical insurance contracts, so they may have an advantage over your practice. Providers should weigh the potential risks and rewards of in-network and out-ofnetwork statuses. Discuss the options with peers, billing companies, and professional organizations that have experience with each status type. Investigate their allowed amounts, the credentialing processes, case acceptance rates, time allotment, and then make the determination that is best for you, your patients, and your practice.


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Confidence in the American Board of Dental Sleep Medicine Certification Process by Jennifer Le, DMD, D.ABDSM, and Ronald Prehn, DDS, D.ABDSM


ew, if any, sleep practitioners are diffident about the inherent benefits and immense importance of a multidisciplinary approach when evaluating and treating sleep related breathing disorders (SRBD). Skepticism does arise when qualifications and standard of care enter the discussion. An array of purported credentialing entities has entered the field creating cacophony of confusion. Is all education created equally, and do all credentialing boards abide by similar rigid process standards?

ABDSM Board of Directors (2018-2020) President Ronald Prehn, DDS, D.ABDSM President Elect Katherine Phillips, DDS, D.ABDSM Secretary/Treasurer Jennifer Le, DMD, D.ABDSM Immediate Past President Steven Scherr, DDS, D.ABDSM Director B. Gail Demko, DMD, D.ABDSM Director Richard Dunn, DDS, D.ABDSM Director Donald Farquhar, DDS, D.ABDSM

The American Board of Dental Sleep Medicine (ABDSM) plays a critical role in certifying Dental Sleep Medicine as a distinguished evidence-based profession, as well as fostering collaboration with physicians and other healthcare providers in the treatment of sleep related breathing disorders. Physicians treating obstructive sleep apnea (OSA) can feel confident when they are working with an ABDSM credentialed Diplomate as part of the healthcare team. In order to earn Diplomate status, dentists must first demonstrate competency in their overall knowledge of sleep disorders. Additionally, they must demonstrate the decision making and clinical skills necessary to treat SRBD with oral appliance therapy (OAT), surgical intervention and interceptive orthopedics. The ABDSM diplomate credential is widely respected by physicians, dentists and other healthcare providers as the “gold standard of excellence in dental sleep medicine.”

ABDSM Achievement

How did ABDSM achieve this position in our profession? For the last 25 years the profession of Dental Sleep Medicine has been gaining in knowledge through broad based clinical experience and important research. Concurrently, the ABDSM has kept pace by

34 DSP | Spring 2020

continually raising the certification excellence bar. One of many qualities that sets the ABDSM apart from other boards offering certification examinations is ABDSM’s status as an independent not-for-profit organization. More recently, the ABDSM certification process has subjected their certification examination to a rigorous, state-of-the-art psychometric test development process, which improves the ability of the exam to accurately discern candidate competency. Through the years, the foundation of the ABDSM certification exam has been peer-reviewed published research. In addition, testing of clinical experience and candidate knowledge of accepted clinical protocols have recently been added to the exam, augmenting what many consider the most accurate and well written certification examination in the field. The examination is now web based and conveniently offered in testing centers throughout the world.

Examination Criteria

The ABDSM Board of Directors works with psychometric professionals and subject matter experts to develop and validate a testing process designed to assess the competency of a dental sleep medicine practitioner. Currently, a licensed dentist may become eligible to sit for the ABDSM exam via two distinct pathways: The Traditional Track (requires submission of prerequisites and case studies for the ABDSM board to review) and the Mastery Track (requires completion of the American Academy of Dental Sleep Medicine (AADSM) Mastery Program offered through the AADSM or an Accredited AADSM Mastery Program Provider). The ABDSM testing model is built on three principles: test standardization, criterion-based testing and equitable difficulty over time. These three principles produce a certification exam that is valid, fair, reliable and defensible.

EDUCATIONspotlight Test Standardization

The test makeup is based on overall general knowledge of dental sleep medicine and is based on a set of core content areas. These distinct areas of knowledge are weighted according to relevance for the dental sleep medicine provider. This test platform is designed to ensure consistency and fairness in testing by sampling material from each content area, proportional to importance. This contrasts with other testing protocols which have been found to vary wildly in content focus and overall difficulty from one exam session to the next.

other material. As old content is replaced with new, the overall difficulty of the exam may also evolve. The method used to develop the ABDSM exam measures the difficulty of each question and adjusts the minimum passing test score to compensate. Unlike applying normative pass/fail standards that alter the passing score (or cutoff point) based on the performance of different groups of candidates, this model adjusts passing criteria based on the inherent difficulty of the exam itself and mitigates concerns about skewed test results that could occur with “easier” or “harder” versions of the test.

Criterion-Based Testing


The ABDSM testing model is criterion-based, which means that all candidates are held to the same standard of competence which is consistent from each exam session to the next. The examination criteria are built on a profile termed the “Sufficiently Qualified Candidate” (SQC), defined as the minimum attributes a sleep dentist must possess to meet established competency standards. After the ABDSM exam testing window has closed, and before the pass/fail standard for that exam has been determined, the performance of each exam question is statistically and critically evaluated. Particular attention is paid to question clarity, fairness, and the ability to successfully distinguish those candidates that meet the standard of competency from those candidates that do not. Any question that performs poorly is not included in the final exam scoring. In contrast, many other formal examinations use arbitrary standards that are not research based and score on an absolute pass rate of some set percentage of questions answered correctly; while others use normative standards (e.g. grading on a curve). Though popular, these methods set a pass score by using arbitrary criteria that have no relevance to identifying sufficiently-qualified candidates. Criterion-based testing is a proven model for delivering accurate, fair, and consistent results.

Equitable Difficulty Over Time

As our knowledge base increases over time, the examination content must also keep pace. An important design consideration is maintaining a consistent level of difficulty. Exam content, by nature, consists of some material that is more difficult than

The need for consistent standards of care and skilled professionals in the Dental Sleep Medicine field continues to grow as sleep disorders pose growing health risks. As patients, physicians and payers seek dentists who have the competency to provide oral appliance therapy, there will always be confidence in the validation of the ABDSM exam and its ability to accurately identify qualified dentists in dental sleep medicine. Jennifer Le, DMD, D.ABDSM, received her dental degree from the University of Pittsburgh in 2001. Dr. Le has a degree in Psychology and certification from the Leadership Program in Integrative Healthcare at Duke University as well as from CTI in Life Coaching, which allows her to approach dentistry from a patient centered perspective. Dr. Le is Chair of Accreditation, and is faculty for the American Academy of Dental Sleep Medicine. Dr. Le is also Secretary/Treasurer of the American Board of Dental Sleep Medicine. Being an Adjunct Clinical Professor at UNC School of Dentistry, allows her to share her many years of clinical experience with dental students. Dr. Le opened her dental office in North Carolina in 2003. The office specializes in unmatched quality of care, and a whole body approach to each patient. Ronald S. Prehn, ThM, DDS, D.ABDSM, is a third generation dentist who focuses his practice on complex medical management of Facial Pain conditions and Sleep Disordered Breathing. He received his degree at Marquette School of Dentistry in 1981 and post graduate education at the Parker Mahan Facial Pain Center at the University of Florida and the LD Pankey Institute. He is a Board-Certified Diplomat of both the American Board of Orofacial Pain and American Board of Dental Sleep Medicine, of which he is president. While being an adjunct professor at the University of Texas Dental School in Houston, he is published in several journals on the subject of combination therapy for the treatment of OSA. He currently limits his practice to management of complex sleep breathing disorders at the Szmanda Dental Center in Wausau, Wisconsin.



Dental Hygienists Becoming Myofunctional Therapists: Part of the Dental Team by Joy L. Moeller, BS, RDH


any dental offices are involved in the treatment of sleep disorders, restricted frenums, orthodontics, cosmetic dentistry, oral facial pain and pediatric dentistry. New studies are now validating the collaboration of the treatment of myofunctional disorders as an adjunctive protocol for obstructive sleep apnea. Sleep specialists are now being taught about the value of working with myofunctional therapists for more comfort with CPAP and MAD.1 Because dental hygienists see their patients for recall visits on a regular basis, a screening for myofunctional disorders should be performed and recommendations for therapeutic treatment should be made which can be part of the services offered in a dental office.

Low rest position of the tongue

36 DSP | Spring 2020

Most successful dental practices have busy hygiene programs and many wonder, “How can I build myofunctional therapy into my practice, retain my patients seen for regular hygiene services, and provide more comprehensive care?” A sizable segment of hygienists have either carpal tunnel, burn out, or shoulder issues and are in search of new pathways to provide new services that are interesting, challenging, and bring value to the patients and the practice. After taking a course and extensive internship, I began seeing patients after work or on my day off and the dentist I worked with was happy to have his patients cared for. I remunerated him based on a percentage of collections, used my own phone, bought my own supplies, bought my own insurance, made my

own appointments, and made sure the office was left clean and neat for the next day. He treated me as a colleague or associate and I felt respected and valued. Benefits for the office include: • Referrals from other medical and dental providers; Frequently these referrals become new patients of record • Happy patients referring new patients • Residual income for the office • Adjunctive treatment was geared to enhance and improve services already offered in the practice such as TMD2, Orthodontics, Sleep Dentistry, Periodontal Therapy, Pediatrics, etc. • I provided marketing of my services though lunch and learns to possible referral sources, wrote articles in our local papers, and attended meetings which built our name in the community. What is involved in developing a program for the treatment of myofunctional disorders? First, the patient and the practitioner must become aware of these disorders and their impact of not only oral health, but systemic health as well. Research articles, before and after photographs, and intra-oral cameras to show the patient what is happening in their mouth are important tools. The Mallampati, Friedman score, Epworth Sleepiness Score, or other sleep screening, observing the patient swallowing, breathing and chewing are all tools that can be utilized to determine need for a more in-depth evaluation.

TEAMeffort Myofunctional therapy has been known in the orthodontic field since the early 1900’s.3 Approximately 10 years ago, I was called to Stanford University to lecture for the Sleep Department on myofunctional therapy and sleep disorders by Professor Christian Guilleminault. After following the Brazilian studies,4 that meeting influenced Stanford University to begin doing research to prove that myofunctional therapy, breathing education, and frenum restriction release may assist in the treatment and prevention of obstructive sleep apnea.5 The next question becomes who, amongst current health care professionals in the USA, has it in their scope of practice to take on the responsibility of the treatment of these disorders? The American Dental Hygienist Association has had it in their position statement for dental hygienists since 1992.6 Also, speech language pathologists, occupational therapists, physical therapists, and nurse practitioners may also be qualified to treat patients with myofunctional disorders with post-graduate training. What does this mean for hygienists? We now have agency to utilize all those anatomy, physiology, psychology, pharmacology, and pathology courses that we had to learn. We are the principal dental health educator in the office, and we can be proactive with children to eliminate noxious habits and improve nasal breathing, lip seal, chewing, swallowing and proper tongue rest position. As far as periodontal disease, we have known for many, many years that mouth breathing can cause inflammation of gingival tissues but we never treated the functional breathing of our patients.7 Because dental hygienists have had training in proper nutrition, we now can add the functional aspects of proper selection of

Over developed mentalis muscle

Tongue thrust swallow

whole foods and why and how to properly masticate and swallow the food correctly. In doing this, the myofunctional disorders may be more successfully treated and eliminated. The tongue is comprised of 16 different muscles that have different functions of moving the food in the mouth, developing a bolus which is safe to swallow without choking,8 and maintaining proper airway with the back or base of the tongue. If the frenum is restricted, the posterior airway may be compromised contributing to sleep apnea.9 Dental hygienists have training in psychology and motivation. Much of the success of myofunctional therapy depends on patient compliance at home and with subsequent appointments (either in person or with tele-practice). For pediatric patients, we must enlist the parent in supporting the treatment. Parents must understand the value of how myofunctional therapy may avoid learning disabilities and reduce behavior problems with proper oral postures. This is in the dental hygienists’ wheelhouse. Because myofunctional therapy relies on active patient participation, we must use several techniques that are based on the ten principles of neuroplasticity.9 Neuroplasticity means the ability of the brain to change, fol-

High narrow palate

Thumb habit

Joy L. Moeller, BS, RDH, is a dental hygienist, formally an associate professor at Indiana University, who has worked as a myofunctional therapist for many years and currently has a private practice in Pacific Palisades and Beverly Hills. Myofunctional therapy has now been proven to be effective in reducing AHI numbers by 50% in adults and 62% in children as well as lower oxygen saturation, snoring and sleepiness outcomes improve. Joy is founding lecturer with the Academy of Orofacial Myofunctional Therapy. Joy wrote a chapter in Sleep Medicine Clinics, a chapter in Sleep Disorders in Pediatric Dentistry, and a children’s book on tongue position as well as many published studies and other chapters in textbooks. She is currently on the board of the American Academy of Physiologic Medicine and Dentistry, a multi-disciplinary medical and dental group interested in airway problems, where she received a life-time achievement award March of 2015. Joy has lectured world-wide and was invited to speak at Grand Rounds at the Mayo Clinic in Rochester, Minnesota and to Stanford Sleep Residency program. She currently teaches with the Palo Alto school of sleep medicine and taught with UCLA dental sleep post-graduate program as well as a guest speaker at USC Dental Hygiene program.



Restricted lingual frenum

Restricted labial frenum

lowing physiologic or pathologic input, generating an adaptive response. We must look at and teach the possible cause of the problem in order to understand the treatment so that the patient will understand why therapy is necessary. Therapy consists of sequential, therapeutic techniques, done over a period of three months and followed for at least one year until the patient has successfully habituated the new muscle patterns and functions. The important goals of myofunctional therapy are: • Developing a lip seal • Attaining palatal tongue rest position • Awareness and elimination of oral habits • Restoring nasal breathing during sleep, sport, and speech using the proper volume and rate of breathing • Teaching bi-lateral tooth contact when swallowing and proper chewing and gathering foods in the mouth • Establishing functional posture training, including sleep position

Some Benefits of Myofunctional Therapy

• Enhance orthodontic treatment (decreasing time and propensity for relapse) • May correct problems with swallowing/digesting food (stomachaches from air swallowing) • Can aid in functional speech impediments (lisps with saying “s” sounds) • Helping ADHD though establishing proper breathing and tongue function •

Before (left) and after (right) treatment

Before (left) and after (right) treatment

38 DSP | Spring 2020

• May provide relief of TMJ dysfunction and teeth grinding by enhancing proper muscle functions • Elimination of oral habits such as nail biting, thumb sucking, lip biting and licking • Proper head and neck posture • Reduction of gingival inflammation due to mouth breathing • Snoring reduction or elimination, reduction of AHI, enhancing use of CPAP or OAT • Improvement of facial esthetics by enhancing muscle functions such as lip seal and development of facial symmetry Where can the dental hygienist be trained to become a myofunctional therapist? Currently in the United States, post-graduate courses are being taught through professional organizations such as the AOMT (Academy of Orofacial Myofunctional Therapy), independent practitioners, and some commercial entities. It is best to study more than a “weekend” course. In addition to the “basic” or “intro” course a serious, practitioner must incorporate a body of knowledge which includes breathing re-education, TMD, sleep, posture and frenulum restriction which are essential courses in order to become a qualified therapist. 1.

Cao MT, Sternbach JM, Guilleminault C. Continuous positive airway pressure therapy in obstructive sleep apnea: benefits and alternatives. Expert Rev Respir Med. 2017 Apr;11(4):259–272. 2. Melis M1,2, Di Giosia M3, Zawawi KH4. Oral myofunctional therapy for the treatment of temporomandibular disorders: A systematic review. Cranio. 2019 Sep 17:1-7. doi: 10.1080/08869634.2019.1668996. [Epubahead of print] 3. Rogers AP. The dental cosmos; a monthly record of dental science. Vol. 60. Philadelphia, PA: S.S. White Dental Manufacturing Co.; October 1918. 4. Guimarães KC, Drager LF, Genta PR, et al. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009 May 15;179(10):962–966. 5. Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep. 2015;38(5):669–675. 6. The American Dental Hygienists’ Association acknowledges that the scope of dental hygiene practice includes the assessment and evaluation of orofacial myofunctional dysfunction; and further advocates that dental hygienists complete advanced clinical and didactic continuing education prior to providing treatment. Dental Hygiene Services 9-92 7. Bhatia A et al. A randomized clinical trial of salivary substitute as an adjunct to scaling and root planing for management of periodontal inflammation in mouth breathing patients. J Oral Sci. (2015) 8. Coceani-Paskay, L., Chewing, Biting, Clenching, Bruxing and Oral Health, Oral Health, March 2016 9. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res. 2016 Jul 29;2(3):pii, 00043–2016. eCollection 2016 Jul. 10. L. Avivi-Arber et al., Neuroplasticity of face sensorimotor cortex and implications for control of orofacial movements, Japanese Dental Science Review (2010) 46, 132-142


SLEEP MEDICINE Mini-Residency 2020-2021

Boston, Massachusetts, USA Module I: October 8 -10, 2020 Module II: January 14 -16, 2021 Module III: April 8 -10, 2021 Tufts University School of Dental Medicine’s Dental Sleep Medicine Mini-Residency has been designated as an Accredited AADSM Mastery Program Provider. Attendees of accredited Mastery Program Provider programs are eligible to earn the AADSM Qualified Dentist designation and apply for the ABDSM certification exam through the Mastery Track.

Registration open! Space is limited.

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Check out our other Mini-Residency programs:

Pediatric Dental Sleep Medicine Module I: September 11-13, 2020 Module II: November 6 - 8, 2020

Further questions, please contact or 617-636-6629 This program meets the accreditation standards to be an AADSM Mastery Program Provider; however, the AADSM does not endorse, recommend or give preference to this program; faculty; or any product, device, or appliance discussed within this program. Any opinion expressed or communication regarding any product, device or appliance is solely the opinion of the individual(s) expressing or communicating that opinion, and not that of the AADSM.

Temporomandibular Disorder (TMD) Module I: October 23 - 25, 2020 Module II: January 22 - 24, 2021


Book Review by Pat Mc Bride, PhD, CCSH


he clear and present danger of the American healthcare system is that it is siloed and broken. Medical costs are skyrocketing for consumers. Physicians and Dentists practice with hands tied by mandates from the system. Quality of overall care and physician confidence has declined because of the seven minute medical appointment where one may address a “single issue” with the doctor. And, most frighteningly, mass media fans the flames of failed health with Big Pharma ads promising a quick fix for everything from balding to blood sugar control. The trend to “managed care,” with its unfulfilled promises of equality and equaniminity in access to care, leaves physicians expected to provide interventional care for sick people by managing symptoms instead of searching for causality. Sadly, managed care has not reached a consensus that assigns inflammatory processes as the root cause for most of our chronic diseases. As a reader of Dental Sleep Practice, you know there must be a better way. Enter: The Shift: The Dramatic Movement Toward Wilkerson and Health Centered Dentistry. Authors DeWitt Lestini show how Wilkerson, DMD, and E. Shanley Lestini, DDS, offer a comprehensive look at a broinflammation ken system which does not take into account responsibility for overall good health actually changes patient and vitality. In other words, taking from the the trajectory of great 20th Century thinker and philosopher Kuhn, a paradigm shift in thinking an individual’s Thomas and practice is presented to empower both clinical outcome patients and providers alike. The detailed and well-cited chapters show the futility of and lifespan. managing disease using only symptoms. Wilkerson and Lestini show how oral and systemic infection and inflammation, airway

Pat Mc Bride, PhD, CCSH, has spent 38 years as a full time clinician, educator and author 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 in collaboration 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. In addition to writing and teaching, she is currently a Clinical Field Specialist for hypoglossal stimulator implant surgery for OSA. Serving the underserved and marginalized patient remains a passion and priority for her. She sits on numerous Boards such as the AAPMD and NAAFO. She has one grown daughter who shares her passion for social justice and education, serving as an eighth grade teacher in the inner city Oakland.

40 DSP | Spring 2020

and breathing disorders, and TM Joint and dental disorders affect not only health and wellbeing but actually change the overall trajectory of an individual’s clinical outcome and lifespan. Issues concerning children and older adults are given specific focus. Chapters need not be read in exact order (I actually jumped to areas of particular interest first). Using a root-cause medical model, each chapter provides a logical pathway for physicians, dentists, and the interested layperson with examples of collaboration, documented studies, case histories, and forms used in their system for examinations and treatment planning. Each and every step of their plan offers means by which you can adapt the information personally and in your practice to empower the demographic you serve. Understanding how a shift toward wholehealth dentistry may work and implementing the step-by-step guide may be challenging, but the ground work is there. It remains for each practitioner and patient to decide which pathway is best for them. Finally, the comprehensive reference section is worth its weight in gold. If one only reads the the books referenced in the blue-boxed inserts throughout The Shift, an amazing education is to be had. Wilkerson and Lestini offer a lifetime work of love, passion and belief that each of us can provide a better and longer life to others.

SomnoDent Avant

SomnoMed’s smallest, slimmest, strongest and first milled oral device with a soft liner for the treatment of mild to moderate obstructive sleep apnea (OSA).

“The SomnoDent Avant is a game-changer!” - Kent Smith, DDS

We are proud to introduce you to our new SomnoDent Avant. SomnoDent Avant is digitally designed for dentists who want a slim, durable device with a quality fit and finish. Our CAD-CAM manufacturing system ensures a precise and consistent fit.The SomnoDent Avant has an innovative titration system and our proprietary BFlex soft liner for patient comfort, all from a company that values service and quality for our dentists and their patients. With both an easy “first time” fit and fast turnaround time of 14 calendar days, your patients will value wearing one of the slimmest and most comfortable oral devices available. • Durable SomnoDent Avant Advancement Straps provide simple calibration in 1mm increments • An initial set of 10 straps provided with your case with additional sizes available in small, medium, large (10 per set) to cover every patients complete advancement range • Completely digital process produces a precisely fit device with exceptional strength • Backed by SomnoMed’s dependable 3-year warranty Try the new SomnoDent Avant. Call us at 888-447-6673, option 4. Early Results are In... • At follow-up, 100% of patients reported that SomnoDent Avant is comfortable* • 96% of patients report that their quality of sleep improved* Quality of Sleep 81%

Very Comfortable







SomnoDent Avant Comfort

4% 4% Acceptable Poor

*SomnoDent Avant Study, Prof. Marc Braem, BE-UZA, Antwerp University Hospital, August 2018.

SomnoDent Avant is the registered Trademark of SomnoMed Ltd.


Fotona LightWalker and NightLase ®


eading the dental industry, the Fotona LightWalker® is a laser that features a full range of hard and soft tissue treatments. It’s known for its precision and superior outcomes, all while offering operating modes that are easy to select for greater simplicity. Treatments include Fotona’s NightLase® therapy, a non-invasive, patient-friendly laser treatment for increasing the quality of a patient’s sleep. NightLase decreases the amplitude of snoring by means of a gentle, laser-induced tightening effect caused by the contraction of collagen in the oral mucosa tissue.

Above: NightLase® therapy courtesy of Jaana Sippus Hannele, DDS, MSc Laser source: Fractional Er:YAG

42 DSP | Spring 2020

Fotona’s patented Er:YAG laser modality optimizes the length of laser pulses, allowing for the safe penetration of heat into the oral mucosa tissue. It is gentle enough to be used on the sensitive tissue inside the mouth, but strong enough to provide clinically efficacious heating. NightLase is easy for any doctor or dentist to perform and has a high success rate in producing a positive change in sleep patterns. Research has shown that NightLase is an effective treatment that reduces snoring in a non-invasive and comfortable way. The average full course of NightLase consists of three separate treatment sessions over a period of only six weeks. The final results of the treatment have been shown to last up to a year, and the therapy can be repeated. Patients find NightLase to be a highly comfortable and satisfying solution. NightLase requires no device to be worn during sleep and involves no chemical treatment. It’s a gentle and easy way for patients to regain a good night’s rest.


A seriously better way to manage continuing education. 1








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CONTINUING education

Bruxism & Sleep Disturbed Breathing A Guide to Critical Thinking about Empiricism, Science, Bruxism, and Sleep by Barry Glassman, DMD, and Don Malizia, DDS

Dentistry’s Empirical History Educational Aims

Evidence based medicine has been described as a combination of good science and clinical experience. The absence of either can be detrimental in a dental sleep practice. It is imperative that clinicians understand the definitions, benefits, and shortcomings of each so they can properly evaluate patient outcomes, relevant literature, and provide optimal care. Synthesizing information through these two lenses will empower clinicians to critically assess information about parafunction, sleep disordered breathing, and any relationships between the two.

Expected Outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 50 or online to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will: 1. Differentiate between evidence based medicine and empirical observation 2. Glean insights into the nature of any relationships between occlusion and TMD 3. Consider the relationships between sleep disordered breathing and bruxism 4. Refrain from assuming direct causation when evaluating contributing factors. 5. Properly evaluate methods utilized when considering validity of studies as opposed to simply accepting the author’s conclusions.

44 DSP | Spring 2020

Restorative dentistry has built institutions based on empirical evidence. Unfortunately, scientific evidence has not been an essential element of dentistry’s history. Without an understanding that empiricism is a theory based in the role of experience and observation in “evidence,” dentistry creates a curriculum devoid of randomized controlled studies. Dental students are not required to read and digest current literature, and are not taught the principles of evidenced based medicine. Dental sleep medicine is the combination of medical sleep principles and dentistry. Dentistry’s empirical evidence is often then cemented in the dental sleep medicine education by confirmation bias. Confirmation bias is defined as “the seeking or interpreting of evidence in ways that are partial to existing belief, expectations, or a hypothesis at hand.” Frequently, an association based on chronology is noted between a potential “cause” and “effect” and a mechanism is imagined that explains what has been observed. Over time the principals at play then become “truth” and taught as fact. While there are many such examples, let’s examine the following commonly taught “facts.”

CONTINUING education 1. Bruxism is caused by occlusal interferences and other forms of malocclusion 2. Bruxism causes joint and muscle pain 3. Bruxism is a protective mechanism caused by sleep apnea. Therefore, if the patient’s sleep apnea is properly managed, bruxism will be eliminated.

Odontogenic Dental Expectations – An Explanation of Dentistry’s Vulnerability to Confirmation Bias

Ralph Waldo Emerson explained man’s desire to look for direct causal relationships when he wrote the following in 1904: “And as mind, our mind or mind like ours, reappears to us in our study of Nature, Nature being everywhere formed after a method which we can well understand, and all the parts, to the most remote, allied or explicable,---therefore our own organization is a perpetual key, and a well-ordered mind brings to the study of every new fact or class of facts a certain divination of that which it shall find. This reduction to a few laws, to one law, is not a choice of the individual, it is the tyrannical instinct of the mind.”1 The diseases of dentistry are largely understood by modern science. We know what factors are involved with periodontal disease, and we understand decay. When patients are presented with treatment plans, rarely is “prognosis” even considered or discussed. It is quite clear that if the patients play the limited role that is required of them, and if our treatment is well delivered, the treatment plan will be successful. If there are difficulties during the treatment process, both the dentist and the patient tend to attempt to determine where the “fault” lies. As a result, we expect to understand mechanisms of disease, we expect that all the disease processes are understood, and we feel responsible to cure our patients of those diseases and create ideal dental health. When there are no exact explanations or when science seems incomplete, our medical colleagues accept the reality that the cause of every migraine, cold, or cancer, for example, is not known. Nor do they assume they can predictably prevent and/or cure these maladies. Patients who received quality dental care from quality dentists die with their teeth. Patients who receive quality medical care from quality physicians…still die. Therefore, when considering odontogenic matters, dentistry is unduly burdened by the expectation of perfec-

tion and success. This burden may in fact be largely responsible for dental burnout and consummate dissatisfaction within the profession.

The Move from Odontogenic Dentistry

Over the years, dentistry has transitioned from attempting to separate the teeth and the supporting structures from the rest of the body to understanding that there are in fact very intricate relationships between these dental structures and the other components of the cranial-cervicomandibular system. These relationships have led to an increased dental role in orofacial pain, headaches, and cervical pain, chronic pain issues and sleep disorders. It is not surprising that both function and dysfunction of these complicated systems are not quite as “finite” as the anatomy and physiology of the teeth and the periodontium. Unfortunately, dentistry tended to take the model of relative simplicity in terms of function and dysfunction involved in their odontogenic world into their understanding of these non-odontogenic structures. Campbell made this observation in 1957: “Time passed and it slowly dawned upon us that the problem of facial pain was bigger than we had thought, and that it could not be completely explained in terms of mechanics. Dentists have every reason to believe in their mechanical arts. They have developed a system of oral engineering of which they can

…dentistry is unduly burdened by the expectation of perfection and success.

Barry Glassman, DMD, has earned Diplomate status with the American Board of Craniofacial Pain, the American Academy of Pain Management, and the American Board of Dental Sleep Medicine. He is also a Fellow of the International College of Craniomandibular Disorders. He is on staff of the Lehigh Valley Hospital network and serves as clinical instructor in Craniofacial Pain and Sleep Disorders. Among his recent publications are The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients with Status Migrainosus in Headache, and The Curious History of Occlusion in Dentistry in Dentaltown. He teaches and lectures internationally on orofacial pain, joint dysfunction, and sleep disorders. Don Malizia, DDS, limits his practice to upper-quarter chronic pain and sleep disturbed breathing at the Allentown Pain & Sleep Center in Wilkes-Barre, Pennsylvania.


CONTINUING education be justly proud. However, their concentration on the restorative aspects of their profession has, to some extent, blinded them to the wide implications of pain. When he suffers pain, the patient embodies all the complexity, the nobility, and the frailty of humanity, so that the compassion and the precision of the dentist is incomplete without a knowledge of biologic and psychogenic values.”2

The Issue of “Causality”

A simple Google search will reveal the bacteria responsible for periodontal disease. We are aware how responsive a patient will be to significantly improved homecare and therefore simple gingivitis and gingival hyperplasia will respond predictably to home care improvements in combination with professional prophylaxis. We are thus comfortable stating that periodontal disease is caused by poor home care. In the same vein, we are also comfortable and accurate in stating the “cause” of dental decay, and we are aware that a combination of increasing the patient’s adaptive capacity to decay with fluoride in addition to good home care will essentially resolve the decay process. Al Fonder coined the term “Dental Distress System” (DDS) when in 1961 he related dental structure in terms of posture of the mandible and the upper cervical spine to altered disorders of nerve root compression and more. This structural concept suggests that when the malocclusions and altered jaw positions are improved, symptoms resolve, thus proving that the altered structure was the “cause” of the symptoms: “DDS patients complain of headache, dizziness, hearing loss, depression, worrying, nervousness, forgetfulness, suicidal tendencies, insomnia, sinusitis, fatigue, indigestion, constipation, ulcers, dermatitis, allergies, frequent urination, kidney and bladder complications, cold hands and feet, body pains and numbness and a host of sexual failures and gynecological problems. Elimination of the DDS reverses these chronic problems, the body chemistry and blood picture normalize. Even backward students when treated rapidly advance in classroom productivity often becoming honor students.”3 It was further suggested that DDS caused Parkinson’s disease and epilepsy.4 An internationally known physician named A. B. Leeds who treated Roosevelt,

46 DSP | Spring 2020

Eisenhower, and Stalin, who worked with the late dentist Willie B. May said “When this treatment is fully researched and understood, it will be capable of revising every diagnosis, treatment procedure and prognosis in the medical world.”5 Is it any wonder, then, that without evidenced based principles at work, empirical evidence suggesting causality continued to dominate the non-odontogenic world of dentistry?

This History of Bruxism, Pain, and Occlusion; Empirical Evidence Reigns

The role of occlusion in pain can be traced from Fonder to Costen, Guichet, Gelb, Dawson and Jankelson and to the rise of the “TMJ camps,” suggesting a causal relationship between occlusion and joint position to pain and dysfunction. Each of these pioneers suggested a causal relationship between occlusion, jaw position and pain. While there was disagreement on what was “normal,” there was the general agreement of a causal relationship between their definition of “abnormal” and pain or dysfunction. Interestingly, all of these “camps” reported some success with patients with the same various signs and symptoms. Of course, the assumption was being made that when the jaw position was changed and resulted in a symptomatic improvement, the symptoms were therefore caused by the “improper” jaw position. And as in the past, causation was assumed and statements of causality were again made between structure and headache, jaw pain, and more. Evidenced-based scientific principles were ignored and anecdotal reporting with assumptions of mechanism reigned. Confirmation bias underlying all of the techniques resulted in each jaw position, no matter how different, being claimed to be responsible for overwhelming successful symptomatic resolution including everything from headaches to internal derangements of the temporomandibular joint. The kneejerk reaction that opposes this thought process suggests that occlusion is not at all related to orofacial pain patterns. This concept is problematic for the general dental population who have personally witnessed many occasions of both odontogenic and nonodontogenic pain relieved with simple occlusal adjustments. The nature of causality thus becomes critically important and needs to be examined carefully.

CONTINUING education Evidenced Based Medicine: The Good, the Bad, and the Ugly

As noted, the earlier paradigm of “science” relied on the collection of empirical evidence. Today, science requires “a systematic assembly of all available evidence followed by a critical appraisal of this evidence.” The old paradigm “has been based on history taking and clinical examination followed by treatment of symptoms; based on the accepted pathophysiology of the condition diagnosed at the relevant time.”6 An evaluation of the history of one form of orthopedic surgery is relevant. For many years an accepted treatment for osteoarthritis of the knee was arthroscopy, based on the accepted concept of the pathophysiology. Orthopedic surgeons had empirical evidence (uncontrolled cases series) that knee arthroscopy was successful. There was empirical evidence (observation) that demonstrated successful response to the arthroscopic surgery. A well-designed random controlled study using arthroscopic surgery, arthroscopic lavage, and sham surgery resulted in finding absolutely no efficacy of arthroscopic debridement or lavage versus sham surgery.7 Karl Popper is credited with providing a solution to the question of “What is evidence?” Popper proposed the idea of falsifiability. “He pointed out that observations/ empirical evidence cannot be used to prove laws but can falsify them. In order to turn empirical evidence into scientific evidence one has to “set up a null hypothesis and then try to refute it.” Clearly, then, the use of Evidenced Based Medicine can be considered “good” as it helps us defeat our need to simplify causal relationships and helps us prevent confirmation bias from playing an inappropriate role in our risk benefit decision making. But misunderstanding Evidenced Based Medicine can be “Bad and Ugly” as well. David Sackett is often credited as being the “Father” of Evidenced Based Medicine as a result of his publication in 2000.8 Donoff pointed out the fallacy of trying to support any procedure with the observations from one’s clinical practice in the face of evidence from random controlled clinical trials that are answering the question expressed as a null hypothesis.9 Unfortunately, Sackett is often misunderstood and interpreted to suggest that ALL

treatment considerations must be a result of randomized controlled trials. This concept is not only used by those who have the knee jerk reaction previously referred to, but also by insurance companies who seek to deny therapy based on its “experimental basis.” Sackett makes it very clear that decision making in the clinical practice needs to be based on an appropriate combination of science AND clinical experience.

TMD and Occlusion

The use of “TMD” in any discussion is problematic.10 “TMD” is an umbrella “diagnosis” that is not specific and includes a host of disparate conditions. The predominance of the evidence suggests no direct causal relationship between any specific pain pattern and any specific scheme of tooth-to-tooth contact. Yet, as dentists, we are well aware that changes in occlusion have resulted in either initiation of pain or resolution of pain pre and post restorative therapy. Occlusion is a “noun” and in dental terminology refers to the relationship of the dental scheme when the elevators contract and bring the teeth into contact in maximum intercuspation. Occluding is a “verb” and refers to the action of dental contact. It would seem obvious, then, that “occluding” and the consequential forces that result are at issue when it comes to possible damage to the components of the cranial-cervicomandibular complex. Despite the fact that dentistry tends to “stipulate” occlusion, the fact remains that studies have suggested that in the absence of parafunction, teeth are actually in contact less than 20 minutes a day.11

Studies have suggested that in the absence of parafunction, teeth are actually in contact less than


minutes a day

Is Bruxism Caused by Malocclusion?

It has been generally thought by most of dentistry that bruxism causes internal derangements and orofacial pain as well as headaches. In 1961 Ramfjord and Ash concluded with poor scientific method and no control group, that bruxism was caused by “interferences” and thus malocclusion.12 Dr. Dawson’s teachings were clearly geared towards putting the condyle in centric relation and eliminating all interferences to that position. When this type of equilibration had been completed and the patient’s symptoms had improved, it was then assumed that the bruxism had caused the pain and that the equilibration had stopped the bruxism.13


CONTINUING education The suggestion that equilibration stopped the bruxism has never been proven. In fact, Goodman and Greene demonstrated that “mock equilibrations” were as effective in symptom reduction as fully performed equilibrations.14 Michelotti demonstrated that when she added interferences (gold foil) into the occlusal scheme of healthy females, not only did it not produce symptoms, but masseter EMG levels decreased.15

The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, un-learn, and relearn.

48 DSP | Spring 2020

Is Bruxism a Protective Mechanism for Sleep Disturbed Breathing?

In 2008 Jerald H. Simmons, MD, and Ronald S. Prehn, DDS, presented a poster at a respiratory meeting that was later published. The poster was entitled “Nocturnal Bruxism as a Protective Mechanism Against Obstructive Breathing During Sleep.”16 This was a retrospective review of 729 consecutive patients with “clinically significant obstructive breathing during sleep.” Patients were placed in the “Bruxism Group” by responding positively to sleep questionnaires that asked about the awareness of nocturnal bruxism or waking up with “aching jaw pain.” The patients were contacted and questioned following successful resolution of the breathing disorder with CPAP therapy. The following was their conclusion: “We postulate that nocturnal Bruxism is a compensatory mechanism of the upper airway to help overcome upper airway obstruction by activation of the clenching muscles which results in bringing the mandible, and therefore the tongue, forward. … After treating the airway with CPAP this protective mechanism is no longer needed and over time the Bruxism resolves. This study suggests such a compensatory mechanism is the etiological force behind nocturnal Bruxism in many patients.”16 Patient’s accurate awareness of their own nocturnal bruxism is well documented, as is the lack of relationship between bed partners’ reports and jaw discomfort.17 Maluly demonstrated the lack of consistency between reported bruxism on “validated questionnaires” and bruxism in a large sample evaluated with EMG’s during polysomnograms.18 Additional support for the concept of bruxism being “caused” by the presence of apnea and thus being a “protective mechanism” has been cited in the work of Kato who reported the tendency of two high am-

plitude breaths to occur immediately prior to the respiratory gasp associated with the sympathetic burst in the recovery of an obstructive episode.19 This has been interpreted to suggest that the patient is obstructed and trying to breath prior to the respiratory gasp. This transient sympathetic activity is often also associated with bruxism. While this may seem to be “logical,” an evaluation of the study population reveals that those patients with “sleep disorders” were excluded from the study. The authors further go on to point out that although it has been reported patients with sleep disordered breathing have a higher risk of reporting tooth grinding, the literature shows a weak correlation between the index of the respiratory disorder and the presence of sleep bruxism. Saito et al. report a weak association between bruxism and SDB in a study of 59 patients with polysomnograms.20 A discussion about causation and potential contributing mechanisms becomes essential and takes us back to both Emerson’s and Campbell’s quotes at the beginning of this paper. Emerson was suggesting that man’s tendency was to attempt to simplify cause and effect. Campbell’s quote made it clear that understanding pain in not simple. Pain is a combination of not only the degree of negative stimulus to the organism but includes a complex physiology that is not totally understood and cannot be simply measured. Pain is not directly related to the painful event but is a complex concept with many compounding not readily measured or always understood factors. Every dentist has adjusted an occlusion and noted a change in a patient’s dental and often non-dental symptoms. Success. Every dentist has then repeated that adjustment for another patient, only to be surprised by a total lack of response. Failure! The Bradford Hill criteria have been accepted as necessary to determine a causal relationship between a presumed cause and an observed effect.21 Without a biological gradient (dose response curve) demonstrated it appears that there is no causal relationship between bruxism and pain, and yet it would be certainly incorrect to suggest that altering the forces during the bruxism event in terms of magnitude and direction by changing the occlusal scheme can’t result in altered symptoms. Raphael has demonstrated that people with pain do not necessarily brux more than

CONTINUING education people without pain. She goes further to suggest that there are those with pain who don’t brux, and those who brux and don’t have pain. In fact, there are those who brux significantly in terms of frequency and duration and do not have any pain or dysfunction.22 It therefore follows that it would be incorrect to suggest that when occlusion is altered, and the symptoms resolve that the occlusal scheme and bruxism were the “cause” of the pain pattern. It would be more appropriate and accurate to suggest that the occlusal scheme and bruxism was certainly a contributing factor, and that the alteration of that scheme with that particular patient’s adaptive capacity considered, helped resolve their pain or dysfunction. It is misguided, therefore, to suggest that the lack of a causal relationship between bruxism and pain would suggest that treatment aimed at parafunctional control and thus altering the forces of bruxism is “misguided.” It is equally misguided to use logic in the absence of science to suggest that bruxism is a protective mechanism and is causally related to apnea. A more careful evaluation of the science makes the observation that, as anticipated, the cause and effect pattern is not direct nor as simple as proposed. In another study with polysomnograms, Kato et al report “in patients with obstructive sleep apnea syndrome, the contractions of the masseter and anterior temporalis muscles after respiratory events can be nonspecific motor phenomena, dependent on the duration of the arousals rather than the occurrence of respiratory events.23 It becomes clear that initiation of muscle contraction leading to nocturnal bruxism is related to arousals, whether they be respiratory related arousals (RERA’s) or non-respiratory related arousals. It would follow then that it would be possible therefore to reduce nocturnal bruxism events by management of a patient’s sleep disturbed breathing. That does not make the relationship a direct one, and thus the assumption of a “protective mechanism” should be more carefully considered.

The Future of Dentistry: The Role of Science This is an exciting time for dentistry. As Campbell noted in 1957, “Dentists have every reason to believe in their mechanical arts.

They have developed a system of oral engineering of which they can be justly proud.”2 Dentistry now plays a significant role in management of orofacial pain, joint dysfunction and sleep disorders. Dentistry cannot be held back because of its empirically based past. It must change its model to allow growth and learning. Dentistry cannot continue to accept the role of confirmation bias. It cannot feel threatened by accepting that the mechanisms once assumed as “fact” may not be correct, and that what has been observed may indeed be accurate, but the assumptions of mechanism may not have been. We must accept that causal relationships are RARELY direct, and that this complex being for whom we have accepted some level of responsibility to help in some ways is more complex than the simple relationships we long to seek. Alvin Toffler summarized this crossroads when he wrote, “The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.” 1. 2. 3. 4.

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

Emerson, R.W., Natural History of Intellect and other papers. 1904, Boston and New York: Houghton and Mifflin and Company. Campbell, J.N., Extension of the temporomandibular joint space by methods derived from general orthopedic procedures. J. Pros. Dent, 1957. 7(3): p. 386-399. Fonder, A.C., The Dental Physician. 2nd ed. 1985, Rock Falls, IL: Medical-Dental Arts. 462. Maehara, K., T. Matsui, and F. Takada, Dental Distress Syndrome (DDS) and Quadrant Theorem - The masticatory System, General ‘signs and Symptomatology. Journal of Biologic Stress and Disease: Basal Facts, 1982. 5(1): p. 4-11. Leeds, A.B. and W. May, Arthritic symptoms related to the position of the mandible. Arizona Dental Journal, 1955. 1(6). Machin, D. and M.J. Campbell, Chapter 1: What is evidence?, in Design of studies for medical research, D. Machin and M.J. Campbell, Editors. 2005, Wiley: Hoboken, NJ. Felson, D.T., Arthroscopy as a treatment for knee osteoarthritis. Best Practice & Research Clinical Rheumatology, 2010. 24(1): p. 47-50. Sackett, D.L., Evidence-Based Medicine. 2nd ed. 2000, Edinburgh: Churchill Livingstone. Donoff, B., It works in my hands. Evidence-Based Dentistry, 2000. 2: p. 1-2. Nitzan, D.W., B. Kreiner, and R. Zeltser, TMJ lubrication system: its effect on the joint function, dysfunction, and treatment approach. Compend Contin Educ Dent, 2004. 25(6): p. 437-8, 440, 443-4 passim; quiz 449, 471. Graf, H., Bruxism. Dent Clin North Am, 1969. 13: p. 659-665. Ramfjord, S.P., Bruxism, a clinical and electromyographic study. J Am Dent Assoc, 1961. 62: p. 21-44. Dawson, P.E., Temporomandibular joint pain-dysfunction problems can be solved. J Prosthet Dent, 1973. 29(1): p. 100-12. Goodman, P., C.S. Greene, and D.M. Laskin, Response of patients with myofascial pain-dysfunction syndrome to mock equilibration. Journal of the American Dental Association, 1976. 92(4): p. 755-8. Michelotti, A., et al., Effect of occlusal interference on habitual activity of human masseter. J Dent Res, 2005. 84(7): p. 644-8. Simmons, J.H. and R.S. Prehn, Nocturnal bruxism as a protective mechanism against obstructive breathing during sleep. Sleep, 2008. 31(Suppl 1): p. A199. Carra, M., N. Huynh, and G. Lavigne, Diagnostic accuracy of sleep bruxism scoring in absence of audio-video recording: a pilot study. Sleep and Breathing, 2015. 19(1): p. 183-190. Maluly, M., et al., Polysomnographic Study of the Prevalence of Sleep Bruxism in a Population Sample. Journal of Dental Research, 2013. 92(7 suppl): p. S97-S103. Khoury, S., et al., A significant increase in breathing amplitude precedes sleep bruxism. Chest, 2008. 134(2): p. 332-7. Saito, M., et al., Weak association between sleep bruxism and obstructive sleep apnea. A sleep laboratory study. Sleep and Breathing, 2016. 20(2): p. 703-709. Hill, A.B., The Environment and Disease: Association or Causation? Proc R Soc Med, 1965. 58: p. 295-300. Raphael, K.G., et al., Sleep bruxism and myofascial temporomandibular disorders: A laboratory-based polysomnographic investigation. The Journal of the American Dental Association, 2012. 143(11): p. 1223-1231. Kato, T., et al., Responsiveness of Jaw Motor Activation to Arousals during Sleep in Patients with Obstructive Sleep Apnea Syndrome. J Clin Sleep Med, 2013. 9(8): p. 759-65.


CONTINUING education

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Bruxism & Sleep Disturbed Breathing by Barry Glassman, DMD, and Don Malizia, DDS 1.




Ralph Waldo’s Emerson’s quote concerning the “tyrannical instinct of man” is relevant because he was referring to ______ a. man’s tendency to respond to Freudian principles when studying science. b. man’s need to simplify a complex relationship, often to turn a multivariate condition into a univariate one. c. the importance of random controlled studies. d. problems associated with confirmation bias. e. c and d In his 1957 article, Campbell observed _____ a. dentistry should be proud of its science regarding the role of jaw position to jaw pain and function. b. dentistry’s increased knowledge of the relationship of dental health to overall health will be critically important for patient care in the future. c. while dentistry should be proud of its mechanical arts, dentistry to date has been blinded to the complexity of pain. d. there is a direct relationship between oral health and chronic pain patterns. Al Fonder’s Dental Distress System _____ a. explains the relationship of periodontal disease to cardiac health. b. directly relates dental posture to general health and chronic pain. c. explained the relationship of Centric relation to joint pain. d. Is supported through random controlled studies. Costen’s syndrome _____ a. related headaches to a loss of vertical dimension. b. related ear pain and dysfunction to a loss of vertical dimension. c. was supported by a large study with random controls.

50 DSP | Spring 2020

d. was a series of anecdotal case studies with a small sample. e. a and c f. b and d 5.


Evidenced Based Medicine _____ a. was “fathered” by David Sackett in a paper entitled Evidenced Based Medicine in 2000. b. suggests that no clinical decision should be made without good evidenced based random controlled studies. c. was “fathered” by Donoff in his editorial, “It Works in My Hands.” d. is based on the principle that clinical decisions should be guided by science and clinical experience. e. a and d f. b and c The diagnosis of “TMD” ______ a. is appropriate only if the patient has joint pain or dysfunction. b. Is appropriate if the patient has a combination of joint and muscle pain. c. Is problematic because it is an unspecific “umbrella” diagnosis. d. Is a common side effect of oral appliance therapy.


The “stipulation” of occlusion _____ a. refers to the assumption of a Class I occlusion. b. refers to the assumption of a malocclusion. c. refers to the dentist’s assumption of “occluding.” d. refers to the patient’s hyper awareness of their occlusion.


In their 1961 text, Ramjford and Ash reported that interferences cause bruxism. ______ a. The predominance of the evidence continues to support this claim.

b. This claim was proven by Dr. Dawson in his texts where it was reported that bruxism was stopped when patients were properly equilibrated, and the interferences were removed. c. The predominance of the evidence now points to bruxism being centrally mediated and not initiated a peripheral factor like occlusion. d. Goodman’s and Greene’s study confirmed the success of well-planned equilibrations in resolving joint and muscle pain. 9.

The Simmons and Prehn study reported that all of the patients who exhibited bruxism prior to the study had their bruxism eliminated with control of their sleep disturbed breathing. This was determined by _____ a. post treatment polysomnograms with EMG’s. b. post treatment video during sleep. c. post treatment questionnaires. d. appliances.

10. Regarding bruxism, it has been stated “that nocturnal Bruxism is a compensatory mechanism of the upper airway to help overcome upper airway obstruction”. This suggestion ______ a. is an accurate description based on the Simmons and Prehn study. b. is appropriately being taught by many in dental sleep medicine. c. is potentially problematic considering the fact that many sleep studies that have evaluated bruxism have been done on patients without sleep disturbed breathing. d. is supported by the work of Kato who reported the tendency of a patient to take two high amplitude breaths just before the respiratory gasp and initiation of bruxism at the end of the obstructive event indicating that the patient is indeed obstructed.

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You Treat “The Silent Killer,” But Are You Aware of the Silent Killer of Your Sleep Practice? by Greg Kamyszek, President, BioRESEARCH, Inc.


s a reader of Dental Sleep Practice, your practice focuses on identifying and treating sleep issues like the silent killer, sleep apnea. What about the silent killer of your sleep practice? TMD, Temporomandibular Dysfunction, or TMJ as most people refer to it.

When you insert any snoring or OSA appliance, you are changing the maxilla/ mandible relationship each night for the rest of the patient’s life, or at least the life of the appliance. Most patients who stop wearing appliances do so due to TMJ or muscular pain. How does that happen and equally important, what can you do to prevent it? When first evaluating a patient, are you acquiring enough data? A JVA Quick Test takes 10 seconds to record and one minute to read. This test can tell you what you don’t know about joint function before treatment and also at your OAT position. Most dental professionals just ignore joint and muscle function and simply treat the present snoring and OSA. When you don’t take the next step, you’re losing a huge opportunity to positively impact the patient’s overall wellness and your practice’s bottom line. The deployment of objective biometric data on stomatognathic and airway function will help you see more and increase the like-

52 DSP | Spring 2020

lihood of positive treatment outcomes. The JVA Quick Test requires so little in terms of increased cost and provides insight regarding the interplay between airway improvement and the limits of stomatognathic function. With this data, you will likely improve results when managing the dual issues of oxygen deprivation and loss of comfort. You may even find that your OSA patient is also someone that can be treated in your office for TMD or orthodontics. If you select not to treat TMD, a referral goes a long way to build relationships within your local market. The tools in your measurement toolbox determine your depth of vision into your patients’ needs and your ability to satisfy them. You’re not going to lose by adding to your armamentarium. Instead, you’re going to begin recognizing and potentially treating myriad issues or you may opt to refer them to a local colleague. You can lose if you choose to ignore or otherwise fail to gather sufficient data. The JVA, EMG, and Rhinomanometry are all tools that do one thing, and only one thing – provide objective data. Get the data to make the best practice decisions possible; for the patients, for your team, and for your bottom line. It’s really that simple. My team has helped thousands of dentists around the world successfully implement these technologies, and would love to help you bring a higher level of care to your community. Let us share these experiences with you at our annual conference in June. Visit https://


The Athlete’s Secret Ingredient: The Power of Nasal Breathing by Michael Flanell, RDH, MBA


thletes continually try to perform better and break records with their athletic abilitities. In their pursuit for personal accomplishments, they dream of winning medals for themselves, their teams, and their countries as well as becoming part of professional organizations. What if small changes in how an athlete breathes could support greater athletic performance? Learning to breathe properly may, in fact, make the difference between winning and losing. In athletic competitions, astute observers will notice that some athletes breathe through their mouths, while others breathe through their noses. I urge you to pay attention to this next time you watch a sporting event. Could this matter in an athlete’s ability to win? Roger Federer, aged 37, ranked number three in men’s singles in 2018 by the Association of Tennis Professionals, and Federer’s mouth is almost always closed during competitions. Nasal breathing presents physiological advantages that are particularly

54 DSP | Spring 2020

helpful to competitive athletes, and athletes should be trained to breathe through their noses whenever possible. Respiration is a fundamental physiological process and finding the most efficient breathing mode during exercise warrants further exploration. Breathing, or ventilation, is the process of gas exchange from the outside environment to the alveoli. For optimal athletic performance, the goal is to utilize oxygen (O2) as efficiently as possible. The greatest athletes in the world are able to consume more O2 in their muscles while keeping carbon dioxide (CO2) levels low.1 Mouth breathing syndrome (MBS) is characterized by inhaling and exhaling primarily through the mouth and is considered to be an abnormal respiratory function. According to Capitanio de Souza,2 MBS is a pathology that is associated with the obstruction of the upper airways and increased resistance of nasal breathing. MBS can be induced by factors such as tonsil hyperplasia, hypertrophic turbinates, rhinitis, tumors, infections, in-

MEDICALinsight flammatory disease, and abnormalities in nasal architecture. Another cause of MBS is improperly developed orofacial muscles from infancy due to factors such as bottle feeding, finger sucking and/or nonnutritive sucking, making those muscles more flaccid and hypotonic.3 Prolonged mouth breathing can lead to muscular and postural alterations, which may cause dentoskeletal changes.4 Consequently, the habit of breathing through the mouth, even without obstruction, alters the balance of facial muscles and causes facial skeletal changes. Many healthcare professionals are unaware of the negative effects of MBS and that MBS can lead to changes in tongue and head position. With MBS, the location of tongue is down and backwards instead of up and forward in the palate. The tongue position influences the palatal development and, if not properly positioned in the palate, can result in a deep vaulted hard palate and a deviated septum contributing to MBS, instead of a domed formation and properly formed septum. The tongue resting in the lower jaw can cause a forward head position. Every inch of forward head posture increases the weight of the head on the spine by approximately 10 pounds5 creating an adverse load on the cervical joints, induced by poor spinal, cervical, and scapular postures. Additionally, the forward head position may strain the deep postural-stabilizing muscles of the spine, reducing the performance of their functional postural-supporting role.6 A significant problem with MBS is the reduction of oxygen absorption leading to a downward spiraling effect on sleep, stamina, and energy levels, all vital to the athlete. This effect is caused by inhaling too much oxygen and exhaling large amounts of carbon dioxide, needed for the transfer of oxygen from the hemoglobin molecule during respiration in the lungs. Breathing through the mouth also causes dryness of the oral and pharyngeal tissues and may lead to inflamed tonsils, tonsil stones, dry cough, swollen tongue, halitosis, and gingivitis. Mouth breathers also chew with their mouths open and swallow air, leading to gas, bloating, flatulence, and burping. In addition, lips become dry and flaccid because they do not stay closed to provide the necessary lip seal.7

Figure 1: Every inch of forward head posture increases the weight of the head on the spine by approximately 10 pounds5

Mouth breathing causes biochemical, physiological, and immunological disturbances. Among the biochemical and physiological disorders related to MBS are lower oxygen absorption (chronic hypoxemia), increased CO2 concentration (hypercapnia), and changes in the acid-base balance, towards respiratory acidosis. Mouth breathing is also associated with increased water loss, decreased energy, and changes in salivary profile resulting in a greater risk of heat stress and disrupted muscle function, thus negatively affecting athletic performance due to dehydration. According to Garcia Triana,8 healthy subjects experienced a 42% decrease in net water loss when they switched their breathing mode from nasal to oral expiration during tidal breathing.

Michael Flanell, RDH, MBA, is a Certified Sleep Apnea clinician from the Academy of Clinical Sleep Disorders Disciplines, a Myofunctional Therapist, and a Breathing Coach. She is a professor to the Department of Healthcare Management at St. Joseph’s College in Patchogue, New York, where her responsibilities include designing and teaching healthcare administration online. Previously, she taught at Briarcliff College in the Dental Hygiene and Healthcare Management Department. Presently, she is an Operations Manager at Sleepwell Orthotics and a clinical consultant at Advanced Dental Sleep Consultants.


MEDICALinsight Additionally, mouth breathing can cause changes in sleep patterns, which can contribute to a decrease in immune defense cells and an increase in humoral serum values related to inflammatory mediators, indicating the occurrence of oxidative stress and an altered systemic inflammatory state. Considering the athlete as a patient, a reduction in the quality or quantity of sleep can result in biological and cognitive imbalance, potentially decreasing physical performance and the recovery process after a workout.2 In addition, the decrease in immune defenses cells puts the athlete at risk for contracting illnesses, which may compromise performance during the athletic event. The nose has numerous functions: olfaction, sensation, mucociliary clearance, filtration, and immunological functions. In addition, the nose has the function of regulating air from cold to warm and humidifying the air during the nasal cycles of airflow dynamics. Nasal breathing cleans the air as it enters the body, produces nitric oxide (NO), and performs the same amount of work with less energy expended. Immunological functions

Mouth breathing is also associated with increased water loss, decreased energy, and changes in salivary profile resulting in a greater risk of heat stress and disrupted muscle function, thus negatively affecting athletic performance due to dehydration.

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of the nose produce mucus and secrete immunoglobulins. The nose has its own self-defense due to its coarse hairs (vibrissae) and the secretions it creates. In addition, the nose protects the lungs from allergens, toxicants, and other bacteria through its immunologic properties. Mucociliary clearance promotes mucus and cilia functions: to filter and trap toxicants and transport airborne particles.9 According to Lacomb, humidification occurs within 80% of the air before it reaches the lungs. Air is heated through conduction, convection, and radiation with blood flow in the opposite direction to incoming airflow, allowing for greater efficiency in warming the air. As ambient oxygen (O2) passes through the sinuses, it diffuses across the nasal epithelium and can be used by the cells to produce NO. As the sinuses produces NO and air is continuously inhaled, NO reaches the lungs and is diffused into the capillaries of the surrounding alveoli, expanding vessels and increasing O2/CO2 exchange. Lundberg,10 noted that the release of NO helps to control blood flow via diffusion to the underlying smooth muscles cells. The powerful vasodilating effects of NO lead to increased oxygen uptake, a reduction in pulmonary vascular resistance, and arterial oxygenation. The benefits of enhanced NO productivity include increased aerobic capacity, reduced hypertension, increased insulin sensitivity and glucose tolerance, capillarization and angiogenesis, and even long-term potentiation (LTP) associated with cellular models for learning and memory.11 An additional benefit of enhanced NO productivity is neurogenesis, which is the process by which new neurons form in the brain. These physiological conditions can either positively influence an athlete’s performance or impair the outcome. Nitric oxide, through nasal breathing, regulates autonomic functions like heart rate, respiration, blood pressure, and digestion along with mood, sleep cycle, fluid balance, and reproduction.11 The increase of blood flow derived from NO synthesis may improve recovery processes as well. According to Lacomb, nasal breathing, due, in part, to increased flow rates of air throughout the lungs, reduces exercise-induced asthma and bronchoconstriction.

MEDICALinsight As demands of physical activity increase, athletes may switch from breathing nasally to oronasally, or to breathing completely orally. There is, however, no exact switching point, due to a wide variance in people’s breathing patterns and needs. Ninnima12 found that the size of the nasal airway was the greatest contributor to switching, and, in addition, the larger the nasal airway, the longer the individual was able to breathe through the nose. Athletic performance can, however, be inhibited by nasal breathing at the point when exertion becomes more intense. Oral breathing occurs in shallow, quick breaths in order to receive more oxygen (O2) into the lungs and higher carbon dioxide (CO2) into the body.13 At higher intensities of physical activity, nasal breathing cannot provide the volume of O2 that oral breathing can, and less O2 content will result in a decrease in athletic performance. On the other hand, while mouth breathing at high levels of exertions may result in hyperventilation, nasal breathing effectively reduces this state. The evidence, thus, still supports nasal breathing, even at higher levels of performance, as a more efficient mode, given that the same

amount of mechanical work is completed at a lower metabolic cost compared with oral respiration. Using nasal expanders can, therefore, increase the capacity to sustain moderate to intense physical exertion during nasal breathing.8 In conclusion, nasal breathing provides significant advantages over mouth breathing, particularly for athletes who want to improve performance as well as recover more efficiently. The many benefits include a better night’s sleep in preparation for an event as well as managing input versus output with O2 and CO2 exchange. Nasal breathing releases NO, which regulates homeostasis in many of the body’s functions such as heart rate, blood pressure, and respiration. The disadvantages of MBS are the ill effects of poor posture from the tongue placement in the lower jaw, causing head-forward position as well as the inhalation of a larger than needed volume of dry, unfiltered air. Breathing through the mouth can also contribute to more dehydration in the athlete. Professional athletes who seek to maximize performance through breathing may want to include breathing coaches on their teams.


Lacomb, C. O. P., Oral vs. nasal breathing during submaximal aerobic exercise. UNLV Theses, Dissertations, Professional Papers, and Capstones. (2015), https://digitalscholarship.


Capitanio de Souza, B. The quality of sleep modified by the mouth breathing syndrome can impair the athlete’s physical performance. Academia Brasileira de Odontologia do Esporte, Rio de Janeiro, RJ, Brazil 74(3) (2017), pp. 225-228 DOI: rbo. v74n3., Rev Bras Odontol


Lopes, T. S., Moura, L. F., Lima, M. C. Association between breastfeeding and breathing pattern in children: A sectional study. Journal de Pediatria (Versão em Português), 90(4) (July-August 2014), pp. 396-402


Basheer, B., Hegde, K. S., Bhat, S. S., Umar, D., Baroudi, K. Influence of mouth breathing on the dentofacial growth of children: A cephalometric study. Journal of International Oral Health: JIOH, 6(6) (2014), pp. 50-55


Kapandji I. A. Physiology of the joints Volume 3, The trunk and the vertebral column. Paris. Second edition. (1974) Edinburgh: Churchill Livingston


Kwon, J. W., Son, S. M., Lee, N. K. Changes in upper-extremity muscle activities due to head position in subjects with a forward head posture and rounded shoulders. Journal of Physical Therapy Science, 27(6) (2015), pp. 1739-1742


O’Hehir, T., Francis, A. Mouth vs. nasal breathing. Dentaltown Magazine (Sept. 2012) Pg. 7-10


Triana,Garcia ,Ali, A. H., León, I. B G.. Mouth breathing and its relationship to some oral and medical conditions: Physiopathological mechanisms involved. Revista Habanera de Ciencias Médicas, 15(2) (2016), pp. 200-212 pats.201007-050RN


Sahin-Yilmaz, A., Naclerio, R. M. Anatomy and physiology of the upper airway. American Thoracic Society, 8(1) (2011)

10. Lundberg, J. O. Nitric oxide and the paranasal sinuses. The Anatomical Record. 291(11) (24 October 2008) https://doi. org/10.1002/ ar.20782 11. Hunt, S. J., Navalta, J. W. Nitric oxide and the biological cascades underlying increased neurogenesis, enhanced learning ability, and academic ability as an effect of increased bouts of physical activity. International Journal of Exercise Science, 5(3) (2012), pp. 245 -275 12. Niinimaa V., Cole P., Mintz S., Shephard R. J. The switching point from nasal to oronasal breathing. Respiration Physiology, 42(1) (1980), pp. 61-71 13. Recinto, C., Efthemeou, T., Boffelli, P. T., Navalta, J. W. Effects of nasal or oral breathing on anaerobic power output and metabolic responses. International Journal of Exercise Sci- ence, 10(4) (2017), pp. 506-514



When Disaster Strikes; A Call to Action by William L. Tycoliz, Jr., DDS


n 2017, America saw the destruction that Hurricane Irma, a Category 4 storm, brought upon Florida, Georgia, South Carolina, North Carolina and the Caribbean. To date, the storm caused an estimated $50 billion in damage and, according to the National Hurricane Center, is considered the fifth-costliest hurricane to hit mainland United States.

Office manager’s husband displaying physical signs of airway deficiency prior to treatment. Photo by Summerland Dental (left) and Aligner Sleep Appliance® worn by the patient. Photo by SleepArchiTx (right).

My practice, located in Summerland Key, Florida, was one of the structures that was obliviated as a result of the storm when it hit Florida. It took me and my staff over two years to rebuild my practice and I am proud to say, that as of July 2019, my practice re-opened to serve the needs of our community. During the time that the practice remained closed, when I wasn’t fighting with insurance companies or securing building permits, I kept up with continuing education. In one of the courses I took soon after the storm hit, I became aware of the policy statement issued by the American Dental Association recommending all dental practices actively screen all patients and when appropriate, treat them for sleep-related breathing disorders. The subject of sleep disorders intrigued me because I suspected that I may suffer from the condition. As a result, I took many courses on the topic and came across SleepArchiTx when I realized that I needed a full-service provider to help me launch a

At top: Remains of a neighborhood destroyed by Hurricane Irma in Big Pine Key, Florida on Wednesday, Sept. 20, 2017. Photo by J.T. Blatty / FEMA

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PRODUCTspotlight dental sleep medicine program at my office once we opened our doors. After evaluating various sleep options in the market, I decided to become a SleepArchiTx Certified Provider and strategically began my training and the training of my team just before we opened doors in July 2019. After our initial training with SleepArchiTx, we didn’t have to dig deep for patients because, among our staff and loved ones, we found people that needed immediate help. One such patient is my office manager’s husband. After receiving a sleep test from SleepArchiTx, their physician diagnosed her husband with sleep apnea. Soon after, we delivered the Aligner Sleep Appliance and the patient reports sleeping better. My staff member, his wife, tells me that she loves the sleep appliance because her husband doesn’t snore as much, and she no longer wakes up in the middle of the night due to his snoring. Since that initial patient, we have now instituted a screening protocol that is provided to all our patients and have several of our patients on sleep appliances. I feel that by partnering with SleepArchiTx, I was able to quickly ramp up my entire team’s knowledge on sleep disorders, provide my patients with the best treatment options and see SleepArchiTx as an extension of our practice efforts to tackle what is considered an epidemic in America. After deploying dental sleep medicine in my practice, I have come to appreciate that everything starts with a proper screening protocol. A simple questionnaire, such as the Sleep Disorders Assessment form by SleepArchiTx, will get your patients properly evaluated and keep your practice compliant with the American Dental Association policy statement on sleep disorders.

The subject of sleep disorders intrigued me because I suspected that I may suffer from the condition. As a result, I took many courses on the topic and came across SleepArchiTx when I realized that I needed a full-service provider to help me launch a dental sleep medicine program at my office once we opened our doors.

Sleep Disorder Assessment form completed by the patient. Courtesy of Summerland Dental.

Dr. William Tycoliz, Jr. has been in practice on Summerland Key since 1987. He earned a Bachelor of Science degree in chemical biology at Rhodes College and a Doctor of Dental Surgery degree from the University of Tennessee. He is a graduate of the University of Florida’s Comprehensive Dental Program. Dr. Tycoliz is a member of the American Dental Association, The Florida East Coast Dental Association and a Fellow in the Academy of General Dentistry. Dr. Tycoliz is a member and qualified dentist of the AADSM and a SleepArchiTx Certified Provider.



The Provision of Oral Appliances and Regulatory Compliance by Jayme R. Matchinski, Esq.


ral Appliance Therapy is recognized as an effective and efficient treatment for snoring and Obstructive Sleep Apnea (OSA) and the management of other sleep-related breathing disorders. Oral appliances are custom fit by dentists for patients to improve the patient’s sleep and address and treat any issues the patient is experiencing as a result of OSA. Oral Appliances have historically been seen as an alternative to the provision of CPAP; however, issues related to the use of CPAP, including: the patient’s intolerance to air pressure, difficulty with mask fitting, maintenance of the CPAP machine, non-adherence to CPAP treatment within several months of initiating treatment, and availability of electricity for the operation of CPAP, have caused the prescription and usage of Oral Appliances to increase and become widely accepted as a non-invasive treatment that effectively treats the patient’s snoring, OSA, or other sleep-related breathing disorders. Depending upon whether a patient has a commercial health insurance plan or is a beneficiary of a government program, including Medicare and/or Medicaid, there are different coverage guidelines and regulations governing the provision of Oral Appliances and re-

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imbursement by third party payors. This article will provide an overview of the key regulatory issues related to provision Oral Appliances that dentists and dental practices should consider prior to billing for Oral Appliances.

Oral Appliance Coverage and Coding Guidelines

The Medicare Enrollment Application – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), CMS-855S, must be submitted by a dentist or dental practice to CMS to become a licensed DME supplier. For a dentist or dental practice to receive reimbursement from Medicare or to bill Medicare for an Oral Appliance, the treating dentist must enroll her practice location as a Medicare DME Supplier. The Local Coverage Determinations (LCDs) for Oral Appliances for Obstructive Sleep Apnea (L28601, L28603, L28606, and L28620) have been combined into LCD L33611, with an effective date of October 1, 2015, and a revision effective date of January 1, 2019. These LCDs set forth the conditions for Medicare coverage and reimbursement, and the LCDs state that the Medicare Program will pay for the Oral Appliance only if the patient has a positive diagnosis of OSA as determined by a Medicare-covered sleep test. Specifically, a

LEGALledger custom fabricated mandibular advancement Oral Appliance (E0486) used to treat OSA is covered if the following criteria are met: A. The beneficiary has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea testing. B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3): 1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or, 2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, b. Hypertension, ischemic heart disease, or history of stroke; or, 3. If the AHI > 30 or the RDI > 30 and meets either of the following (a or b): a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, b. The treating physician determines that the use of a PAP device is contraindicated. C. The device is ordered by the treating physician following review of the report of the sleep test. The physician who provides the order for the Oral Appliance could be different from the one who performed the clinical evaluation in criterion A. D. The device is provided and billed for by a licensed dentist. The LCDs specify the conditions that determine whether the item or service is reasonable and medically necessary and the related policy articles detail the requirements that must be

met for an Oral Appliance to be classified as DME and coded as E0486. The term “durable medical equipment” is defined in Section 1861(n) of the Social Security Act as equipment furnished by a DMEPOS supplier that is: • Able to withstand repeated use; • Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years; • Primarily and customarily used to serve a medical purpose; • Generally not useful to an individual in the absence of an illness or injury; and • Appropriate for use in the home. Code E0486 may only be used for custom-fabricated mandibular advancement devices. Specifically, only Oral Appliances that have undergone coding verification review by the PDAC Contractor are eligible for Medicare reimbursement. To qualify for reimbursement, the Oral Appliance must fulfill all criteria specified in the durable medical equipment definition, the Oral Appliance Therapy must be necessary and reasonable for the treatment of OSA, and all other billing coding and documentation requirements must be met. To be coded as E0486, custom-fabricated mandibular advancement devices must meet all of the following criteria: • Have a fixed mechanical hinge at the sides, front or palate; • Have a mechanism that allows the mandible to be advanced by the patient in increments of one millimeter or less; • Be able to protrude the mandible beyond front teeth when adjusted to maximum protrusion; • Retain the adjustment setting when removed from the mouth; • Maintain the adjusted mouth position during sleep; • Remain fixed in place during sleep so as to prevent dislodging the device; and,

Items that require further adjustments beyond the initial 90-day period after delivery of the oral appliance are not eligible for classification as DME.

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


LEGALledger • Require no return dental visits beyond the initial 90-day fitting and adjustment period to perform ongoing modification and adjustments in order to maintain effectiveness. Items that require further adjustments beyond the initial 90-day period after delivery of the oral appliance are not eligible for classification as DME. These items are considered dental therapies, which are not eligible for reimbursement by Medicare under the DME coverage guidelines, and cannot be coded using E0486. Billing for Oral Appliance Therapy is all inclusive. The lump sum payment derived from the DMEPOS Fee Schedule includes: all time, labor, materials, professional services, radiology and laboratory costs incurred in fabricating and fitting the device, as well as adjustment and professional services required during the 90 days following the initial placement. The reimbursement is payable only by the regional DME MAC, not the Part B local carrier. Medicare claims related to the fitting, initial/ subsequent adjustments and repairs of an Oral Appliance should be submitted to the appropriate DME MAC and not as evaluation and management (E/M) services to the A/B MAC. Additionally, any radiological or other services performed in order to guide the adjustments of the oral device should not be submitted separately to the A/B MAC, as the Medicare payment associated with Healthcare Common Procedure Coding System (HCPCS) code. E0486 includes any required adjustments to ensure a properly fitted device, and services related to the E0486 code, including: initial patient evaluation, any required imaging, all fitting and post fabrication adjustments, are contained in the code and payable only by the DME MAC. The HCPCS encompasses both billable and payable codes. A billable HCPCS code is one that is submitted on a claim to the DME MAC. A payable HCPCS code is one that is considered for payment by the DME MAC only if the item meets the definition of durable medical equipment, falls under a statutory benefit category, and meets all other statutory and regulatory requirements.

Documentation Requirements

Dental practices, as DMEPOS suppliers, must have a written order on file from the treating physician before dispensing an Oral Appliance to a Medicare beneficiary. Dentists

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may not generate the written order for Oral Appliance Therapy themselves since they are not licensed to perform and interpret sleep tests and diagnose OSA. The written order must contain the beneficiary’s name, physician’s name, legible signature and signature date, date of the order, and detailed description of the item. The detailed description in the written order may be either a narrative description or a brand name/model number. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original pen-and-ink document. Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements. The written order must be maintained in the dentist’s files for seven (7) years and available to Medicare contractors upon request. If the dentist does not have a signed order before submission of the claim for Medicare payment, the claim will be denied. Additionally, for DMEPOS items to be covered by Medicare, the medical record must contain sufficient documentation of the medical condition to substantiate medical necessity for the item ordered. Section 1833(e) of the Social Security Act precludes payment to any service provider unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.” Since physicians are tasked with diagnosing and treating the Medicare beneficiaries, dentists and dental practices must obtain from them copies of the treating physician’s notes, pertinent test reports, and other health care records to substantiate the reasonableness and medical necessity for the Oral Appliance ordered. The DME MAC may request this information in selected cases from the physician and/or dentist or dental practice. If the DME MAC does not receive the information when requested or if the information in the patient’s medical record does not adequately support the medical necessity for the item, then on the assigned claims, the dentist may be liable for the dollar amount involved unless a properly executed advance beneficiary notice (ABN) of possible denial has been obtained. To meet the Medicare coverage guidelines and reimbursement requirements, the information in the medical record should include evidence that the treating physician conduct-

LEGALledger ed a face-to-face clinical evaluation prior to the sleep study to assess the patient for OSA. The clinical evaluation should be documented in a detailed narrative note in the patient’s chart in the format that the physician uses for other entries. At a minimum, the clinical evaluation should include the following information: • Patient’s Medical History, • Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches, • Duration of symptoms, • Validated sleep hygiene inventory such as the Epworth Sleepiness Scale, • Physical examination, • Body mass index, • Neck circumference; and • Focused cardiopulmonary and upper airway evaluation. The information in the medical record should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course, prognosis, and therapeutic interventions and results. Neither the physi-

cian’s order, a supplier’s prepared statement nor a physician’s attestation by itself, provides sufficient documentation of medical necessity, even though signed by the treating physician or supplier. There must be information in the patient’s medical record to substantiate the information in these documents. Moreover, the patient’s medical record is not limited to the physician’s office records but may also include hospital, nursing home, or home health agency records and records from other health care professionals. Once the Oral Appliance is custom fabricated and delivered to the patient, the dentist and/or dental practice is required to maintain proof of delivery documentation. The Medicare coverage guidelines and documentation requirements continue to evolve and change, and well as reimbursement requirements by other third party payors, including commercial insurance companies. Enforcement and recoupment efforts by third party payors related to the provision of Oral Appliances have also intensified, and dentists and dental practices must stay tuned to any regulatory changes which impact the provision of Oral Appliances in order to ensure regulatory compliance and receipt of reimbursement for such Oral Appliances.

NEW “THE ZZZ PACK” PODCAST THE prescription for dental sleep we have all been waiting for. Uncensored, real talk. Proudly introducing our hosts… Lisa Moler: DSP Publisher, Sleep Apnea Slayer, and Patient Dr. Erin Elliott: The fearless OSA doctor aka “The Queen of Good Air” Jason Tierney: Multi-syllabic thought provoker in all things sleep Download and Subscribe Now

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...The Lighter Side of Sleep Apnea

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Dental Sleep Education that fits your schedule The Academy of Clinical Sleep Disorder Disciplines is the only organization offering a fully online and on-demand certificate in Dental Sleep Medicine. Study the lectures and course materials at your own pace, then when you are ready, take the exam. 12 modules present both the medical and dental science of sleep medicine providing a solid foundation for understanding clinical applications. Most dentists are able to complete the 13 CE program in 4-6 months. The certificate is a prerequisite for ACSDD Fellow and Diplomate.

Enroll Today at ACSDD.ORG The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider at or to ADA CERP at This program has been submitted for approval by the ACSDD for a maximum of 13 credits as meeting general dental requirements.

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