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AADSM Issue

Improving Soldier Readiness: DSM in the Army

The Changing World of

Dental Sleep Medicine by Dr. Warren Schlott

by CPT Michael S. Pagano, DDS

Introducing ProSomnus [CA] ®

Continuously Advancing the Patient Experience

SUMMER 2018 | dentalsleeppractice.com PLUS

Continuing Education

A Checklist

for Evaluation of Potential Airway & Breathing Disorders Supporting Dentists Through PRACTICAL Sleep Apnea Education

by DeWitt C. Wilkerson, DMD


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INTRODUCTION

Airway, Airway, Airway!

A

dmittedly, I have a narrow focus in my professional life. Maybe you do, too. Does it seem to you that every part of dentistry is being tied to airway? A friend of mine half-jokingly said that dandruff and toe fungus must be airway problems, too. Whole curriculums of dentist training are being revamped to include airway awareness. Dental Hygienists are recruited to become myofunctional therapists to help people, from the earliest days to final years, to control the shape and size of the airway. Why is this? Didn’t we get trained as scientists to establish cause and effect, etiology of disease prior to treatment of it, and proffer evidenced-based recommendations to the patients who trust us? Can we apply those same standards to airway connections to nearly everything? Short answer: pretty likely, but not every clinically obvious effect can be connected in a straight line to airway. Consider this: What are the big drivers of survival? Eating, sleeping and breathing, with moving air the most powerful, overwhelming all barriers in the need for air. One would think that physiology that is so dependent on gas exchange would have systems and processes similarly reliant on oxygen-in, waste-gas out. Metabolism of the smallest building blocks of our cells, and of the synergistic organisms that outnumber those cells, depends on supply of oxygen and balance of CO2. We can supply those cells with every necessary mineral and protein, but without oxygen to burn, the process cannot move forward. As goes the cells, goes the organs, the systems, the organism, the purpose behind why the person exists. We learn in this issue about the Army’s attempt to make every soldier deployable – fulfilling their mission of serving us, the citizens of their country. No breathing, no safety. The patients most dentists serve may not have that high of calling, but their lives are all they’ve got and they need to be able to serve their own missions in life. No breathing, no fulfillment. Keeping adults alive and improving their health is exciting stuff – and worthy of all our effort. This is underlined by the ADA’s Policy Statement on Dentists Treatment of Sleep Related Breathing Disorders, which

we continue to explore in these pages. This statement will impact dentistry forever – every dental practice. Children, still capable of growing an airway that will allow them a trajectory of health unknown to previous generations, are dentistry’s biggest opportunity. The American Dental Association is hosting an unprecedented gathering of physicians, researchers, dentists, surgeons, myofunctional therapists, orthodontists and other stakeholders who are demanding that a protocol be created that any provider, no matter the profession, can use to help children grow to their maximum potential. While this will take some time

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

Keeping adults alive and improving their health is exciting stuff – and worthy of all our effort. This is underlined by the ADA’s Policy Statement on Dentists Treatment of Sleep Related Breathing Disorders, which we continue to explore in these pages.

and work to create, it’s encouraging that our ADA shares the same vision of so many professionals who are looking to help the next generation. Is the evidence in place that connects all these physiologic bits to breathing? No, it isn’t. But children, and the patient in your chair asking for solutions, are ready to trust you with the best available clinical wisdom you can muster. The evidence is growing daily. Meanwhile: Airway is, indeed, everywhere. It’s every person. It’s everything. DentalSleepPractice.com

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CONTENTS

6

Cover Story

A Collaborative Quest for Better OAT Devices and Outcomes by Mark T. Murphy, DDS Listening to their customers, creating solutions.

Left to right: David Kuhns, PhD, VP Technology; Len Liptak, CEO; and Sung Kim, VP Engineering & Operations

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2 CE CREDITS

Practice Development

The Changing World of Dental Sleep Medicine by Dr. Warren Schlott Staying up on current events means a more successful practice.

20

Continuing Education

A Checklist for Evaluation of Potential Airway & Breathing Disorders by DeWitt C. Wilkerson, DMD Making finding airway patients easy for your practice.

44

Education Spotlight

Improving Soldier Readiness: DSM in the Army by CPT Michael S. Pagano, DDS Important care for our troops.

2 DSP | Summer 2018

36

Team-Based Care

Sleep Medicine: A Team Sport by James D. Geyer, MD; Paul R. Carney, MD; and Monica M. Henderson, RN, RPSGT Perspective from our medical colleagues.


With ProSomnus

®

Precision means... I have a better patient experience.

—B. Kent Smith, DDS, D-ABDSM, ASBA

The ProSomnus Sleep Device material is so much smoother and easier for the patient to keep clean, you just don’t see the typical bio-gunk as you do with other appliances. The appliances come back with no smell and no stain even after 2-3 years. With all the discussion around oral systemic connections, our appliances have to be healthy too. —Dr. Michael Gelb, DDS, MS

The smaller, lingualess design of ProSomnus Sleep Devices means I don’t violate tongue space and with precision engineering, I don’t have to protrude the patient so far to find the best therapeutic bite position. They love the fit, feel and comfort and that means better outcomes and compliance. One study demonstrated 7 hours per night and 7 nights per week averages. Now that’s compliance! —Jerry C. Hu, DDS, DABDSM, DASBA

Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness. Visit ProSomnus.com or call 844 537 5337 for a free starter kit.

844 537 5337 ProSomnus.com Leader in Precision OAT™


CONTENTS

28

Practice Management

48

Advanced Treatment

Orthodontic Treatment Strategies for Sleep Apnea in Children by Dr. Satish Pai Our orthodontic colleagues are key to success.

Is Medicare Billing for Oral Appliances Worth the Time and Effort? by Rose Nierman Every office must decide about medical billing.

30

Laser Focus

Functional Frenectomy (Osteopathically Guided) by Michael Geis, DO; Leonard Kundel, DMD; and Peter Vitruk, PhD There is a way to know how far to go.

33

Product Spotlight

Adopting New Technology to Grow Your Practice by Dr. Ryan O’Neill Want to see more details? Have a look!

34

Practice Management

Recover, Repair, and Heal from Super Stress with BrainTap® by Sandra Marlowe How to nurture a relaxation response in everyday life and the dental office.

46

Expert View

OSA – Dentist and Sleep Physician Working Together by Teresa E. Jacobs, MD Supporting each other will lead to better care.

4 DSP | Summer 2018

52

Product Spotlight

EMR vs. PM Software; Get With the Program

Summer 2018 Publisher | Lisa Moler lmoler@medmarkmedia.com Editor in Chief | Steve Carstensen, DDS stevec@medmarkmedia.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com

by Jason Tierney

Editorial Advisors

Using the right tool for the job.

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

54

Team Focus

TEAM Impact on Dental Sleep Medicine by Glennine Varga, AAS, RDA, CTA Systems for making it work for your office.

56

Practice Growth

“Magic Wand” Marketing by Chris Bez Changing times means more opportunities.

58

National Account Manager Rob Akert | rob@medmarkmedia.com

Pediatrics

Changing the World, One Airway at a Time by Diana Batoon, DMD The next generation can grow up healthier.

60

Legal Ledger

Sleep Medicine Malpractice Negligent Failure to Refer by Ken Berley, DDS, JD, DABDSM Continuing to examine the ADA Policy Statement.

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VP, Sales & Business Development Mark Finkelstein | mark@medmarkmedia.com

Seek and Sleep

DSP Word Search

Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Office Manager/Executive Assistant Mystey Helm | mystey@medmarkmedia.com Office Assistant Lauren Drake | lauren@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2018. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.


AAD Visit N3 Sle SM e A nnu p at th Bal al M e tim ore or c Jun eetin all Boo e 1g 8 th 44 ask 3 abo .363.7 104 53 u t th

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• Online, on-demand academic certification • Individualized training programs • In-office clinical training • Team Coaching • Screening • Practice Management Systems • Medical Billing • Physician Communication

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COVERstory

A Collaborative Quest for Better OAT Devices and Outcomes by Mark T. Murphy, DDS, ProSomnus Lead Faculty Clinical Education

A

patient diagnosed with moderate OSA sits in a dental chair. The patient is CPAP non-compliant and has been referred to a dentist credentialed in Dental Sleep Medicine for Oral Appliance Therapy. One of the many decisions facing the dentist is OAT device selection. Does the dentist choose a familiar OAT device? Or is there something unique about a specific patient that suggests a different option? And what about one of the new OAT devices that has been recommended by a colleague? Is this the time to try something different? OAT device selection matters. A review of the forty-two papers cited in the AADSM’s Clinical Practice Guideline for OAT efficacy reveals considerable variability in AHI improvement, ranging from 82% to 21% AHI improvement.1 Differences in OAT efficacy are reported in eight of the nine papers, amongst the forty-two, that directly compare two or more OAT devices. Further, the literature suggests variability in compliance, side effects, quality of life, and other generally accepted measures of OAT outcomes. Though differences in methodology and sample characteristics likely account for some of this variability, OAT device selection warrants important consideration. This very same variability also represents opportunity; the potential for better OAT device design. What if an OAT device could facilitate more frequent AHI improvements in the 82% end of the spectrum? Or better comfort and compliance rates? Or mitigate the risk of tooth mobility, and other side effects?

Len Liptak, CEO, with ProSomnus [CA]

6 DSP | Summer 2018


COVERstory Or more reliable, predictable, clinical performance? What might this mean for patients, the dental practice and the Dental Sleep Medicine industry? Or how it influences a dentist’s OAT device selection process?

The Quest for Better OAT

In early 2017 ProSomnus Sleep Technologies arranged a meeting of two dozen leaders in dental sleep medicine with these types of questions in mind. The specific objective was to investigate opportunities to design a better continuous advancement (expansion screw style titration) OAT device, based on consensus input. What are the clinically relevant limitations of existing continuous advancement devices? And which of these opportunities for improvement, if adequately addressed by a new OAT design, might compel an expert dental sleep medicine expert to try a new OAT device? “ProSomnus is about developing OAT devices that help dentists create better treatment experiences and outcomes for their OSA patients,” noted Len Liptak, ProSomnus CEO and Co-founder. “Collaboration with clinical experts is integral to our R&D process. It is a process that has, historically, worked very well in the dental and medical device industries.” The group arrived at a handful of actionable insights. What follows are a few of the insights from the meeting, and some of the ProSomnus engineering solutions that led to the creation of the new ProSomnus [CA] Sleep Device.

Figure 1: OSA Efficacy Studies Chart

Insight: Asymmetrical Titration

A chief concern that the group described, and an important opportunity for improvement upon traditional continuous advancement OAT devices, is the concept of unwanted, asymmetrical, titration. What does unwanted, asymmetrical titration mean? Simply put, fifty turns of the expansion screw on the left side of the device usually does not express the same A/P titration as fifty turns of the expansion screw on the right. This often results in extra adjustments, appointments, and an overall increased challenge of controlling the case. There are two main sources of asymmetrical titration errors: anatomical variance and fabrication variance. Anatomical variance is the acknowledgement that arch forms are rarely symmetrical. Arch forms vary from patient to patient, from left side to right. These

Figure 2: ProSomnus [CA] Device

Mark T. Murphy, DDS, FAGD, is Lead Faculty for Clinical Education at ProSomnus, serves on the Guest Faculty at the University of Detroit Mercy, is a Regular Presenter on Business Development, Practice Management and Leadership at the Pankey Institute and is the Principal of Funktional Consulting. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. 

DentalSleepPractice.com

7


COVERstory Figure 3: Titration symmetry variance: example and analysis

Figure 4: Fiducial Markings

Pt. Right Side (29 Degree)

Pt. Left Side (14 Degree)

L/RExpansion Screw Displacement (mm)

A/P Displacement (mm)

A/P Variance (mm)

A/P Displacement (mm)

A/P Variance (mm)

L/R Difference (mm)

1.0

0.9

0.1

1.0

0.0

0.1

2.0

1.8

0.2

1.9

0.1

0.1

3.0

2.6

0,4

2.9

0.1

0.3

4.0

3.5

0.5

3.9

0.1

0.4

5.0

4.4

0.6

4.9

0.2

0.5

6.0

5.3

0.7

5.8

0.2

0.5

natural, anatomical, variances result in different A/P titration when an expansion screw is adjusted. For example, if the right side of the arch presents a 29-degree angle, 6.0mm of expansion screw displacement will express 5.3mm of A/P advancement. However, if the left side of the arch presents a 14-degree angle, 6.0mm of expansion screw displacement will express 5.8mm of A/P advancement, a 0.5mm difference between the left and right. Limitations of the traditional, artisanal fabrication method for OAT devices is the second source of asymmetrical titration errors. It is challenging for a technician to embed each expansion screw in perfect symmetry with respect to the A/P titration path, particularly when the anatomy itself is likely not perfectly symmetrical. Expansion screw assembly errors in the X, Y and Z dimensions result in three-dimensional errors that make it challenging to achieve the target A/P location.

ProSomnus Solution: Fiducial Markings

Figure 5: Linear Guide

To eliminate the need to count, record and communicate turns of the expansion screw during adjustments and to compensate for the aforementioned A/P titration asymmetries, fiducial markings are scored into the occlusal surface of the ProSomnus [CA] splint. The new fiducial markings feature corresponds to the true A/P titration, and not how far the screw has been adjusted. ProSomnus automatically calculates the trigonometry for each fiducial marking to compensate for the curvature of each side of each arch. In other words, a +1.0mm adjustment according to the fiducial marks relates to +1mm of true, anterior/posterior titration.

Insight: Expansion Screw Assembly Breakage

The group reported that existing continu-

8 DSP | Summer 2018

ous advancement OAT devices are prone to breakage in the expansion screw assembly region. The titration mechanisms of existing continuous advancement OAT devices are ostensibly lever arms. Cantilever forces generated during routine OAT usage are amplified by the traditional lever arm design. The stress from the normal intraoral forces associated with OAT are concentrated toward the distal regions of the titration mechanisms. As a result, traditional continuous advancement OAT devices can break more frequently than is desirable. Breakage often results in a series of clinical and therapeutic inefficiencies, not to mention the potential for the patient being out of treatment until a device is repaired or replaced.

ProSomnus Solution: Linear Guide

To address the concerns of asymmetrical titration and breakage, ProSomnus [CA] features a 3-dimensional channel machined into each side of the splint called a Linear Guide. The patent pending Linear Guide ensures predictable, symmetrical, advancement and mitigates the cantilever forces that are associated with breakage. The expansion screw is embedded into a CAD designed engineered pocket that is oriented to the Linear Guide, which are both aligned to the simulated A/P titration path. This innovation is designed to both strengthen the expansion screw assembly and provide a precision engineered, controlled titration experience. “The ProSomnus [CA] Sleep and Snore device uses a patent pending precision advancement mechanism designed to remove the guesswork out of protruding a patient’s mandible,” added Dave Kuhns, VP Technology and ProSomnus Co-founder. “The [CA] uses a proprietary approach to ensure that adjust-


With ProSomnus [CA] ®

Precision means...

taking the guesswork out of titration.

Introducing ProSomnus [CA]. The only precision continuous advancement device. • Platform. A smaller, stronger, hygienic material designed to improve the patient experience. • Advancement. 12.0mm total range, from -1.0mm to +11.0mm. • Linear Guide. Ensures precise, symmetrical protrusion with advancement markings. Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness. Visit ProSomnus.com or call 844 537 5337 for a free starter kit.

844 537 5337 ProSomnus.com Leader in Precision OAT™


COVERstory ments are symmetrical, aligned to true anterior/posterior protrusion, and easy to monitor.”

Insight: Limited Titration Range

Occasionally OSA patients require more than the 5 or 6mm of displacement offered by a traditional expansion screw style OAT device, though most patients are treated within 3mm of the target position. Getting additional expansion is challenging, and often requires a complete reset of the device at a new target position. This process is time consuming, expensive, and might adversely impact the patient experience.

ProSomnus Solution: Enhanced Titration Range

Collaboration with clinical experts is integral to our R&D process.

To address the occasional need for additional titration range, the new ProSomnus [CA] device offers +12.0mm of total adjustment range. This is achieved by providing a second lower arch with 5.0mm of advancement, when needed, on demand, at no additional charge. The additional 5.0mm advancement arch is made using the digital records on file, and the company’s patented method for simulating titration. No reset is required. No additional impressions or bites are required. The patient does not need to go without their device for any period of time.

Insight: From Side Effects to Bio-Gunk

The group also discussed a series of opportunities for improvement. Unwanted tooth movement, bulk and discomfort, device not matching the provided bite, minimization or elimination of metal, bio-gunk buildup, and limited customization options were amongst some of the more frequently mentioned areas that could be improved.

ProSomnus Solution: Precision Manufacturing and Engineered Materials

Though ProSomnus [CA] might not address every continuous advancement OAT device insight generated by the group, many of the additional insights are addressed by

1. 2. 3. 4. 5.

Figure 6: ProSomnus [CA] Device Titration Range

the foundational manufacturing technologies and materials utilized by ProSomnus. For example, there are indications of better therapeutic results,2 robust compliance and nightly usage,3 that the retainer-like fit of ProSomnus device splints are associated with a reduction in tooth mobility,4 and indications of reduced bio-gunk build-up due to the reduced porosity of the material used by ProSomnus.5 “The challenge for the [CA] program was to design a device that addresses the opportunities that leading dentists identified about traditional expansion screw devices while satisfying the comfort, control and overall performance characteristics that dentists expect from a ProSomnus device,” noted Sung Kim, VP Engineering and ProSomnus Co-founder. “We applied ProSomnus’ forward engineering approach to the key inputs identified by leading dentists.” Back to the patient with moderate OSA who is waiting, or perhaps snoring, in the dental chair. The dentist reaches for a prescription pad and considers the OAT device options, and what is best for the patient. Perhaps this is the time to try, firsthand, if the new OAT device creates a better experience for the dental practice and the patient. Special Note: ProSomnus Sleep Technologies would like to thank the leading dentists who participated in our R&D programs. The ProSomnus [CA] Device is cleared by the FDA, and currently being used to treat hundreds of patients across multiple dental practices in the United States and Canada.

Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. Journal of Dental Sleep Medicine 2015;2(3):71– 125. Remmers JE, Topor Z, Grosse J, Vranjes N, Mosca EV, Brant R, Bruehlmann S, Charkhandeh S, Jahromi SA. A feedback-controlled mandibular positioner identifies individuals with sleep apnea who will respond to oral appliance therapy. J Clin Sleep Med. 2017;13(7):871–880. Accepted for Publication: Hu J, Liptak L. Evaluation of a new oral appliance with objective compliance recording capability: a feasibility study. Journal of Dental Sleep Medicine. 2018;5(2):XX–XX. Hu J. Minimizing Side Effects: A Retrospective Case Series Analysis of Tooth Movement in Oral Appliance Therapy. Dental Sleep Practice 2018; March. Gelb M. Say No to Bio-Gunk! Dental Sleep Medicine Insider Magazine 2018; March: 6-8.

10 DSP | Summer 2018


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Take the survey now at: www.surveymonkey.com/r/dentalsleeppractice2018

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PRACTICEdevelopment

The

Changing World of

Dental Sleep Medicine by Dr. Warren Schlott

T

he practice of sleep medicine and dental sleep medicine is rapidly changing. The Affordable Health Care Act has forced changes in medicine that have consequences for dental sleep medicine. Exploring what “was” and what “is” can be beneficial to the success of a dental sleep practice. For those that can adapt, dental sleep medicine can and will flourish in the future. Changes in Medicine and Practices

Not so long ago, medicine was dominated by the family doctor who was associated with a hospital. The doctor ran his practice as an independent business. The idea of being an employee was foreign to the physician. However, with the exception of concierge physicians, the independent primary care physician (PCP) is slowly becoming extinct. Primary care physicians are becoming employees of independent practice associations (IPA) or health maintenance organizations (HMO). Financial and “network” issues are the foremost reason physicians are driven this route. Too many physicians exit their education heavily in debt and are unable to fund the opening of a practice. Furthermore, medical insurance companies favor IPA- and HMO-employed physicians over the solo practitioner. To contain costs, insurance companies create “networks” that control the supply of medical patients to the physicians. To gain access to patients, physicians must join the insurance networks. Insurance companies find it easier to negotiate with IPAs and HMOs rather than individuals physicians. Hence, the solo primary care physician finds it nearly impossible to compete with IPAs and HMOs with regard to pricing and more importantly, access to the network. Therefore, most physicians become employees of IPAs or HMOs. This dictates changes in the manner PCPs practice medicine.

12 DSP | Summer 2018

Whereas IPAs and HMOs don’t exactly dictate how the doctor is to practice, they create financial incentives that influence PCP’s choices. One carrot IPAs and HMO use is scheduling. Most often the primary care physicians are scheduled to see patients every 15 minutes. Among other items, physician’s bonuses often are affected by the number of patients seen. Because the patient’s first encounter in the treatment/exam room is with a nurse who weighs the patient, takes his or hers’ blood pressure, temperature, determines the patient’s chief compliant, and add chit-chat, the physician is left with only 5-8 minutes to see the patient. During this time the physician is suppose to listen to the patient’s complaints, examine the patient, and give treatment. It is no wonder why family doctors often run behind schedule. Unless the patient complains of sleep disorders it is unlikely the physician will inquire about sleep issues. This is one of the reasons sleep disorders are under diagnosed. With a plethora of other medical problems to address, there is essentially no time in their busy schedule for the PCP to screen for sleep issues. However, this creates a paradox!

PCP, the Sleep Physician, and DMEs in the Real World

In an ideal world, patients with sleep disorders including sleep apnea would be seen by a sleep specialist. The sleep physician would examine, test, and treat the sleep patient. However, in the real world, this is the exception rather than the rule. It has been reported that the number of physicians electing to study sleep disorders and become boarded in sleep is declining. Presumably, this is because other fields of medicine offer more financial rewards. The vast majority of sleep patients are referred for a sleep study by their “too busy” primary care physician only after complaining of sleep problems. The sleep study can be completed at home by the patient (HST), or conducted by a


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PRACTICEdevelopment technician in the sleep lab (PSG). Which type of sleep study is often directed by the patient’s insurance company. Because of cost differences between HST and PSG, the trend is to the less expensive home sleep study. Once completed, the studies are then auto scored by computer, or more often by the lab technician. The sleep study is then reviewed by a sleep physician who makes a diagnosis and offers treatment recommendations. Rarely does the sleep physician see the patient to discuss the sleep malady and offer treatment. Most often the sleep physician’s report, including a diagnosis and treatment recommendations is then sent to the PCP. The recommendations for treatment are almost always CPAP, surgery, mandibular advancement device, and weight loss. It is up to the PCP to prescribe the treatment choice. The The reality is that reality is that the vast majority of primary the vast majority care physicians have no training and little knowledge about sleep. (When the author of primary care has surveyed PCPs, less than 2% claim to have attended a lecture about sleep apnea physicians have in or out of school). So what does the PCP no training and do? He or she calls the Durable Medical Equipment (DME) representative selected little knowledge by the IPA, HMO, or the representative who calls on their office. The doctor knows the about sleep. DME will treat the patient with CPAP and remove the sleep problem from his or her domain. The DME will follow the sleep physician’s first treatment of choice, CPAP; and thus will provide the patient with a CPAP, hose, mask, and basic instructions. Needless to say, it is in the DME’s financial interest to sell a CPAP unit. Unfortunately, what occurs too often is that once the CPAP is delivered to the patient, the patient has little to no contact with the DME until it’s time for a new hose and mask. Often the patient struggles with CPAP. Sometimes the DME will help with CPAP use, but often the patient’s complaint is ignored. Especially vulnerable to this scenario are

Warren J. Schlott has been a practicing dentist in Brea, California since 1978. Dr. Schlott developed a thriving restorative dental practice and then in the early 2000’s developed a busy full time sleep practice. He has published numerous articles, and has helped other dentists establish sleep practices. Dr. Schlott is a member of the American Academy of Sleep medicine and is a Diplomate of the American Academy of Dental Sleep medicine. Dr. Schlott can be reached at wschlott@wschlott.com.

14 DSP | Summer 2018

Medicare patients and patients with poor insurance plans. The patient may call the PCP for help. Unfortunately, the family doctor cannot offer help because of their lack of knowledge, and other than the DME, the physician has nowhere to turn for aid. Remember, most sleep physicians do not see patients. So the patient is helpless and gives up on treatment for their sleep apnea. The good news is that not all is lost. New CPAP units come with a card that monitors patient use. This allows the patient to be monitored via the cloud by DMEs, and hence insurance companies. If the patient is not using their CPAP as prescribed for the first three months, insurance companies are beginning to repossess the CPAP unit. For financial gain, it behooves the DME to help the patient maintain CPAP treatment. The jury is still out if this will change CPAP compliance. Regardless, it appears that treatment for sleep apnea is shifting from the sleep physician to the primary care physician, who just happens to be poorly trained to deal with this malady. So where does this leave dentistry?

Dental Sleep and the PCP

Since the primary care physician is too busy and has little knowledge of sleep apnea, it appears that at the very least, screening for sleep apnea could fall to dentistry. At the very most, dentistry can offer hope for those patients who fail CPAP treatment. However, it is not that simple. All dental patients should be screened for sleep apnea, just as all dental patients should be screened for oral cancer. Patients can be screened with a written questionnaire such as the Epworth Test, Berlin Questionnaire, or Stop Bang Assessment. However, it’s the author’s opinion that many patients do not truthfully answer the questions. Not many patients will admit to falling asleep while driving. Perhaps a better way to screen patients is to verbally ask questions about how the patient sleeps, and to look for oral signs of sleep apnea. If you suspect that the patient may have sleep apnea, the patient should be referred to their PCP with a report of your findings. Most PCPs will be impressed with you, and perhaps become a referral source. The primary care physician appreciates your referral because a diagnosis of sleep apnea can potentially mean more money, as patient management becomes more complex, and hence


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PRACTICEdevelopment can create more insurance reimbursement for each patient visit. If the patient does not have a family doctor, the patient should be directly referred to a sleep lab for a sleep study. There a sleep physician can make a diagnosis and treatment recommendations. There is a trend for dentists to bypass the physician and use a home sleep company. This company provides the dentist with test results, a sleep physician diagnosis, treatment recommendations and perhaps a prescription for oral appliances. The problem is that too many dentists for their own financial gain, treat every patient, even if treatment success chances are slim to none, with an oral appliance. This only reinforces many physicians’ biases against sleep dentistry. If this route is taken, it behooves the dentist to establish a relationship with a local sleep physician and/or DME who can provide CPAP therapy when oral appliance therapy fails. Without local physician oversight, use an of out-of-area sleep physician violates the spirit of the AADSM’s guidelines, and may even violate state medical laws. The author has been audited by insurance companies to check that among other things an appropriate physician prescription for an oral appliance was in the patient chart. Dental appliance treatment for snoring and sleep apnea is becoming more main stream, but there is a long way to go. Many sleep physicians now recognize the benefits of treatment with oral appliances. However, a plethora of sleep physicians still believe that CPAP is the only viable treatment for snoring and sleep apnea. As they are more likely to hear about patient complaints of CPAP, primary care physicians seem to be more enthusiastic than many sleep physicians of oral appliance therapy. Since PCPs appear to be the new directing force for sleep apnea treatment, this is probably a positive for dentistry. Nonetheless, obstacles remain.

Insurance Effects

The Affordable Care Act has changed medical insurance coverage. HMO plans are declining and PPO plans are on the rise. However, this positive is negated by high deductible plans. Gone are the days of $250 deductibles. The trend is to high deductibles, $3000-5000 or higher, or to consumer directed plans. Minimal insurance coverage generally has high deductibles. Unfortunately, these plans gen-

16 DSP | Summer 2018

erally tend to be held by the lower income population who may have problems meeting the deductible. Consumer directed plans have high deductibles, but are off-set by money set aside in accounts funded by the patient and often matched by the employer. Even though the insurance may offer coverage for oral appliances, until the high deductible is met, many patients are being required to pay cash for services rendered. This is inexpedient, as medical patients, unlike dental patients, still have the mindset that all procedures should be covered by insurance. Being reimbursed for providing treatment for sleep apnea has become more problematic. Adding salt to the wound, regardless of what many are stating, insurance reimbursement for treatment is trending lower. (Dental insurance reimbursement is also drifting lower.) Hence, the practitioner must adapt to the new realities and collect more money from the patient, or cut costs or profits. Further complicating matters is the fact that many insurance companies have their own requirements that must be met before payment is rendered. Whereas, most insurance companies require a copy of the sleep study, some need documentation that the patient failed CPAP therapy before payment is made. Others demand a prescription for an oral appliance from a physician. Still others require a copy of a paid lab slip demonstrating that a FDA approved appliance was used. And some insurance companies want all of the above. Reimbursement is becoming more complicated.

Sleep Dentistry Treatment Options

Unfortunately, medicine and sleep dentistry do not have the perfect treatment for snoring and sleep apnea. CPAP effectively treats most, but not all, sleep apnea. However, its effectiveness is off-set with severe compliance issues. Oral appliances have higher compliance, but cannot effectively treat all sleep apnea. Surgical procedures for sleep apnea are becoming more of an adjunct to other therapies, than a treatment per se. Neural stimulation holds promise, but still is in its infancy. These facts create a quandary for which treatment to use. Guidelines suggest using oral appliances for mild sleep apnea, for patients who have mostly hypopneas as opposed to apneas, or for patients who fail CPAP therapy. But what do you do when oral appliances don’t effectively treat sleep apnea, but the patient won’t wear CPAP?


PRACTICEdevelopment A developing trend is to use combinations of therapies when oral appliances by themselves fail to sufficiently treat apneas. For example, oral appliances can be combined with positional therapy for individuals who have moderate to severe “positional” sleep apnea. Good results have been obtained with this combination. An example of this treatment would be use of an oral appliance and “Night Shift”. Rumor has it, that a major manufacturer of oral appliances may soon routinely provide a positional aid with their appliances. Another option is to combine CPAP with oral appliance therapy. An example of this is the CPAP Pro. This combination removes straps from the head and neck that were once required to hold the nasal pillow in place. Combination of oral appliance and CPAP routinely reduces air pressures by about 25-50%. The author’s experience is that patients readily accept this treatment protocol, and this may be the answer for those severe apnea patients who don’t tolerate “stand alone” CPAP. From a health and business perspective, this treatment protocol makes everyone a winner. The patient wins because they are getting treatment and become healthier. The DME wins because the patient remains on CPAP, and semi-annual hoses and masks sales can be made. The dentist wins by making an oral appliance. Unfortunately, most physicians including sleep physicians are not aware of this mode of treatment. Another alternative treatment is to provide the sleep patient with a custom CPAP mask. The custom mask removes straps and pressure points from the face. It is more stable than a standard mask, and it often leads to a reduction of pressures. Physicians and DMEs are unaware that such a product exists. Because of these facts, and because of matters previously discussed, new strategies are required to develop a dental sleep practice.

Dental Sleep Practice Development

The easiest method to start a dental sleep practice is to screen the dental practice patients. Statistically, about 30% of these patients will have sleep apnea. With an ongoing patient relationship, it is easy an first step to convert these patients to dental sleep patients. Treating these patients allows the dentist to develop skills with oral appliance therapy. With confidence the dentist can then move to develop outside patient referrals. Since the beginning of dental sleep practices, it has been gospel

to associate with a sleep physician(s) and/ or sleep lab(s) for their help in referring patients to the dentist for oral appliance therapy. However, with the primary care physician becoming the “de facto general” of sleep apnea treatment, it would be prudent for the sleep dentist to develop relationships with PCP. This does not mean relationships with sleep physicians, sleep labs, and other medical specialists should be abandoned. They can be sources of patients, but remember most labs and many sleep physicians own part or all of a DME. Hence, they have financial incentive to place all patients on CPAP. Unless you refer a great number of patients to them, oral appliance therapy is secondary to them. On the other hand, the PCP has little or no financial A developing incentive with regards to CPAP or oral appliance therapy. Their goal is to have the trend is to use patient satisfactorily treated without regard combinations of to treatment method. Thus, the new norm should be to target the primary care phy- therapies when sicians for help with developing the sleep practice. Unfortunately, as stated earlier, oral appliances most PCPs do not routinely screen for sleep by themselves apnea. Therefore, to develop a healthy dental sleep practice, a great number of fail to sufficiently referring PCPs are required. Remember, most PCPs only refer for sleep testing for treat apneas. only after the patient complains of sleeping problems. To overcome this issue, it may be wiser to become a provider for an IPA or HMO group with their large group of PCPs. Practitioners of IPAs and HMOs only refer to the “network” sleep dentist. However, becoming a member sleep dentist of an IPA or HMO is easier said than done. Most if not all such groups, limit the number of sleep dentist providers (generally one) to a given geographic region. To become a provider of the IPA or HMO requires knowing the medical director or the managing business person who is in charge of network membership. The sleep dentist must convince this person that you benefit the group with your hire. Once a dentist becomes a member, the work is not done. To receive referrals from PCPs requires that the dentist educate them about sleep apnea and oral appliance therapy. This is best accomplished during the group’s business meetings. Often the IPA or HMO will provide the dentist an hour for education. It is the author’s experience that most physicians do not want to meet after their long day’s work, so lunch meetings work best. Expect PCPs to be DentalSleepPractice.com

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PRACTICEdevelopment enthusiastic to learn that sleep dentist can be of great service to their patients. (Remember they are the ones hearing patient complaints). It is reasonable to expect referrals, but it takes to time to build physician confidence. One key to winning physician acceptance is to be a Medicare provider. Physicians accept Medicare and expect the sleep dentist to treat their Medicare patients. Hence the sleep dentist should become a Medicare provider. Also, it helps to provide the physician with written SOAP notes, letters, and /or e-mails detailing the dentist’s finding and treatment. Programs such as Dental Writer can simplify this task. It is also recommended that the dentist, not patient, make adjustments or titrations Marketing to the the to the appliance. This allows the dentist public can produce to “stay on top” of the patient. Be sure to follow-up with a sleep study to verify reresults, but it is sults. If conditions warrant, add positional or CPAP. If the dentist chooses to more expensive therapy use combination therapy, he or she must be than developing familiar with the various types of positional devices and methods. They also should be physician referrals. familiar with CPAP machines and hoses. Patients will ask questions and the answers needed to be known. It is wise to notify the PCP or sleep physician if you choose to add combination therapy or revert to a custom mask. The physician understands that treatment doesn’t always cure or manage the disease. They appreciate the dentist’s efforts to manage a condition they know little about. There are some who advocate placing your employee in the physician’s office to screen for snoring and sleep apnea. Most IPAs and HMOs will not allow this, and even if they did, it would be an expensive proposition. Regardless, the PCP would have to concur with the findings of your employee, refer the patient for a sleep study, and then if conditions warrant (mild sleep apnea) refer the patient to you for treatment. It seems more prudent and less expensive to just develop a large referring base of PCPs and other physicians and let them handle the leg work.

Marketing

It is possible to market to the public at large, by-passing the physician. Again, there are issues to overcome. The dentist cannot diagnosis sleep apnea, and for insurance to pay for oral appliance treatment, insurance companies are most often requiring a prescription for oral appliance therapy from a physician. These issues

18 DSP | Summer 2018

can be overcome by having a referral base of PCPs and sleep physicians, and simply sending the patients to them once you have screened the patient. Newspaper ads are relatively inexpensive. A simple message in the ad will generate responses, but most will be Medicare patients. Younger people as a rule don’t generally read newspapers. They receive their news via the internet. A presence on the internet is prudent. However, to have a successful presence there must be key words on the web-site, and because of competition a service that places you at the top of searches is a must. In metropolitan areas this can and will likely costs thousands of dollars monthly. Radio is the most expensive advertising and can bring exceptional results. The problem is that in many metropolitan areas, radio can cover large areas. Since many patients are unwilling to drive great distances, multiple office locations are necessary. In addition, radio ads must be heard multiple times before a person reacts. This means the ad must play for weeks, but more likely months before a return on investment is reached. Other than network television, TV is generally less expensive than radio. There is an upfront cost of thousands of dollars for producing an ad, but running the ad on cable TV is quite reasonable. The trick is to pick shows that draw the audience you want to see your advertisement. Again, like radio, repetition of showings is required before potential patients respond. All in all, marketing to the public can produce results, but it is more expensive than developing physician referrals.

Conclusion

The medical field is rapidly changing and having effects on dental sleep medicine. Instead of targeting sleep physicians and sleep labs for patient referrals, the sleep dentist should concentrate on primary care physicians and indirectly IPAs and HMOs. The dental sleep dentist will need to develop communication skills with these groups. Marketing to the public can be effective, but is more expensive than developing a referring network. Insurance companies are becoming more responsive to oral appliance therapy, but requirements for reimbursement are becoming more stringent. The sleep dentist should be familiar with positional therapy and know the ins and out of CPAP therapy so that combinations of therapies can be considered to enhance oral appliance efficacy.


CONTINUING education

A Checklist for Evaluation of Potential Airway & Breathing Disorders by DeWitt C. Wilkerson, DMD

I

n October 2017, the American Dental Association (ADA) released a policy statement addressing dentistry’s role in sleep-related breathing disorders.1 The policy encourages dental professionals to screen their patients for Obstructive Sleep Apnea (OSA), Upper Airway Resistance Syndrome (UARS), and other breathing disorders. The ADA advocates working in collaboration with other trained medical colleagues and emphasizes the effectiveness of intra-oral appliance therapy for treating patients with mild to moderate OSA and CPAP-intolerant patients with severe OSA. 20 DSP | Summer 2018

Educational aims

This article is written in behalf of all clinical team members, to orient each of us in the basic understanding of the signs and symptoms of dysfunctional breathing and sleep commonly found in our dental practice population. The dedicated clinician is encouraged to read each of the references from this practical article.

Expected outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 26 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader will: • Gain a basic understanding of the signs and symptoms of dysfunctional breathing and sleep. • Have a practical clinical guide which can be implemented immediately.


CONTINUING education With the endorsement of the ADA, screening and treating sleep-related breathing disorders has become the newest focus of integrative dental medicine. The purpose of this article is to provide a simplified Checklist to guide the dental team in reviewing each patient’s: • History (signs & symptoms) • Clinical Evaluation • Screening & Testing

History (signs & symptoms)

1. MOUTHBREATHER - + Are you aware being a mouth breather? Mouth breathing is considered dysfunctional breathing, because it bypasses the critical physiologic benefits of nasal breathing.2 Through the nose, air is humidified, warmed, sterilized/anti-microbial effect of nitric oxide produced in the para-nasal sinuses, and the breathing rate is controlled to help maintain an optimum carbon dioxide-oxygen ratio in the bloodstream (Bohr Effect). Mouth breathing eliminates the possibility of ideal physiologic breathing, allowing “dirty air” containing microbes, pollutants, pesticides, smog, allergens, pollen, and spores, to name a few, to pass through the mouth straight to the lymphoid tissues of the adenoids and tonsils. This can result in both inflammation and infection in the posterior throat. 2. SNORE - + Are you aware of snoring in your sleep? Snoring is a sign of airway blockage as the tissues of the soft palate vibrate against the posterior wall of the pharynx. This can be accompanied by the tongue dropping back as

well. Approximately one in three snorers also suffers from obstructive sleep apnea. 3. SLEEP APNEA - + Have you been diagnosed with Sleep Apnea or been observed to stop breathing in your sleep? Obstructive Sleep Apnea is a very serious breathing disorder that has significant systemic effects due to mechanical collapse of the posterior throat airway. An apneic event occurs when breathing ceases for 10 seconds or longer accompanied by drops in oxygen saturation in the bloodstream. During sleep, multiple events in intervals of several minutes or longer can mimic the experience of choking and stimulate activation of the Sympathetic Nervous System, “Fight or Flight” response. Stress hormones, including Cortisol, are released into the bloodstream, producing an acute excitation of the heart rate. The increase in blood flow is an attempt to deliver needed oxygen throughout the body. Chronic elevated cortisol levels in the blood can produce several deleterious effects including increased blood pressure, cardiac arrhythmia, insulin resistance, and leptin/ghrelin imbalance. An increased hunger drive can be stimulated by imbalances between leptin and ghrelin. Central Sleep Apnea (CSA) is a CNS disorder in which the respiratory center in the brain fails to transmit a signal to the body to inhale. CSA frequently occurs among people who are seriously ill from other causes: chronic heart failure, diseases of and injuries to the breathing control centers in the brain-

History 1. 2. 3. 4. 5. 6. 7.

Mouthbreather Snore Sleep Apnea Poor Sleep Quality Daytime Sleepiness Nasal Congestion Forward Head Posture 8. Tongue-tie 9. Chronic Cough 10. Deviated Septum

Dr. DeWitt “Witt” Wilkerson graduated from the University of Florida, College of Dentistry in 1982, the same year he joined the Dawson group private practice in St. Petersburg, Florida, and where he presently practices. He is Past President of the American Equilibration Society, Immediate Past-President of the American Academy for Oral-Systemic Health, Senior Faculty/Lecturer and Director of Dental Medicine at the Dawson Academy, an Adjunct Professor of Graduate Studies at the University of Florida, College of Dentistry, and Past Associate Faculty and Special Lecturer at the L.D. Pankey Institute. Dr. Wilkerson lectures both nationally and internationally on the subjects of Restorative Dentistry, Dental Occlusion, TM Disorders, Airway/Dental Sleep Medicine, and Integrative Dental Medicine. He has taught over 600 days of lectures and hands-on instruction at the Dawson Academy. Personally, Witt and his wonderful wife, Pat, have been married 37 years and are the proud parents of Todd, Whitney, Ryan, and a beautiful 3 year old granddaughter, Carolina. The Wilkerson family has been privileged to participate in many dental missions trips including Romania, Kenya, and Nicaragua.

DentalSleepPractice.com

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CONTINUING education stem, Parkinson’s disease, stroke, kidney failure, and even severe arthritis with degenerative changes to the cervical spine and base of the skull. It is seen among users of opiates. Idiopathic CSA is a description used when the cause is unknown. Mixed Apnea describes the simultaneous occurrence of both OSA and CSA. 4. POOR SLEEP QUALITY - + Do you sleep poorly or wake up during the night? Breathing disorders during sleep disrupt the normal sleep pattern. Stimulation of the Sympathetic “Fight or Flight” response to decreased oxygen levels, the release of steroid hormone Cortisol from the Adrenal glands, and increases in heart rate are all involved in producing arousals from deeper to lighter sleep levels or even waking up. Frequent urination at night is a common side effect. 5. DAYTIME SLEEPINESS - + Do you feel tired and sleepy during the day? Failure to spend adequate time in deeper sleep stages produces non-restorative sleep and its consequences: daytime fatigue and sleepiness.

Chronic cough and similar throat issues are highly correlated with Sleep Apnea and Gastroesophageal Reflux Disease (GERD), which often occur together.

6. NASAL CONGESTION - + Do you experience frequent nasal congestion or difficulty breathing through your nose? Nasal congestion due to allergies from food or environment, nasal stenosis, deviated septum, nasal polyps, turbinate enlargement, and/or acute and chronic sinusitis, will affect breathing and often cause a conversion to dysfunctional mouth breathing. Eustachian tube blockage can produce a fullness feeling in the ears. 7. FORWARD HEAD POSTURE - + Does your neck bother you and do you find yourself in a forward head posture? “Mouth-breathing Syndrome” is characterized by significant nasal obstruction, whereby an effort to overcome this resistance increases the work of accessory muscles of inspiration. Furthermore, forward head posture, common among mouth breathers, facilitates the air to enter the mouth which can lead to a deterioration of the pulmonary function. Chronically, the hyperactivity of the neck muscles may be associated with cervical changes that, as a result, can influence temporomandibular disorders (TMD) and spine cervical disorders.3 8. TONGUE-TIE - + Do you have a tongue-tie or any tongue restrictions affecting sucking, swallowing or speech? A short lingual frenulum has been associated with difficulties in sucking, swallowing and speech. The oral dysfunction induced by a short lingual frenulum can lead to oralfacial dysmorphosis, decreasing the size of upper airway support. Progressive change increases the risk of upper airway collapsibility during sleep.4 9. CHRONIC COUGH - + Do you have a chronic cough, sore throat, or difficulty swallowing? Chronic cough and similar throat issues are highly correlated with Sleep Apnea and Gastroesophageal Reflux Disease (GERD), which often occur together. It’s reported that 80% of the 60 million Americans who’ve been diagnosed with GERD report worse symptoms at night, and 3 in 4 wake up routinely from sleep.

22 DSP | Summer 2018


CONTINUING education 10. DEVIATED SEPTUM - + Are you aware of having a deviated septum or nasal deformity or damage? A deviated septum can be present from birth, be the result of poor maxillary development, or can occur after injury. It can contribute to difficulty breathing through the nose, nasal congestion, recurrent sinus infections, nosebleeds, difficulty sleeping, snoring, sleep apnea, headaches and post-nasal drip.

Clinical Evaluation

1. NECK CIRCUMFERENCE > 16” Women, > 17” Men It has been demonstrated, through several studies, that enlarged necks are associated with increased soft tissue volume in the throat area.5 Neck size can be associated with being overweight, same as waist size. 2. MALLAMPATI > 2 The Mallampati Score6 comprises a visual assessment of the distance from the tongue base to the roof of the mouth, and therefore the amount of space for an adequate airway. The score is assessed by asking the patient, in a sitting posture, to open the mouth and protrude the tongue as much as possible, rating in 4 classes. • Class 1: Soft palate, uvula, fauces, pillars visible. • Class 2: Soft palate, uvula, fauces visible. • Class 3: Soft palate, base of uvula visible. • Class 4: Only hard palate visible. A higher Mallampati score is a predictor for risk of OSA and can be a helpful screening tool during the clinical examination. However, its role in predicting severity of OSA remains doubtful and needs further study.7 It should be noted that some individuals with a Mallampati 1 or 2 may have serious airway compromise. 3. SCALLOPED TONGUE The presence of tongue scalloping has shown a high correlation for abnormal AHI, and nocturnal desaturation. The presence and severity of tongue scalloping has shown a positive correlation with increasing Mallampati. In high-risk patients, tongue scalloping has been found to be predictive of sleep pathology. Tongue scalloping is a useful clinical indicator.8

4. 40% TONGUE RESTRICTION (Tongue-tie) A normal range of free tongue movement is greater than 16 mm.9 Ankyloglossia can be classified into 4 classes based on Kotlow’s assessment(10) as follows; • Class I: Mild ankyloglossia: 12 to 16 mm, • Class II: Moderate ankyloglossia: 8 to 11 mm, Clinical Evaluation • Class III: Severe ankyloglos1. Neck Circumference sia: 3 to 7 mm, > 16" Women, > 17" Men • Class IV: Complete ankylo2. Mallampati >2 glossia: Less than 3 mm. 3. Scalloped Tongue Class III and IV tongue-tie cate4. 40% Tongue Restriction/ gory should be given special conTongue-tie sideration because they severely 5. Nasal Stenosis restrict the tongue’s movement. 6. Skeletal Profile Restrictions include limitations of movement protrusively, laterally and vertically. One screening evaluation involves: 1. Have the patient open their mouth as wide as possible. Normal maximum opening is 40-50 mm. 2. While maximally open, raise the tip of the tongue, attempting to touch the incisive papilla behind the upper central incisors. Successful touching represents “normal” tongue mobility. Tongue restrictions can be visualized as a percentage of movement from rest to full extension towards the incisive papillae. 40% restriction or greater often has significant clinical implications. 5. NASAL STENOSIS A simple observation can be made by having the patient breathe in and out through the nose. Does the nostril on one or both sides collapse during nasal breathing? This provides a visible indicator of nasal airway collapse or obstruction. It would be common that these patients struggle with upper airway resistance and default to mouth breathing. 6. SKELETAL PROFILE Maxillary and/or mandibular skeletal underdevelopment can compromise airway volume.11 Arnett’s True Vertical12 is a useful assessment for mandibular retrusion, maxillary retrusion, and bimaxillary (maxillo-mandibular) retrusion, by observing the patient’s profile, facing to the right. DentalSleepPractice.com

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CONTINUING education A line dropped vertically down from the nose-lip intersection (SN) relates ideally to the fully developed lower face when: Upper Lip = 2-5 mm in front of the line Lower Lip = 0-3 mm in front of the line Chin Point = -4-0 mm behind the line. Measurements less than these ranges can implicate craniofacial, mid-face underdevelopment, with increased risk for airway compromise.

Screening & Testing

Screening & Testing

• Screening: High Resolution Pulse Oximetry (HRPO) • Testing: Home Sleep Testing (HST)

24 DSP | Summer 2018

SCREENING: HIGH RESOLUTION PULSE OXIMETRY (HRPO) Overnight HRPO monitors two significant factors that relate to healthy or dysfunctional breathing. 1. SO2 – Oxygen saturation is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin (unsaturated + saturated) in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal blood oxygen levels in humans are considered 95–100 percent. If the level is below 90 percent, it is considered low (hypoxemia). Blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart. Continued low oxygen levels may lead to respiratory or cardiac arrest.13 2. Pulse Rate – During non-REM sleep, the pulse rate tends to slow down 1424 beats per minute, compared with wakefulness. The average heart rate range during all 3 stages of non-REM sleep is between 60-100. Some individuals may have a normally slower or faster heart rate range. Non-REM represents roughly 75-80% of time asleep. REM sleep includes periods of dreaming and increased heart rate, with more variability. REM is often concentrated in the last few hours of sleep. HRPO can screen for disordered breathing during sleep by observing the recorded “Delta” of both SO2 and Pulse Rate. Delta involves the difference between high and low values. Large swings in both SO2 and Pulse Rate over short intervals, on multiple occasions throughout sleep, may indicate a breathing disorder. Precise interpretation is often difficult.14

TESTING: HOME SLEEP TESTING (HST) Home sleep testing has become a standard for evaluation and diagnosis of sleep disorders in recent years. Though less information is gathered relative to polysomnography (PSG) studies, the accuracy appears comparable15. Most home testing recorders can track time of the test period, but not sleep time, which requires EEG signals. They also gather data about oximetry, pulse rate, sleep position, apnea & hypopnea episodes, snoring, and chest effort. The reports include an AHI. A new term, REI, or Respiratory Event Index, has been adopted by the American Academy of Sleep Medicine to designate results from testing when true sleep time is not measured. There is a lot of other data on even a ‘simple’ test that provides insight to the patient’s sleep. Note: Dentists are not qualified or licensed to interpret sleep apnea. HST should be interpreted by a Board Certified Sleep Physician. Many HST manufacturers provide an interpretation service. Dentists are the ideal health professionals to screen patients and gather studies for potential airway disorders. When HST reveals significant signs of breathing dysfunction and elevated AHI, referral for an overnight laboratory PSG will analyze important additional information such as EEG and CSA. The results may significantly altar the treatment plan. Dr. Tom Colquitt, Past President of the American Academy of Restorative Dentistry (AARD), addressed the 2016 session of that Academy with the following critical statement: “Other than emergency care, the first procedure performed by every dentist, for every patient, of any age should be a proper airway examination and evaluation of breathing function.” Airway and breathing disorders are becoming an increasing area of emphasis in Dentistry. Form follows function. Properly functioning nasal breathing, tongue posture, and swallowing patterns greatly influence a properly formed dental occlusion. On the contrary, dysfunctional mouth breathing, tongue posture, and swallowing patterns greatly influence an improperly formed dental malocclusion. This may include TMD symptoms, clenching, bruxism, tooth abrasion and erosion, headaches, GERD and broad systemic effects.


CONTINUING education Brent Bauer M.D., Internist and Editorial Board member for the Mayo Clinic Health Letter wrote an article entitled, Buzzed on Inflammation.16 “Inflammation is the new medical buzzword. It seems as though everyone is talking about it, especially the fact that inflammation appears to play a role in many chronic diseases.” One of the most important sources of systemic inflammation is related to breathing dysfunction. For example, OSA may activate the sympathetic/adrenomedullary and the hypothalamic-pituitary-adrenal (HPA) axis limbs of the neurologic stress system.17 Nocturnal micro-arousals and awakenings are associated with chronic cortisol release. Over days, months and years this can influence a number of inflammatory related problems including insulin resistance and diabetes; dysregulation of the hunger hormones, leptin and ghrelin, leading to weight gain and obesity, and OSA directly affects the vascular endothelium by promoting inflammation and oxidative stress while decreasing NO availability and repair capacity.18 The demands of clinical practice are ever-increasing. Dentists must be aware of more health concerns every day. Patients are asking about airway because they read about health effects of sleep related breathing disorders and look to their trusted dentist for

Properly functioning nasal breathing, tongue posture, and swallowing patterns greatly influence a properly formed dental occlusion. On the contrary, dysfunctional mouth breathing, tongue posture, and swallowing patterns greatly influence an improperly formed dental malocclusion.

direction. You can be ready to help them by using the provided Checklist to identify airway and breathing related disorders in your dental practice.

1.

ADA Adopts Policy on Dentistry’s Role in Treating Obstructive Sleep Apnea, Similar Disorders. ada.org October 23, 2017 News Releases

2.

The Oxygen Advantage. Patrick McKeown 2015, William Morrow/Harper Collins Publisher

3.

Implications of mouth breathing on the pulmonary function and respiratory muscles. Vern, H Antunes, A Milanesi J et.al Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

4.

A frequent phenotype for pediatric sleep apnea: short lingual frenulum. Guilleminault C, Huseni S, Lo L ERJ Open Research 2016 2: 00043-2016

5.

Which Oropharyngeal Factors Are Significant Risk Factors for Obstructive Sleep Apnea? An Age-Matched Study and Dentist Perspectives Nat Sci Sleep. 2016; 8: 215–219

6.

Mallampati Score, Wikipedia

7.

Importance of Mallampati score as an independent predictor of obstructive sleep apnea. Kanwar M, Jha R European Respiratory Journal 2012 40: P3183;

8.

The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Weiss TM, Atanasov S, Calhoun KH Otolaryngol Head Neck Surg. 2005 Dec;133(6):966-71.

9.

Ankyloglossia and its management. Chaubal T, Dixit M J Indian Soc Periodontol. 2011 Jul-Sep; 15(3): 270–272.

10. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Kotlow LA. Quintessence Intl. 1999;30:259–62. 11. Impact of Mandibular Distraction Osteogenesis on the Oropharyngeal Airway in Adult Patients with Obstructive Sleep Apnea Secondary to Retroglossal Airway Obstruction. Ramanathan Manikandhan, Ganugapanta Lakshminarayana, Pendem Sneha, Parameshwaran Ananthnarayanan, Jayakumar Naveen, and Hermann F. Sailer. J Maxillofac Oral Surg. 2014 Jun; 13(2): 92–98. 12. Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. William Arnett, DDS, FACD, Jeffrey S. Jelic, DMD, MD, Jone Kim, DDS, MS, David R. Cummings, DDS, Anne Beress, DMD, MS, C. MacDonald Worley, Jr, DMD, MD, BS, Bill Chung, DDS, Robert Bergman, DDS, MSh. American Journal of Orthodontics and Dentofacial Orthopedics Volume 116, Number 3 September 1999 13. Oxygen saturation(medicine) Wikipedia 14. Examination of pulse oximetry tracings to detect obstructive sleep apnea in patients with advanced chronic obstructive pulmonary disease. Adrienne S Scott, Marcel A Baltzan, and Norman Wolkove Can Respir J. 2014 May-Jun; 21(3): 171–175 15. Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis Mohamed El Shayeb, MD MSc, Leigh-Ann Topfer, MLS, Tania Stafinski, PhD, Lawrence Pawluk, MD, Devidas Menon, PhD. CMAJ. 2014 Jan 7; 186(1) 16. “Buzzed on inflammation.” Brent Bauer MD, Mayo Clinic Health Letter. N.p., n.d. Web. 16 Sept. 2014. http://health letter.mayoclinic.com/editorial/editorial.cfm/i/163/t/Buzzedon inflammation 17. Buckley TM, Schatzberg AF. On the interactions of the hypothalamic-pituitary-adrenal (HPA) axis and sleep: normal HPA axis activity and circadian rhythm, exemplary sleep disorders. J Clin Endocrinol Metab. 2005;90:3106–3114. 18. Inflammation, Oxidative Stress, and Repair Capacity of the Vascular Endothelium in Obstructive Sleep Apnea. Sanja Jelic, MD, Margherita Padeletti, MD, Steven M. Kawut, MD, MS, Christopher Higgins, MD, Stephen M. Canfield, MD, Duygu Onat, PhD, Paolo C. Colombo, MD, Robert C. Basner, MD, Phillip Factor, DO, and Thierry H. LeJemtel, MD. Circulation. 2008 Apr 29; 117(17): 2270–2278.

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A Checklist for Evaluation of Potential Airway & Breathing Disorders by DeWitt C. Wilkerson, DMD 1. Mouthbreathing is considered dysfunctional breathing because ____________. a. It interferes with swallowing b. It could lead to inflammation in the throat c. Passing air over the tonsils produces excess nitric oxide d. Lip dryness results in increased chance of infection 2. Using a checklist in your office for assessing airway ____________. a. Enables your office to implement the ADA Policy Statement on Sleep Related Breathing Disorders b. Provides you an opportunity to evaluate one of the key parameters of health c. Distinguishes your office from those who only provide typical dental services d. All of the above 3. During sleep apnea events ____________. a. Cortisol is released into the bloodstream b. Breathing can stop for 5 seconds or longer c. Leptin increases the heart rate d. The body is more likely to develop central sleep apnea 4. Central Sleep Apnea ____________. a. Is triggered by many of the same problems that create obstructive sleep apnea

26 DSP | Summer 2018

b. Is less common at higher altitudes due to relatively larger percentage of CO2 in the air c. Primarily is a central nervous system disorder d. Is more readily observed by bed partners due to lack of breathing effort 5. Sleep Quality may be assessed by questioning ____________. a. Whether the patient moves frequently during sleep b. If dreams can be recalled c. How many hours the patient is able to stay asleep d. How often they have to use the bathroom during the night 6. Nasal Breathing ____________. a. Nasal patency is best left to the otolaryngologists to address b. Is part of any airway assessment by a trained provider c. Contributes to sleep apnea because it requires more work than mouth breathing d. Can be improved by using EPAP devices 7. Dentists should evaluate their patient’s neck posture ____________. a. So they can properly adjust the dental chair for comfortable procedures b. Because it influences how far forward the jaw can go with an oral appliance

c. It is a major clue for airway behavior during sleep d. Because chronic hyperactivity of neck muscles can influence TMD 8. Scalloped Tongue ____________. a. Is pathognomonic for bruxism b. Means there is insufficient room for the tongue within the dental arches c. Is positively correlated with a crowded oropharynx d. Could be any or all of these 9. Arnett’s True Vertical ____________. a. Requires a cephalometric tracing to evaluate b. Is a measurement of the quality of prior orthodontic therapy c. Is a useful tool to assess how skeletal development relates to airway volume d. Is used to avoid path of insertion problems when incisors are flared facially 10. Respiratory Event Index ____________. a. Is used in sleep labs to correlate obstructive and central apnea with brain responses b. Is more accurate than Apnea Hypopnea Index in assessing airway problems c. Is made up of snoring sounds plus body movements divided by test time d. Is a new term from American Academy of Sleep Medicine for use with HST


PRACTICEmanagement

Is Medicare Billing for Oral Appliances Worth the Time and Effort? by Rose Nierman, CEO Nierman Practice Management

I

f you’ve been on the fence about increasing the presence of Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA) in your practice and billing Medicare, consider this; Medicare is the largest health insurer in the US. By 2020, 64 million individuals will have Medicare. Medicare reimburses for OAT when the facility has a Durable Medical Equipment (DME) supplier license. Not only does being a Medicare DME supplier help patients who suffer from this potentially life-threatening condition, but Medicare billing increases your OSA patient pool significantly. A recent Nierman Practice Management (NPM) client survey revealed that well over 70 percent of NPM Dental Sleep Medicine (DSM) practices are properly enrolled to bill Medicare for oral appliances for OSA. In fact, our most successful dental sleep practices are enrolled to do so. Why bill Medicare? Isn’t government coverage evil? One of the reasons for the success of the practices I mentioned stems from the relationships these practices cultivate with physicians. Billing Medicare, even as a nonparticipating DME supplier (which we’ll discuss shortly), gives physicians the peace of mind to refer all oral appliance patient candidates to you, regardless of insurance type. A great way to earn the respect of your physician colleagues is to bill Medicare. A common

Rose Nierman, RDH, is the Founder and CEO of Nierman Practice Management, an educational and software company (DentalWriter™ and CrossCode™ Software) for Medical Billing for Dentists, TMD and Dental Sleep Medicine advanced treatment, and co-founder of the SCOPE Institute, a non-profit educational organization dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry. Rose and her team of clinical and medical billing experts can be reached at Rose@Dentalwriter.com, at 1-800-879-6468 or at www.NiermanPM.com.

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misconception we hear is that practices believe they must accept a Medicare allowed amount as payment in full and not balance bill the patient anything, ever. This isn’t true! Of course, there are situations in which those rules apply, however, most of the dental practices that I’m referencing have made Medicare work in their practice by enrolling as a nonparticipating Medicare DME supplier.

What’s the big difference between participating and nonparticipating? Being a participating supplier means “accepting assignment” on all cases or in other words – accepting Medicare’s allowable fee for OAT as payment in full, and not balance billing the patient for any amounts beyond your fee and their allowable fee. A nonparticipating DME supplier can elect to accept assignment or not on a case-by-case basis. The system pays 80 percent of the allowable fee (after a small deductible). If the patient has a supplement or secondary, that policy picks up the other 20 percent of the allowable fee. Another big difference to be aware of is when a nonparticipating DME supplier chooses to not accept assignment, the reimbursement check gets sent to the patient instead of direct-deposited into your bank account. Nierman Practice Management clientele typically sign up as nonparticipating DME suppliers and collect as a fee-for-service office with the reimbursement going to patients. Medicare’s reimbursement fee varies by location. Fees for your location can be verified by emailing contactus@ dentalwriter.com.


PRACTICEmanagement Is Medicare difficult to bill?

You may be surprised to learn that many NPM clients report that Medicare, while the application process may be a bit lengthy, is actually their favorite medical insurer to bill! One thing many practices we work with tend to particularly enjoy about billing Medicare is that a preauthorization is not necessary for oral appliances. When the patient meets criteria for coverage, there’s no need to wait around for permission to proceed! Another little-known fact about billing Medicare DME is that if you enter the supplemental insurance policy information on the primary claim, Medicare DME automatically forwards the secondary claim for you, so you file one claim and sit back. Also, you don’t have to send a packet of information with your claim as supporting documentation. Yes, that’s right! If you code properly, Medicare will release the payment, with the option to review later, so make sure your

“ducks are in a row” with the right documentation on file.

Where do we go from here?

There are various steps to successfully enrolling as a Medicare DME supplier. The application can be confusing, so it’s helpful to have expert help not only to apply, but also to ensure that you follow Medicare’s DME guidelines. Whether you are thinking of becoming a Medicare DME supplier or are currently a supplier, Medicare patients don’t have to be a loss leader. With lower cost Medicare approved appliance designs available, streamlined clinical handling, claim processes and balance billing, making it work for Medicare beneficiaries is common among NPM clients and can help more patients receive treatment. If you have questions or need assistance, please contact us at 800-879-6468 to speak to one of our DME Oral Appliance Billing experts.

Did you know? In 2016, over $54 million was submitted to Medicare for sleep apnea appliances.

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LASERfocus

Functional Frenectomy (Osteopathically Guided) by Michael Geis, DO; Leonard Kundel, DMD; and Peter Vitruk, PhD Introduction

In order to rebuild the necessary orofacial function in adult patients, a Tongue-Tie Functional Release1 includes the mandatory pre- and post- frenectomy myofunctional therapy and the CO2 laser frenectomy, preferably under topical anesthesia and in combination with the Tongue Movement Assessment for ideal release to achieve optimal function. This article introduces a more advanced functional approach to the release of oral restrictions: the Osteopathically Guided Functional Frenectomy performed under the real-time palpatory guidance of an osteopath trained in assessing the soft tissues and myofascial strains. Pre- and post-surgical osteopathic assessment and myofunctional therapy exercises are critical parts of such Functional Frenectomy (Osteopathically Guided) as they help to better identify the restrictions as well as to re-pattern tongue function once the restriction is released and ensure long-lasting functional results.

Tongue and Lip Oral Restrictions

The lingual frenum2-4 is the median convergence point of two lateral lingual swellings in embryologic development; and it is visualized as a small midline fold of mucus membrane connecting the floor of the mouth to the undersurface of the tongue. Histologic studies have shown high concentrations of type I collagen in all types of lingual frenum.1-5 Type I collagen is also found in ligaments and connective tissues required to withstand high traction resistance. A restrictive lingual frenum (referred to as ankyloglossia or tongue-tie), is a common congenital abnormality where the lingual frenum is overly short and tight (posterior ankyloglossia) or aberrantly attached anteriorly to the ventral surface of the tongue (anterior ankyloglossia). The morphology of the lingual frenums helps to justify the release of the sustained tension, within restrictive frenums, in ones attempt to restore normal tongue function. Through intra-procedural observation, predictable patterns of oral tissue restriction and the surrounding anatomy are being identified. It has been consistently observed that the mandibular labial frenums have a superficial anterior fascial connection through the platysma and infrahyoid muscles into the clavicles and anterior chest wall; that the maxillary labial frenums have a more posterior fascial connection most significantly observed in the condyles of the

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occiput, the suboccipital region, and surrounding the temporal bones; and that the lingual frenums have a deeper, more central fascial connection extending down the deep cervical myofascial system and beyond the cervicothoracic junction. Constant, repetitive, and incorrect use of tongue and lips leads to deformation and damage to orofacial structures that needs to be corrected. Oral restrictions may affect the maxilla, the palate, the mandible, and, beyond the oral cavity, the occiput and the anterior cervical fascia that go in through the chest. A combination of oral frena may create a fascial restriction that extends all the way down into the thoracic spine and sometimes lower. Oral soft tissue contains numerous little fibers, not immediately obvious, restric-

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Figure 1. 1A: Hillary, the 41 y.o. female patient, had suffered from chronic neck and upper back tension and pain for over a decade. She had been diagnosed with cervical disc degeneration, and right sided brachio-plexopathy. She had many failed attempts at alleviating her pain, including prescription medication, physical therapy, acupuncture, yoga, chiropractic manipulation and osteopathic manipulation. All of these treatments were effective in providing some relief, but unfortunately with short duration, usually lasting less than a week. On her initial evaluation with Dr. Geis the tongue and lip ties were identified. The presence of these ties, in combination with the chronic nature of her pain, multiple failed treatments, and multiple findings on physical exam led to the decision to release the tethered oral tissues. 1B-1D: Intraoperative views of the lower lip tie release with the SuperPulse CO2 laser. The sequence of photos shows the tension in the fascia released as the lower labial frenum was removed. This release led to the platysma (superficial muscle in the front of the neck, extending from the upper part of the shoulder to the corner of the mouth) to let go. This allowed for a broad superficial release. 1E: Immediately postoperative view. No sutures were placed. Note lack of bleeding and clean margins of the surgical wound. 1F: Two weeks postoperatively. Note excellent healing.


LASERfocus tive impact of which may be very significant. And in the authors’ experience, after having these small restrictive fibers released, patients had noticeable results, where their shoulders relaxed and lowered, their head posture changed, their breathing improved, and so on.

Functional Frenectomy (Osteopathically Guided)

Treatments for ankyloglossia and labial frenal restrictions include frenectomy; most up-to-date techniques involve lasers.4-6 With CO2 laser frenectomy, patients report less post-operative pain and discomfort than with the scalpel.5 CO2 laser ablates tissue while coagulating small blood and lymphatic vasculature; this creates clear surgical site and helps preventing post-surgical edema. The presence of an aberrant frenum is often obvious on the initial examination and it is clear what tissue to ablate in order to remove the restriction. But sometimes restrictions are not always immediately noticeable. And to truly benefit the patient and specifically target areas that are interconnected to oral restrictions, frenectomy procedures are performed under the palpatory guidance of an osteopath who is trained in assessing the soft tissues and myofascial strains. The laser clinician uses a probe inside the patient’s mouth to find “tight places” or tension bands, while the osteopath provides constant feedback pointing out whether the spot that appears tight is, indeed, restrictive in the way it is connected to other structures. This approach makes the procedure most effective allowing the laser clinician remove only the true restrictions that need to be released. The authors’ technique for the osteopathically guided Functional Frenectomy involves of the following phases: 1. Pre-surgical osteopathic structural assessment and manipulative treatment, and myofunctional therapy exercises to prepare and re-pattern tongue function once the restriction is released; 2. CO2 laser frenectomy, preferably under topical anesthesia and combined with real-time lingual and labial restriction assessment by palpatory guidance of an osteopath to achieve ideal release for the optimal function; 3. Post-procedure osteopathic structural assessment and manipulative treatment, and myofunctional therapy exercise program to ensure long-lasting functional results.

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Figure 2. 2A: Pre-op aspect of the maxillary labial frenum. 2B: SuperPulse CO2 laser release in progress. Note complete lack of bleeding. 2C: Immediately after the laser release. Wound was left to heal by secondary intention. 2D: Healing two weeks following the laser frenectomy. Note lack of inflammation or swelling.

The osteopathically guided Functional Frenectomy (for both labial and lingual restrictions) is illustrated by the clinical case shown in Figures 1-3. Note both the immediately improved mobility and lift of the tongue. The well controlled hemorrhage, sealed lymphatics and reduced zone of thermal impact result in less edema and discomfort to the patient. Magnification during the frenectomy is strongly encouraged due to the close proximity of large blood vessels to the surgical site. The authors prefer using topical anesthesia to increase the reliability of the functional assessment during the release. However, the patient in this case felt the laser at times and small amounts of local anesthetic were administered to the upper and lower frenectomy sites. In order to achieve the proper myofascial release in adult patients, it is not sufficient to just remove the aberrant frena. Under the osteopathic guidance, the clinician should often re-access the effect of the restriction release on other myofascial structures. The clinician must take into account the jaw range of motion, the floor of the mouth flexibility, along with the tongue’s ability to elevate,

Dr. Michael Geis is a traditional Osteopathic Physician specializing in Neuromuscular Medicine (NMM) and Osteopathic Manipulative Medicine (OMM). He graduated from New York College of Osteopathic Medicine in 2011 as a member of the Psi Sigma Alpha National Osteopathic Honor Society, was awarded a one year academic teaching fellowship and was the recipient of the Stanley Schiowitz Award for Excellence in Osteopathic Medicine. Dr. Geis completed his residency training in NMM/OMM at St. Barnabas Hospital in the Bronx, NY as the Chief Resident in 2014. Dr. Geis has treated thousands of patients with OMM including: evaluation and treatment for newborns to the elderly, pre- and post-surgical patients and in-patients care at a level one-trauma center. Leonard Kundel, DMD is a 1999 graduate of Tufts Dental School. He is a member of American Academy of Craniofacial Pain, International Academy of Oral medicine and Toxicology, American Academy of Physiological medicine and Dentistry, and Academy of Sleep Disorder Disciplines. Dr. Kundel’s practice has always been focused on treating his patients as a complete system. He collaborates with medical professionals from various disciplines to bring about the best result possible. Peter Vitruk, PhD, MInstP, CPhys, DABLS is a founder of the American Laser Study Club www.americanlaserstudyclub.org, and LightScalpel, LLC www.lightscalpel.com. He is a Member of the Institute of Physics, UK and is Diplomate of and Director of Laser Physics and Safety Education at the American Board of Laser Surgery, USA. Dr Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com.

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LASERfocus protrude, and achieve lateral functions. The clinician should proceed slowly and cautiously. It is important to remember that full range of motion is not always possible due to other limitations, i.e., clinician needs to know when to stop to achieve the maximum benefit. Frenum that restricts proper lingual or labial motion feels tight to finger pressing in. Unrestricted tongue and lips feel soft. To feel for restrictions, one can grasp the tip of tongue or lip with gauze and gently pull the tongue upwards and the lip outwards. Finger pressure of the other hand could help reveal accessory restrictions as push back would be felt. In this case study, the clinician used the tongue director as a probe to apply pressure to the points that appeared restrictive, and removed those fibers, or not, depending on the real-time osteopathic feedback from Dr. Geis. The patient normally returns to the dental office for healing assessment at varying intervals. The team then reviews and re-evaluates the benefits achieved. This is necessary for evaluation of the performance of the tongue and lips, the tone and function changes of the lingual muscles and the suppleness of the healing tissue at the surgical sites.

Figure 3. 3A: Pre-operative aspect of restrictive frenum. Patient showed lack of mandibular stability/ hyperlax ligaments. 3B-3D: Intra-op view of the laser lingual frenectomy. The LightScalpel SuperPulse CO2 laser handpiece was maintained 1-3 mm away from the tissue and moved at a hand speed of a few millimeters per second. For a rapid switch from cutting to photo-coagulation, the clinician defocused the laser beam by simply moving the hand piece away from the tissue (by approximately 5-10 mm), and “painting” (sweeping/scanning/“painting” motion) the bleeder for enhanced hemostasis. 3E: Immediately following the tongue-tie release with the SuperPulse CO2 laser. No sutures were placed. Note the immediate improvement in tongue mobility: tongue is able to elevate all the way to the top without the patient’s mandible moving at all. 3F: Two weeks postoperatively. Note lack of inflammation or swelling. At the follow-up exam the patient reported that the knot in the back of her neck was gone and she had not had any back pain or tightness. She was thrilled with the result of the release of her oral restrictions and shared her experience in this video https://bit.ly/2q4QYFY.

Why CO2 laser?

Summary

Not all lasers are equally good at vaporizing (i.e., ablating or cutting) and coagulating soft tissue. Figure 4 demonstrates the difference in the absorption spectra for the main soft tissue chromophores.7-9 The CO2 lasers offer the following benefits for oral soft tissue surgery: • Approximately 1,000 times greater photo-thermal cutting efficiency relative to dental diodes, and in approximately 10 times greater photo-thermal coagulating efficiency relative to erbium lasers; • Close match between the coagulation depth of CO2 laser and the blood capillary diameters (Figure 4).6,8,10 This close match distinguishes CO2 from erbium lasers and provides instant hemostasis during high speed ablation or cutting. It provides improved visibility of the surgical field and therefore enables more precise and accurate tissue removal; • Minimal post-operative edema, pain and discomfort; due to the intraoperative closure of lymphatic vessels on the margins of the CO2 laser incision;11,12

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A.

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The osteopathically guided labial and lingual functional frenectomy is performed with real-time palpatory feedback of a traditionally trained osteopathic physician, who helps the laser clinician to determine whether the seemingly apparent “ties” are truly restrictive in the way they are connected to other anatomical structures. The use of CO2 laser for frenectomy enables the clinician to utilize only topical anesthetic most of the time. Pre- and post-surgical osteopathic assessment and manipulative treatment, and myofunctional exercises are integral elements of such Functional Frenectomy (Osteopathically Guided) as they help achieve long-lasting functional results. Acknowledgments: The authors greatly appreciate the help and contribution from Anna (Anya) Glazkova, PhD, in preparing this material for publication. 1. 2. 3.

Fabbie P, Kundel L, Vitruk P. Tongue-Tie Functional Release. Dent Sleep Practice. Winter 2016: 40-45. Queiroz Marchesan I. Lingual frenulum: classification and speech interference. Int J Orofacial Myology. 2004;30:31-8. Defabianis P. Ankyloglossia and its influence on maxillary and mandibular development. (A seven year follow-up case report). Funct Orthod. 2000;17(4):25-33. 4. Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. Early lingual frenectomy assisted by CO2 laser helps prevention and treatment of functional alterations caused by ankyloglossia. Int J Orofacial Myology. 2004;30:64-71. 5. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol. 2006;77(11):1815-9. 6. Namour S. Atlas of Current Oral Laser Surgery. Boca Raton, FL: Universal Publishers; 2011. 7. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58:37-61. 8. Vitruk P. Oral Soft Tissue Laser Ablative & Coagulative Efficiencies Spectra. Implant Practice US. 2014;7(6):22-27. 9. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644. 10. Wilder-Smith P, Arrastia AM, Liaw LH, Berns M. Incision properties and thermal effects of three CO2 lasers in soft tissue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(6):685-91. 11. Kaplan M, Vitruk P. Soft tissue 10.6 micrometers CO2 laser orthodontic procedures. Orthodontic Practice US. 2015;6(6):53-57. 12. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004;48(4): 861-888.


PRODUCTstudy

Adopting New Technology to Grow Your Practice by Dr. Ryan O’Neill

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magine this: An asymptomatic patient is in your dental office for a routine checkup. No complaints. No concerns. All your routine diagnostic imaging and tests show no signs of pathology, degenerative disease, infection or chronic disease. Now imagine that same patient in your chair with cone beam computed tomography (CBCT) imaging at your fingertips. A once routine checkup now shifts to an in-depth 3D diagnostic appointment where your CBCT drives the conversation. Let’s face it. You cannot diagnose what you cannot see. And our Dentsply Sirona CBCT shows everything we need to know to treat our patients and deliver predictable treatment outcomes. But…what about the risks involved in CBCT imaging? Are the risks worth the reward? Remote radiology reports allow clinicians of all types to be able to acquire large amounts of data without assuming large amounts of risks of interpreting that data. Companies such as Dental Radiology Diagnostics (DRDx) allow for thorough analysis of the CBCT data. More complete diagnosis will result in more referrals and a greater need to collaborative care between physicians and dentists. Most dentists are not accustomed to regularly referring to ENTS, Neurologists and Pulmonologists but implementing CBCT technology into a dental office with a thorough diagnostic radiology team driving the process is a recipe for success and broadening your collaborative network.

Combining CBCT and Intraoral Scan

OPTISLEEP oral appliance

Dr. Ryan O’Neill is a general dentist in Nashville, TN and owner of Sleep Nashville, a dental practice devoted entirely to treating sleep-disordered breathing through oral appliance therapy. Dr. O’Neill lectures nationally on sleep apnea, 3D imaging, medical billing and is a key opinion leader for the OPTISLEEP oral appliance. Dr. O’Neill has a passion for training and equipping general dentists on how to treat sleep apnea in their own dental practice through the True North Continuing Education’s courses 3D Sleep & True Sleep. Dr. O’Neill personally wears an oral appliance at night that in his words “changed my life”.

Colors show difference in airway volume before/after treatment

One of the ways that our dental sleep medicine office, Sleep Nashville, accomplishes this is through the airway analysis feature of SICAT Air. This software can analyze before and after volume changes in our patients’ airways with different jaw positions. This really helps our patients understand how mandibular advancements devices, such as OPTISLEEP, can be effective at improving airflow. Our office does not use the scan to diagnose OSA, which is consistent with American Academy of Dental Sleep Medicine guidelines stating that only a board-certified sleep physician can diagnose sleep apnea, but it is a great conversation starter with patients. The airway analysis really allows us to educate our patients on the need for a sleep study which furthers our collaborative efforts with local pulmonologists. The cost of CBCT systems can be seen as a common barrier to entry into advanced imaging and can exceed $100,000. How do we justify such a large investment? The answer depends on the clinician, but for me in my dental practice, I analyzed the various services I was either already incorporating in my office or wanted to incorporate in my office. In other words, I wanted to do what I was doing better and start offering more solutions for my patients. Purchasing my CBCT in 2014 allowed me to add services to my office that without 3D imaging I was nervous to begin doing such as guided implant surgery, third molar extractions, and sinus augmentations. My Dentsply Sirona CBCT allows me to screen and educate my patients in a way that I was unable to before. Financially, it’s worked out well – the increased production generated by the conversations I start from my CBCT images justifies the monthly expense. Think about that patient in your chair again. Maybe there’s more to them than meets the eye. DentalSleepPractice.com

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PRACTICEmanagement

Recover, Repair, and Heal from Super Stress ® with BrainTap by Sandra Marlowe

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ighttime sleeplessness may be a result of our minds and our bodies combined response to stress. A study in International Journal of Psychophysiology pointed out Chinese researchers’ discovery that our bodies are primed to stay awake when we perceive threats, and nighttime stress may amplify this response. Our bodies are responding to stress much like our ancestors did when they faced nighttime threats from predators — our brain thinks we’re in danger and keeps us on high alert, diminishing the possibility of a good night’s sleep. Most people experience “super stress,” in their everyday lives, so the brain has to cope by generating high-intensity brain waves, which overpower calming brain waves, especially at night. Once your brain becomes used to this hyper alert state, it can become very difficult to wind down again. Super stress often manifests in disorders such as ADHD, obesity, diabetes, insomnia, headaches, and high blood pressure, to name but a few.

To obtain a state of homeostasis (balance) for recovery, repair, and healing to take place, try the following five simple steps to optimal health. 1. Breathe deeply. 2. Focus on the moment. 3. Reframe the situation. 4. Keep your problems in perspective. 5. Practice mindful meditation and visualization.

To obtain a state of homeostasis (balance) for recovery, repair, and healing to take place, try the following five simple steps to optimal health.

Tip No. 1: Breathe deeply Deep breathing sends a message to your brain to calm the body. Detrimental stress responses — such as increased heart rate, increased hormone production, and high blood pressure — all decrease as you breathe deeply to relax. Just a few minutes of deep breathing can calm you and put the body back into recovery mode. For this reason, every audio session in our BrainTap® Library includes deep, relaxing, guided breathing designed to bring your body to ultimate relaxation.

Tip No. 2: Focus on the moment When you are stressed and anxious, you may be worried about the future or regretting a past action. This can cause immense amounts of stress from which our bodies need recovery time. One way to lessen this type of stress is to bring yourself back to the moment. If you’re walking, feel the sensation of your legs moving your body. If you’re eating, focus on the taste, the smell, the sensation of the food you’re consuming. If you’re relaxing, be

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PRACTICEmanagement

BrainTap’s sessions for optimal health For Breathing deeply – Recommended BrainTap session: SR01 – Create Your Enchanted Forest for Stress Reduction For Focusing on the moment – Recommended BrainTap session: SR04 – Putting Future Events into Perspective For Reframing the Situation – Recommended BrainTap session: SR05 – Reducing Uncertainty and Doubt For Keeping Your Problems in Perspective – Recommended BrainTap session: SR 06 – Eliminate Negative Thinking For Practicing Mindful Meditation and Visualization – Recommended BrainTap session: SR 10 – Developing Spontaneous Relaxation

mindful of the heaviness of your limbs and the deep, rhythmic sound of your breathing. Rather than seeing only the negatives, focusing on the moment offers you a space to think differently about stress and respond in a more appropriate manner without past regrets or future worries.

Tip No. 3: Reframe the situation When you are stressed or overwhelmed, focus on a positive thought. (This is called “reframing” the situation.) It’s not as hard as you think. Look at the same situation in a new way that highlights the possibilities. Viewing our stressors as opportunities can help us stop feeling trapped and reduce the physical effects of stress on our bodies almost immediately. Ways to reframe the situation 1. Look at what is actually stressing you. 2. Consider what you can change, if anything, about the situation. 3. Look for the positives. 4. Find the humor.

Tip No. 4: Keep your problems in perspective Don’t stress too much on a specific problem. It’s important to remind ourselves of the positives in our lives — we woke up this morning; we can see; we can walk; we have family and friends to support us. It might seem a little silly at first, but the next time you’re feeling stressed, consciously make the effort to think about the things you’re grateful for. This can be a surprisingly easy way to reduce the stress in your life.

Tip No. 5: Practice mindful meditation and visualization By practicing mindful meditation and visualization, you can achieve a physical

state of deep rest that changes the physical and emotional responses to stress. Once you enter this “relaxation response,” the brain sends out neurochemicals that neutralize the effects of stress on the body, allowing you to change your reactions to the stressful events going on around you. The sessions offered in the BrainTap Library are designed to help you reach the relaxation response. In 20 relaxing minutes a day, you can reduce or eliminate brain fog and negative mind chatter, have more energy, relax and develop positive sleep habits, rid yourself of unwanted habits and behaviors, gain memory and focus, and improve the quality of your life. Fortunately, your BrainTap headset produces the relaxation response, which can help your brain relax and feel safe — giving your body precisely what it needs to get back in balance and reverse the effects of stress on the body. The BrainTap headset will help dental patients before, during, and after dental procedures as well. Regular use of BrainTap Technology will help rebalance your brain wave activity, allowing your brain to relax, rejuvenate and reboot itself — helping you to sleep more deeply and awaken refreshed. So, the next time you’re wide awake and feeling the stress, take comfort in knowing that your brain is doing exactly what evolution taught it to do, but you can take back control and ease into a great night’s sleep by using the BrainTap headset.

Sandra Marlowe has authored, co-written, or ghostwritten eight selfimprovement books, including an award-winning bestseller. She has earned a Pushcart Prize nomination in literature. She regularly writes and speaks on topics related to brain health and self-development.

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TEAM-BASEDcare

Sleep Medicine: A Team Sport The effectiveness of the team will be reflected in the effectiveness of treatment. by James D. Geyer, MD; Paul R. Carney, MD; and Monica M. Henderson, RN, RPSGT Reproduced in its entirety with permission from Practical Neurology. 2018;17(3):53-55.

N

o man is an island entire of itself; every man is a piece of the continent, a part of the main – John Donne

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Donne’s classic line applies to modern medicine, and sleep medicine is no exception. The complexity of identifying at risk patients, diagnosing sleep disorders, implementing effective therapy, and working with patients to ensure compliance requires a team of well-trained, empathetic professionals. In short, sleep medicine should be a team sport. While this is true for every facet of medicine, opportunities for team-based care in the management of patients with sleep disorders remain largely unrealized. We can and should achieve more for our patients and our profession. Building a successful team does not require the infrastructure of

a university health system or a major corporate multispecialty center. An effective sleep team can be built by anyone with vision and dedication.

The Problem

At least one-third of the population of the United States suffers from some type of chronic sleep problem including insomnia, excessive daytime sleepiness, sleep-related breathing disorders, and parasomnias. The indirect cost of these sleep disorders is estimated to exceed $40 billion yearly because of lost productivity, over $20 billion yearly related to motor vehicle crashes, and more than $10 billion yearly from work-related accidents.1 Direct medical costs related to obstructive sleep apnea (OSA) and the impact on longterm health are even more staggering.


TEAM-BASEDcare

An effective sleep team can be built by anyone with vision and dedication.

Sleep accounts for about one-third of our lives but continues to receive little meaningful attention during medical training. Most physicians are not trained on effective ​team building. The following overview is meant only to begin the conversation about how to build an effective sleep team.

primary care providers can provide vital encouragement, feedback, and monitoring to patients suffering from sleep disorders. Sleep specialists in turn may assist primary care providers by ensuring they and their referred patients have the information they need about sleep disorders.

The Players

Nurse/Nurse Educator The nurse and nurse educator are central to the managing care of patients with sleep disorders. In many cases, a message is being taken by a nurse for the sleep specialist, who can often act as a coordinator between medical specialties and durable medical equipment providers. Sleep specialists must ensure that nurses and nurse educators understand which follow-up questions are needed for a particular complaint. In smaller practices, this role may be filled by the sleep specialist alone. While advanced certification in sleep education is beneficial, excellent patient care can be achieved through a rigorous and ongoing educational program provided by the sleep specialist.

Patient Although it can be easy to forget that patients play a central role in every aspect of care, the patient’s role during the evaluation and subsequent management of identified sleep problems must remain at the fore. Therapeutic interventions are only effective in the compliant patient. Communication and education are central to achieving the desired goal. Knowledge is power. Sleep Specialists The sleep specialist must fill a number of different but important roles in any sleep team. The sleep specialist must evaluate, diagnose, and direct the educational and treatment approaches for the patient. It is important to remember that the sleep specialist need not provide each of these important services him- or herself, but must actively be involved in an advisory and supervisory role. Primary Care The primary care physician should take a central role coordinating the patient’s overall health management, acting as the medical home. Unfortunately, most of these physicians have little or no formal training on the identification and management of sleep disorders. Therefore, the sleep medicine specialist must collaborate closely with the primary care provider. These professionals can help identify patients who are at risk by simply adding a few sleep screening questions to their routine assessments. Furthermore,

James D. Geyer, MD Alabama Neurology and Sleep Medicine Tuscaloosa, AL

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Nurse Practitioner/Physician Assistant Physician extenders can dramatically improve the care of patients with sleep problems. It is extremely important to ensure that the nurse practitioner or physician’s assistant is adequately trained, has adequate supervision, and has ready access to consultation with the sleep specialist. Consultants A wide array of subspecialists plays a pivotal role in any sleep care team. Dentists, otolaryngologists, and maxillofacial surgeons can all contribute directly to the management of sleep-related breathing disorders. Cardiologists, pediatricians, gastroenterologists, allergists, pulmonologists, neurologists, psychiatrists, and psychologists can provide

Paul R. Carney, MD Department of Neurology UNC Neuroscience Center University of North Carolina at Chapel Hill Chapel Hill, NC

Monica M. Henderson, RN, RPSGT Alabama Neurology and Sleep Medicine Tuscaloosa, AL


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TEAM-BASEDcare

Even the most expert of individual team members will be undermined by poor communication. Good communication between welltrained individuals enhances care.

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extremely important input for the optimal management of various sleep disorders and their associated comorbidities. Allergy. As with many subspecialists, the allergist may identify patients with sleep-disordered breathing during initial or follow-up evaluations. The allergist also serves a vital role in the management of nasal congestion and sinus symptoms which can limit compliance with central positive airway pressure (CPAP) treatments of sleep-related breathing disorders. It is incumbent upon the sleep specialist to communicate the specific nature of the problem and the importance of the allergist’s management of the associated conditions. Anesthesiology. During any postoperative period, patients are at increased risk of complications related to sleep apnea. If a patient with a sleep disorder is scheduled for a procedure, the anesthesiologist must be made aware of the sleep disorder. During education of patients newly diagnosed with OSA, they should be advised to always notify any surgeon or anesthesiologist that they have OSA. If a patient does not bring the CPAP system for the procedure, the surgeon or anesthesiologist should contact the sleep specialist for specific directions. Furthermore, the surgeon and anesthesiologist are in an extremely advantageous position in the postoperative care unit to identify patients with a previously undiagnosed sleep-related breathing disorder. Cardiology. A large percentage of patients visiting a cardiologist are at risk for a sleep-related breathing disorder. The cardiologist should include standard sleep screening questions as a component of a standard cardiac evaluation. Conversely, the sleep specialist should screen for cardiac symptoms, which might arise primarily at sleep onset or at awakening. Polysomnography frequently identifies previously unknown cardiac arrhythmias. Dentistry. Dental sleep medicine has been increasing over the past several years as the quality and effectiveness of oral appliances has improved. A good working relationship between the dentist and the sleep specialist is of utmost importance. Close follow-up of the efficacy and tolerability of an oral appliance is vital. Gastroenterology. Patients with restless leg syndrome (RLS) should be screened for low ferritin and serum iron levels. A gastroen-

terology referral may be necessary to screen for causes of chronic blood loss through the gastrointestinal tract. In terms of identificating patients with OSA, observing the patient following endoscopic procedures can be beneficial. Hematology. Patients with RLS secondary to low serum ferritin or iron levels may require treatment with intravenous iron. In some cases, a ferritin level that is low enough to contribute to RLS may not be low enough to contribute to anemia. Therefore, a close collaboration between the sleep specialist and a hematologist is of great importance. Neurology. The patient population evaluated by a neurologist includes large numbers of patients who suffer from comorbid sleep disorders. Patients who have had stroke or have degenerative neuromuscular disorders are at high risk of sleep-related breathing disorders. Parasomnias such as REM-sleep behavior disorder are much more common in patients with Parkinson’s disease and related degenerative disorders. Neurologists should screen their patients for sleep disorders and make the appropriate referrals. The sleep specialist may need to involve a neurologist if a parasomnia suggests the presence of Parkinson’s disease or if a polysomnogram reveals evidence of a potential seizure disorder. Psychiatry/Psychology. Many sleep disorders are associated with mood disorders. OSA can contribute to the development of depressive symptoms. Insomnia is often associated with depression, anxiety, posttraumatic stress disorder, and bipolar disorder. A close collaborative relationship between the sleep specialist, psychiatrist, and psychologist can help produce an enhanced outcome for both the sleep disorder and the psychiatric condition. Pulmonology. Numerous pulmonary disorders, including chronic obstructive pulmonary disease (COPD), asthma, pulmonary fibrosis, and more, can be associated with sleep-related breathing disorders. Furthermore, management of sleep disorders can improve management of pulmonary disorders. Certain pulmonary treatments, however, can worsen insomnia and RLS. Therefore, the pulmonologist should screen for any comorbid sleep disorders, and the sleep specialist should communicate management options and treatment limitations to the pulmonologist.


Dental Sleep Practice is honored... to have been chosen to sponsor the Dental Sleep Education Track for the Greater New York Dental Meeting, Nov. 25-28, 2018

Dental Sleep Practice will sponsor two lectures each day from Sunday, November 25 through Wednesday, November 28. These eight seminars, taught by industry leaders who represent the top educators in sleep dentistry, will support dentists through practical sleep apnea education. The program will be led by DSP’s Editor in Chief Dr. Steve Carstensen. DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry. Watch for more details this Summer: Connect. Be Seen. Grow. Succeed.

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TEAM-BASEDcare Sleep Technologist The sleep technologist must fulfill numerous duties in order to ensure optimal patient care. When the study is being performed, the technologist must be able to put the patient at ease. The sleep specialist must have a good understanding not only of the technical aspects of the procedure but also of the clinical issues surrounding the individual patient. A simple order for a sleep study is not typically sufficient for optimal care. The sleep technologist should have access to the clinical history and any special recommendations or orders from the sleep physician. Furthermore, the sleep technologist is in an extremely advantageous position to observe subtle findings, obtain additional history, and provide detailed patient education regarding the disorder, the treatment options, and any potential complications which might interfere with treatment. An open line of communication and ongoing educational program between the sleep physician and a sleep technologist can enhance these roles. Administrator In addition to the typical administrative oversight duties, a collaborative relationship between the hospital or clinic administrator and the sleep specialist can help optimize care by ensuring the availability of necessary equipment, personnel, and software upgrades. This has become even more important with the recent shifts in care paradigms. Office/Laboratory Secretary The office and sleep center administrative and secretarial duties are central to the smooth operation of a comprehensive sleep program. Secretarial duties include not only scheduling patient visits, but also daily adjustments of appointments to provide flexibility and maximize efficiency. Specific patient studies often need to be matched with particular sleep technicians for specialty studies requiring special skills or expertise. The replenishment of supplies including masks and the scheduling of educational seminars regarding this equipment is of extreme importance. Durable Medical Equipment Provider The durable medical equipment (DME) provider should supply the prescribed equipment, educate the patient regarding the care for and cleaning of the equipment, and mon-

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itor the patient for compliance and potential complications. In addition, the DME provider should have an open dialogue with the sleep specialist and a sleep specialist’s staff regarding compliance and any problems or complaints voiced by the patient and be willing to work with all parties to overcome obstacles to effective treatment. Housekeeping The importance of the housekeeping staff in the operation of a sleep center should never be underestimated. A dirty or unkempt room can easily send a message that the sleep team does not really care about the patient. It is incumbent on the sleep center administration and the sleep specialist to consider the housekeeping staff as a central component of the care team and to make sure that these individuals are aware of their importance. Team Meetings Given the complex nature of sleep medicine and the interactions between numerous medical specialties and types of health care providers, regularly scheduled continuing education and team meetings are extremely important. When possible, sleep specialists, consulting physicians, nursing staff, and technologists should be included in the programs. Communication Effective communication is obviously of paramount importance. Even the most expert of individual team members will be undermined by poor communication. It is incumbent on the sleep specialist to foster a collegial program that places a high value on good communication and allows input from each member. Good communication between welltrained individuals enhances care.

Conclusion

Teamwork is vital for optimal management of patients with sleep disorders. The specific design of a team does not need to fit one particular pattern. Simply put, it just needs to be effective. No matter what the design, the key is effective communication between team members and the patient. Building a cohesive team not only improves patient care but also increases efficiency and enhances the work environment. 1. Stoller MK. Economic effects of insomnia. Clin Ther. 1994;16:873-897.

Reproduced in its entirety with permission from Practical Neurology. 2018;17(3):53-55.


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EDUCATIONspotlight

Improving Soldier Readiness: Dental Sleep Medicine in the Army by CPT Michael S. Pagano, DDS

T

he United States Army has recognized the unique issues sleep breathing disorders (SBD) bring to the battlefield. Since 2012, approximately 14,000 soldiers have been diagnosed with obstructive sleep apnea each year. In order to maintain a force ready to deploy, the Army Dental Corps has developed an initiative to train Army Dentists to treat Sleep Breathing Disorders. Lieutenant Colonel (LTC) Phillip Neal took on the challenge to develop a course with the goal of educating Army Dentists in Dental Sleep Medicine. The reasons for needing internal training revolve around the two main missions of the Army Dental Corps: Readiness and Ready for Mission.

44 DSP | Summer 2018

Readiness refers to each individual soldiers ability to deploy and “Fight Tonight.� It is a top priority of the Army and the main reason the Army Dental Corps exists. Soldiers with either untreated symptomatic mild or moderate to severe obstructive sleep apnea are considered non deployable. Soldiers treated with a Positive Airway Pressure type device are restricted to deploy only in developed areas with reliable electricity and access to additional supplies such as masks and tubing. Soldiers treated with an oral appliance can be deployed anywhere in the world. Treatment of sleep breathing disorders is one of the only medical procedures that directly correlates with improved soldier cognition and performance on the battlefield.


EDUCATIONspotlight

Figure 1: Sleeping conditions experienced by soldiers are often less than ideal.

Ready for Mission refers to the individual Army Dentists ability to deploy and maintain the oral health of soldiers with limited resources and equipment. The army trains its dentists to be proficient in every aspect of dentistry to prepare for these conditions. Army Dentists need to be aware of the different types of oral appliances used in the treatment of SBD. They need to be able to resolve any possible side effects of the treatment and be able to repair devices that have defects from use while in a deployed environment. Led by LTC Neal, the Army developed a 40-hour continuing education course to train Army Dental Providers in Dental Sleep Medicine. Prior to attending the weeklong course, each provider completed approximately 12 hours of online CE in DSM. The weeklong course included classroom and hands on learning from industry leading instructors. To date over 100 Army Dental Professionals have been trained and more courses are planned for 2018. Each Dental Officer that attended the training returned to their respective installation to establish or enhance the local Dental Sleep Medicine Program. It is estimated in 2017 Army Dentists were able to recapture over 1.7 million dollars in care and increase the medical readiness of the force. The Army plans on taking advantage of its Dental Residency Programs and become the leader in published literature in the field of Dental Sleep Medicine. The Army DSM education course focuses on a multidisciplinary approach to healthcare. The Army is in a unique position for

enhanced coordination of care between dental and medical providers. The training programs and treatment delivery systems being developed in the Army Dental Corps is a model that should be replicated to train all dentists in DSM.

CPT Michael S. Pagano graduated from the University of Iowa College of Dentistry as an Army Health Professions Scholarship Program recipient. CPT Pagano completed the Army’s Dental Sleep Medicine Short Course at Joint Base San Antonio, TX. After attending the American Academy of Dental Sleep Medicine Conference in Boston he helped teach the Army’s next Dental Sleep Medicine Short Courses at Fort Gordon, GA, Fort Hood, TX, and Fort Bliss, TX. CPT Pagano presented at the Greater New York Dental Meeting Sleep Apnea Symposium and looks to continue to be a leader in DSM education.

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EXPERT view

OSA – Dentist and Sleep Physician Working Together by Teresa E. Jacobs, MD

P

atients enter the evaluation for sleep apnea from four primary sources: subjective symptoms, complaints of a bed partner, concerns of a doctor, or the observations of a dentist. Patients put off coming in for evaluation because they are apprehensive about spending a night in the laboratory. With increasing frequency, medical insurance companies require that the first assessment for sleep apnea be a home sleep apnea test (HSAT), which often helps patients agree to start the process when advised of this by the referring doctor or dentist. It can also be reassuring to the patient to know that using a sleep aid for testing may be possible without affecting the test results. Another reason that patients delay coming in for evaluation is the fear that they may actually have sleep apnea and that the sleep physician will only recommend CPAP therapy. It is helpful for me when a patient knows that both their dentist and I would consider an oral appliance as primary treatment. It is also helpful if the dentist can encourage CPAP treatment when the clinical circumstances support that initial approach, such as in severe sleep apnea with co-existing cardiac conditions. When an oral appliance is used as primary therapy, it is important for the patient to adjust the device at home prior to having follow up testing, whether the test is at home

46 DSP | Summer 2018

or in the laboratory. The most successful laboratory device titrations happen after the patient had protruded the jaw maximally but still with nightly comfort so we can minimize the number of awakenings. Whether follow up testing is done at home or in the laboratory, technician scoring is preferred over automatic scoring because additional information can be gleaned from the raw data. Heart rate variability, which is not described in autoscored summary data, can suggest other disorders with cortical arousals, such as periodic limb movement disorder (PLMD), a motor condition related to restless legs syndrome. I have managed many patients with obstructive sleep apnea treated with an oral appliance. In some, while snoring and sleep at night improved, daytime sleepiness did not. In one recent patient, a laboratory sleep study with further titration of the appliance improved OSA control during REM sleep and identified significant periodic limb movement disorder (PLMD) causing cortical arousals. When the PLMD was treated, daytime sleepiness resolved. While follow up testing with the appliance is recommended for the vast majority of patients to document the efficacy of OSA treatment, residual symptoms are important reasons to urge follow up with the sleep physician.


EXPERT view When an oral appliance is inadequate to control OSA, what happens next depends on several factors: the severity of the residual sleep apnea, the presence of significant medical comorbidities, and patient preference. Combination treatment with ENT surgery can improve residual apnea and snoring. When sleep apnea remains moderate to severe with the oral appliance in the optimal position, especially if there are significant medical concerns, I would recommend that the patient consider using CPAP with the OAT, the combination of which may be more tolerable because treatment pressures might be lower. The Inspire nerve stimulation therapy, a new approach which uses a pacemaker relay to stimulate the tongue to contract forward with the start of each breath, may also be an option when moderate to severe apnea persists. Ultimately, the goal is for a patient to have a treatment that they can use reliably with good results. I aim to provide patients with information on all therapeutic options

and guidance to find their personal optimal treatment for OSA. I rely on my dental colleagues to help identify patients at risk, provide a treatment option with good instruction, and monitor patients for dental complications of treatment. When symptoms do not resolve with OAT, this does not mean automatically resuming CPAP, but should lead to a discussion of possible approaches, including the investigation for a secondary sleep diagnosis.

Dr. Jacobs is Board Certified in Sleep Medicine and is the Medical Director of Creekside Sleep Medicine Center. She received her medical degree from the Mount Sinai School of Medicine, CUNY. She completed her Internal Medicine Internship and Residency at Michael Reese Hospital in Chicago, IL. She completed fellowships in Pulmonary and Critical Care Medicine at the University of Massachusetts Medical Center in Worcester, MA.

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ADVANCEDtreatment

Orthodontic Treatment Strategies for Sleep Apnea in Children by Dr. Satish Pai

S

noring during sleep is fairly common among people of all ages, but you shouldn’t just assume it’s normal. Adults who snore heavily or loudly may be suffering from sleep apnea, and the same may be true for a child who snores or has noticeable breathing sounds when they’re asleep. Snoring is usually the most noticeable indicator of Obstructive Sleep Apnea (OSA), which is far from harmless. In addition to disturbing bed partners and family members, sleep apnea can have a wide range of long-term side effects on physical and mental health. These are particularly worrisome when they affect children. While OSA needs to be diagnosed by a specialist, orthodontists are well-placed to diagnose growth and development problems that increase the risk of sleep apnea. They can also help devise an effective strategy for treatment.

What Are the Signs and Symptoms of Sleep Apnea in Children?

Some common warning signs of childhood sleep apnea include: • Snoring, choking, gasping or snorting during sleep • Mouth breathing, difficulty breathing, or pauses in breathing • Grinding or clenching of teeth during sleep, which may lead to jaw joint pain or clicking/popping sounds in the jaw • Complaints of restless/poor sleep, daytime headaches, morning fatigue, drop in concentration and lack of energy during the day • Secondary signs include nightmares/ night terrors, bedwetting, trouble paying attention, behavioral issues, and learning problems

What Causes Obstructive Sleep Apnea in Children? There are many possible causes of child-

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ADVANCEDtreatment

It’s critical to screen every patient for sleep-related breathing problems no matter how young they may be.

hood sleep apnea, including: • Enlarged structures causing obstruction in the back of the throat, such as the tongue and tonsils, or in the back of the nose, such as adenoids. • Growth deformities in the upper jaw or airway, such as a narrow palate or small patent airway, can also block air flow to the lungs. • Hay fever and long-term allergies, childhood obesity and low muscle tone or weak muscles may also contribute to sleep apnea.

Effective Orthodontic Treatment Strategies for Childhood Sleep Apnea

Sleep apnea is a medical condition that requires proper diagnosis by an ENT or sleep specialist. After diagnosis, the treatment for OSA will depend on the severity as well as underlying causes of the condition. In many cases, an orthodontist can help with prevention and treatment. Here’s how orthodontic strategies can help with childhood OSA: • Orthodontists and other dental health professionals play a key role in diagnosing sleep disorders, since they tend to be in contact with their patients more frequently than other health professionals. They can ensure that every patient is screened for OSA and other breathing disorders, no matter their age. • As a result of their specialist education and experience in facial growth and development, orthodontists are also in a unique position to identify sleep-related breathing disorders in patients of any age. They are also trained to guide the growth of various facial structures in younger patients.

Dr. Satish Pai is an Ivy League trained dentist and a faculty at Columbia University, believes that a perfect smile not only makes a person look great but feel great while boosting confidence. As the founder of Putnam Orthodontics, he is dedicated to not only creating perfect smiles for his patients but also educating people with his engaging articles about all things related to a perfect smile and oral health. Spending time with his family always brings a smile on his face. In his free time, you can find him golfing, doing yoga or surfing.

50 DSP | Summer 2018

• Almost half of all patients with obstructive sleep apnea have abnormalities in the bony structure around the airway, which could be corrected with early orthodontic treatment. This could potentially prevent and in some cases reverse the underlying causes of OSA in children as well as adolescents and adults. • Early orthodontic treatment for expanding the upper jaw or upper arch, advancing the mandible and otherwise modifying the bony structure of the face could help manage the condition. This can also eliminate clenching and grinding of teeth during sleep, or other habits that are associated with childhood sleep apnea. • Mandibular advancement, maxillomandibular advancement and slow or rapid maxillary expansion (RME/SME) can be combined with orthodontics to expand the airway. These techniques help with reducing resistance in the nasal airway, normalizing tongue position, and reducing or eliminating OSA symptoms. • An orthodontist can also use oral appliance therapy (OAT) to improve breathing patterns for sleep apnea treatment in children and older patients. They may also suggest removal or tonsils/adenoids if necessary, and refer patients with serious breathing disorders or behavioral problems to a specialist physician. Orthodontists are well-versed at managing OSA with dental appliances or modifications to the facial structure. As such, they are ideally suited for working as part of multi-disciplinary team for sleep apnea treatment.

What Should An Orthodontist Do?

By asking critical questions while examining patients, orthodontists and other dental health experts can help with the diagnosis of developmental problems that may lead to sleep apnea. It’s critical to screen every patient for sleep-related breathing problems such as OSA, no matter how young they may be. Ask parents to make note of sleep, snoring and breathing patterns in children before bringing them in for a checkup. Most importantly, ensure that a specialist confirms the diagnosis before you commence any treatment.


PRODUCTspotlight

EMR vs. PM Software; Get With the Program by Jason Tierney

P

racticing dental sleep medicine (DSM) places dentists in a unique position in which they fall under the auspices of both dentistry and medicine. Most dentists that have successfully implemented DSM into their practices utilize a dedicated DSM practice management software, typically an electronic medical record (EMR). Many dentists attempt to use traditional dental practice management (PM) software to manage DSM in their practices. This decision is understandable, but, as I’ll show you, not advisable. It likely is detrimental to growth, with the benefits of EMR far outweighing the direct and indirect costs. Screwdriver vs. hammer

“Screwdrivers and hammers are both tools, yet their uses differ. Can you use a screwdriver as a hammer? Sure, but why would you if a hammer is available?”, asks Dr. Stacey Layman, co-founder of GoGo Billing and owner of two practices in the Phoenix, AZ area. “For years, I tried to manage sleep in my practice using a PM software but it was sorely lacking in many ways. Switching to a DSM software Dr. Layman was a game changer. It saved time and helped us keep track of our patients without any details falling through the cracks. Now we conduct exams, send physician letters, and file claims directly through our software.”

Valuation of the practice

Dr. Saba Khalil owned a successful restorative practice in St. Louis, MO where he treated dozens of patients with oral appliance therapy (OAT) monthly. He ultimately decided to sell his restorative practice and focus entirely on DSM. Because his DSM practice records were stored exclusively in his DS3 software, his practice valuation did not include the DSM production. Dr. Khalil was able to sell the restorative Dr. Khalil practice but move to a new location and practice DSM. He retained all patient records and there was no confusion regarding production figures or encounter note history during the sale. He said, “Had I used my restorative PM software for DSM, the sale of my practice would’ve been a nightmare. DS3 ensured that all of the records and figures were set up to allow for a clean break.”

DS3 Software - Patient Tracker Feature

Protection during audits

Dr. Richard Drake of San Antonio, TX utilizes a DSM-specific EMR to document treatment and file medical insurance claims for his OAT patients. Dr. Drake has been randomly selected for audits on three occasions by various medical payors. He referred to his EMR as a “life saver” Dr. Drake when facing these audits. “I just logged into DS3 and went back to seeing patients while the auditors reviewed my records. There was nothing to worry about. With a typical practice management software, I wouldn’t have been so confident,” Drake shared.

Conclusion

For practices that plan to implement and grow DSM, you can use your PM software, but employing a specialized DSM program is the optimum way to go. Incorporating an EMR can decrease your liability and administrative efforts while increasing your productivity and positioning you for success in the event you opt to transition into practicing only DSM in the future.

Jason Tierney is the Chief Operations Officer of Dental Sleep Solutions, LLC, and he is the Event Organizer for the North American Dental Sleep Medicine Symposium. DS3 Software - Verification of Benefits Feature

52 DSP | Summer 2018


TEAMfocus

TEAM Impact on Dental Sleep Medicine by Glennine Varga, AAS, RDA, CTA

D

ental Sleep Medicine (DSM) is a therapy that thrives with team interaction. Don’t get me wrong – I’ve seen successful offices function with only two people. All the same, Talking, Educating, Assessing and Marketing (TEAM) is the way to spring Sleep forward in your practice.

There is a great article: Sleep Medicine: A Team Sport, that was originally published in Practical Neurology and is reproduced in its entirely in this issue of DSP. The authors sum up the spirit of collaboration that is needed to maximize patient success with sleep medicine. Dentists (and their teams as an extension) are major players on that roster as Durable Medical Equipment (DME) suppliers and consultants. It’s so great to see that dentists are becoming more recognized as true provider partners within our medical community. This means it’s time for us team to step up and help facilitate our role in sleep medicine. The role of any dental team member is to help enrich a patient’s understanding of his/her oral health including airway health. This is my opinion and the opinion of the American Dental Association (ADA) as well. In the recently released statement from the ADA, all dentists should be screening for sleep breathing disorders in both children and adults. Since team is so vital in sleep medicine, let’s look at some specific techniques that will create opportunities and make an impact on patient experience. T – Talk (Ask Questions & LISTEN) E – Educate A – Assess (Document to Maximum Medical Improvement MMI) M – Market (Communicate with physicians & document success)

T – Talk

I’ve had the honor of being selected to teach for Dr. Dick Barnes of Arrowhead Dental Lab. One of many things I’ve learned from Dr. Barnes is to talk with your patients. I believe having conversations with your patients is key to presenting comprehensive dentistry, which blends perfectly with sleep breathing therapy. There are many points to TEAM, but I feel the fundamental fact of allowing your patients to contribute to their experience is key. Talking with patients means asking questions and listening to answers – and that makes all the difference. Many dental offices screen patients by handing them a clip board with an Epworth questionnaire or STOP BANG. Some patients take screening forms and draw a straight line down declining any sleep issues. I’ve seen the most effective way to get your patients engaged in conversation regarding sleep is to ask the right questions based on medical history, signs and symptoms, and risk factors. Give your patients an opportunity to communicate in their own words their feelings about their dental or airway health. The most minimal way of doing this is to change your existing medical history to ask: “Have you ever been diagnosed with Obstructive Sleep Apnea? Have you ever been told to were Continuous Positive Airway Pressure CPAP or PAP therapy? Do you snore?” If you want to take it to the next level, instead of handing your patient’s medical history on a clip board,

54 DSP | Summer 2018

sit down with them eye to eye, knee to knee and interview your patient. Once we can gather patient’s relevant information while listening with intent to repeat, we team pass along our interview findings to our doctors. If you would like to really impress your patients, report what the patient has told you in their own words to your doctors after introductions. You will see how this one tip could change the entire dynamics of your practice – I’ve seen this happen over and over.

E – Educate

Many times, educating patients is a longterm process. We want to take every opportunity we have to give our patients enough information to make educated decisions toward therapy. The best time to educate is while the patient is in the office. However, I’ve seen successful teams spend a lot of time on the phone with patients upfront to help manage their therapy journey. Educating patients on your website, Facebook page, reception monitor, treatment/consultation rooms and in your community should be being done at all times. If you offer sleep breathing therapies to your patients, bombard them with sleep breathing facts. This will get patients to ask questions and start talking about sleep. I’ve learned how important it is for patients to co-discover their deficiencies and take ownership for improvement. Educating patients on what ideal sleep breathing is and where each patient is on the spectrum is relevant to separating the decision to do something about it versus problem


TEAMfocus solving how to pay for it. Most patients are used to being told there is a problem, given a therapy option and follow all the rules necessary to have insurance “cover” it. This starts the downward spiral of “I will only do what my insurance covers.” Instead, help your patients discover for themselves the impact their sleep breathing condition is making on their chief complaint or issues they have expressed concern about.

A – Assess

I’ve heard the statement that Dental Sleep Medicine is a thinking person’s game. This is because it requires us to assess every patient about where they are on their sleep medicine journey. Sleep medicine is a team sport because it can modify many areas of life and physical functions. Evaluating patient progress, tracking management and communicating with your sleep medicine team is integral to prosperity. We team can help with this by completing patient’s subjective intake, documenting and transferring information correctly and most importantly following up on required actions. Assessing patients starts at intake, gathering risk assessment and signs/ symptoms information for non-diagnosed patients. If patients need to obtain a diagnosis, help facilitate the testing for them. When working with diagnosed patients, collecting a copy of the base line sleep test report and physician intake notes. This will start the assessment process in your practice. Many offices use their dental software system to store documents and notes. However, to be more organized there are some great dental sleep medicine systems on the market you can invest in that will keep you on track like DS3, DentalWriter or SleepConnect. I’m most excited for the latest addition in this arena ImagnSolutions which has full integration with Dentrix for those dentists that do not want to separate medical from dental ledgers. Regardless if you use a system or not it’s imperative to keep track of your patient’s progress and encourage their efforts to reach Maximum Medical Improvement (MMI). When patient success happens, be sure to Celebrate!

M – Market

A verb in this example, marketing is to advertise or promote. You can spend time marketing in the traditional sense of the word and purchase radio time or put up a billboard

to spread the word. Most offices I’ve had the honor working with attribute most new patients to internal patient and physicians referrals. Promote! Everything we team do to interact with patients gives us an opportunity to promote our services. There should be a balance of listening to patients and promoting our services when the opportunity presents but we first must learn to recognize these opportunities. When patients call in for the first time, help to ensure their decision to take action by saying things like “I’m so glad you called, in my opinion you’ve called the best!” or “Thanks for calling us, if anyone can help you with _________ (enter patient’s reason for calling- snoring, excessive daytime sleepiness, getting elbowed by bed partner) our office can!” Strengthen your patient’s decision to choose you by personalizing their experience and promoting their success during therapy. Take every advantage to communicate with your medical team. This is by far is the biggest complaint I’ve heard from physicians regarding dentists and oral appliance therapy (OAT). Physicians say they’ve worked with other dentists that do not communicate so they move on to find those that understand their need to be informed of patient therapy. This is a perfect opportunity to promote. As patients reach MMI create a spread sheet of before and after sleep vitals that can be marketed to your medical team.

When patients co-discover their deficiencies they can take ownership for improvement.

Editor’s Note: This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. Let us know your specific issues by email to: SteveC@MedMarkMedia.com, while we can’t respond to every individual. Your feedback will help us create the most useful Sleep Team Column we can! 1.

Thank you, Dr. Kevin Kwiecien!

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

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PRACTICEgrowth

“Magic Wand” Marketing by Chris Bez, opportunity engineer

T

here’s something about magic that compels attention. At some point you know there is slight of hand or trickery involved, and yet you’re drawn to watch. Repeatedly. Perhaps it’s curiosity or the unspoken challenge of catching the magician in the act that draws you in, but whatever it is, one thing is certain; the better the practitioner, the more it looks like magic and the less it appears to be simply manipulation of reality. As a career marketing professional, I have always been drawn to watching the environment surrounding brand and product promotion. Over the course of time, I have come to realize the effectiveness of marketing is There is an outcry affected by economy, politics, entertainment, trends, scientific discoveries, in fact for information virtually anything that catches the public’s so that when imagination. The result can leave the care giver who is attempting to gauge the best they make their approach to take, challenged by a moving treatment choices, target that often seems intent on confusing, much the same as well-executed magic.

they are better informed and knowledgeable about options.

Sometimes, when the environment

changes completely but does so gradually, we only sense the change in hindsight or we get lost in the process instead of recognizing the call to action. We are at such a point. For years we have looked at dental sleep medicine as a world apart – different from general dentistry and different from the medical model. Some thought marketing dental sleep medicine as a consumer directed product would be inappropriate or ineffective. We worried about alienating referral

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

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resources and generating negative feedback from those who, for years, had seen CPAP as the only viable treatment for snoring and obstructive sleep apnea – ignoring to some degree the conflict a DME supplier might have with referring a patient to us. Things have changed. The public has clearly shifted in their approach to things once reserved for “those who know better.” They are asking, actually demanding, greater transparency in everything from labelling and pricing to health care. There is an outcry for information so that when they make their treatment choices, they are better informed and knowledgeable about options. Accessing media usually reserved for consumer advertising takes a leap of faith (and for some, a learning curve), but consider the implications of well done, well placed, advertising. Public education leads to informed choices and informed choices, according to long-term compliance studies, lead to growth for dental sleep medicine practices that are positioned as educators and accessible resources. “Yes, but,” is the response most often received to this statement. The tried and true model of wooing referral resources is deeply ingrained. It strikes fear into the hearts of many when the suggestion is made to, (dare I say it?) market directly. In response to this, I submit that there are good magicians and there are those who are less skilled. When we own that providing information as a service that moves patients to be treated, often getting them to seek diagnosis instead of avoiding it for fear of the prescribed treatment, it shifts our perspective. Letting those who suffer from snoring or sleep apnea know there are alternative, viable, treatment options, does not translate to performing sleight of hand, nor is it manipulating reality. In fact, in pulling away the curtain, the conscientious care provider is actually showing them that there is less to be feared and much to be gained when addressing snoring in a manner that is acceptable to them. Good referral resources understand and respect that approach and share the desire to act on behalf of patients in a way that encourages compliance and supports overall health. It’s not magic, it’s just intentionally good patient care the true magic wand of marketing.


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PEDIATRICS

Changing the World, One Airway at a Time by Diana Batoon, DMD

M

aybe you have the next Steve Jobs, Lebron James, or Malala Yousafzai in your practice and they are 8 years old. Yet they have asthma, crooked teeth, and a bed-wetting problem. What’s a dentist to do? 20 years ago, we were focused on prep depth, line angles and shade-matching porcelain. Dentistry has changed; our duty is no longer limited to correcting teeth – it has expanded to correcting the airways of our patients. We are facing a major dilemma: If the majority of dentists do not become aware of silent epidemic of Sleep Disordered Breathing occurring in children, the future of successful entrepreneurs, phenomenal athletes, and inspiring leaders may never be fully realized. We have a tremendous opportunity to improve breathing, improve futures, and improve society.

58 DSP | Summer 2017

Sleep Disordered Breathing (SDB) in children is widespread but most parents do not see the signs. They need to learn what to look for. What is our role? Our teams can talk about it to our patients. We can provide user-friendly literature on the topic and offer easy preventive solutions. Why don’t most dentists take this critical step? Frankly, we get complacent doing what we’ve always done: Basic dentistry. Treating decay is something we are really good at diagnosing and treating. It’s time to shift our focus to the overall health of our patient population and increase awareness…starting within the walls of our own practice. I will be the first to admit that I was not great about watching my children sleep. Before I learned much about the problems, in my dental practice I hardly ever asked a parent “How does your child sleep?” Then I read medical research on how mouth breathing, snoring and hyperactivity are directly linked to lack of quality sleep. I learned that kids with breathing disorders are all around us, probably including someone you know. It might have been the now-29-yearold that went through orthodontics twice, had her tonsils and adenoids removed, and was a frequent patient at the pediatrician’s office with ear infections, strep throat or bad allergies. Remember when Johnny had a bed-wetting issue at age 9 and missed out on sleep overs or summer camp for fear of embarrassment? These are actually patients in my practice who never brought up these episodes because I didn’t know to ask. In my practice, a sleep questionnaire is now part of the new patient intake forms. Implementing a dialog with your patients is the easiest and most important first step you can take. Active growth in children provides an opportunity to correct a retrognathic mandible or to expand the maxilla. We can start by using a habit corrector and myo-functional therapy to ensure tongue placement is correct and a proper swallow develops. If need be, a RPE or Schwarz appliance may be a suitable option. Either way, we are evaluating for outward signs that may belie a restricted


PEDIATRICS airway or poor tongue habits. Crooked teeth get straighter, yes, but that’s a nice benefit, not a primary goal! Children with behavioral and physical differences often have treatment plans that focus more on their disability instead of their ability. Society slaps them with labels and compartmentalizes them in sub-categories that come with social stigmas. Their journey among all the appointments with doctors, speech therapists and other specialists are too often focused on what is “wrong” rather than what is “right”. While peers may accept their difference, carrying the burden of being different is challenging. Many parents seek a quick-fix… especially when their child is suffering physically or emotionally. It takes time to identify and treat the root cause, but it is worth it. Preventing and correcting sleep disordered breathing could save countless children from being misdiagnosed and mislabeled, especially for social challenges. Our committment to identifying and addressing the root cause may prevent much of the overmedication and lost opportunities found today in children. Parents may not know how damaging mouth breathing can be. Noticing behavioral problems such as elevated anxiety or GI upset, many families resort to changing their diets to eliminate dairy, wheat or gluten to seek relief from their symptoms. SDB due to a restricted airway or lack of nasal breathing can cause a lack of oxygen to the brain during REM sleep that leads to improper amounts of hormones released by the pituitary gland. This is especially true for children that may have short stature. When mouth breathing changes to nasal breathing, these children exhibit a growth spurt and the development of the brain is maximized. Every child should sleep soundly and breathe properly. Could it be possible that the child with ADD/ADHD actually is not? What if their symptoms were a direct result of poor diet, poor sleep and improper tongue-position? Mouth-breathing causes adverse effects on the immune system and endocrine system. I have an 9-year-old patient in my practice who suffers from allergies and asthma. When we corrected his mouth-breathing while he was sleeping and he became a nasal breather, his eczema improved drastically and his daily dependency on an anti-histamine has been eliminated. There is an increasing number of adults who suffer from sleep apnea. The question

is: Did their condition appear in adulthood or was it overlooked in childhood? As adults, their choices to managing their condition are lifetime use of a CPAP or an oral appliance, with surgery and weight loss being less often chosen. We can easily rescue people from this sad destiny. All parents must be encouraged to start observing their children’s sleep to ensure nasal breathing, even as infants. For many years now, lactaction specialists have identified that tongue-tied or lip-tied infants are unable to latch or nurse properly. Once these hindrances are solved, proper and effective nursing can ensue. In the last year, I have done more tongue-releases than I did in the previous 20 years! I have found that many of these children had difficulty nursing or were babies who were bottle-fed. In every hygiene check and every comprehensive exam, the airway is addressed. When we examine a child who predominately mouth breathes and has a tongue-tie, we discuss the benefits of frenectomy. Changing team systems is hard – but we’ve started paying attention to neck circumference because of a sleep apnea course we took. We have our sleep apnea patients do things that are unusual for a dentist to ask for; we give them devices that create small problems. In fact, sleep apnea patients may feel worse before they feel better. The main point is we are helping them to breathe better, maximize the oxygen flow to their lungs, and in turn… stay alive. For many patients, treating their apnea is life-changing. We are proud of our clinical dentistry but we don’t save lives with it. Helping a child sleep soundly, breathe better and develop into a thriving individual is undoubtedly life-changing – for them, for the parents, and for us, too. Maybe one of our young patients will grow up to change the world. Maybe one of yours will.

When mouth breathing changes to nasal breathing, these children exhibit a growth spurt and the development of the brain is maximized.

Dr. Diana Batoon, founder of the AZ Center for Breathing & Sleep Wellness in Scottsdale, AZ, combines passion and expertise to challenge the way dentistry is done. She invites her patients and her audiences to question popular misconceptions and face the intimate connection between oral health and overall health. Dr. Batoon generates momentum for change through practical action steps attained from over 20 years in the field. Dentistry is not just about teeth anymore. This truth is technology is changing the dental industry as well as patient expectations. Will your practice set the bar or be judged against it?

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LEGALledger

Sleep Medicine

MALPRACTICE Negligent Failure to Refer by Ken Berley, DDS, JD, DABDSM

I

write this article out of concern for Sleep Medicine. The treatment of Sleep Disordered Breathing is undergoing a revolution. As with any revolution, passionate patriots are taking up arms to defend their turf. On one side of this conflict we have dentists who are now screening for SDB and wishing to participate in the treatment of their patients. They have taken courses in Oral Appliance Therapy for the treatment of OSA and they have seen oral appliances change the lives of their patients. Many dentists are convinced that MAD therapy is as effective as CPAP with much better compliance and they do not understand why sleep physicians refuse to refer CPAP failures for therapy. Entrenched on the other side of this conflict we have Sleep Physicians who seem to view dentists as a threat (joke) and are not a fan of MAD therapy. Frequently these Sleep Physicians only prescribe CPAP and don’t offer mandibular advancement devices to their patients as a treatment option. Many of these sleep physicians do not even refer their patients for MAD therapy after failing CPAP. So, the fight is on! Yes! Dentists and Sleep physicians seem to be at war. Both sides are refusing to give ground and neither willing to admit that they are wrong. What a mess! How did we get to this point? Dentists and sleep physicians should be working together but many are stubbornly refusing to allow the other to participate in the treatment of their patients. Seven years ago, I started screening my patients for airway issues and began referring my patients to the sleep physicians in my area for evaluation of SDB. I sent letters to the lo-

60 DSP | Summer 2018

cal sleep physicians and referral information. I sent brochures and oral appliance models. As I referred, I impatiently waited for the physicians to begin to reciprocate. The first year of screening for SDB, I referred 82 patients to local sleep physicians and all were placed on CPAP. None of my patients were even offered oral appliance therapy. I visited the offices and called and could not get past the receptionist. I did not make an appliance until my patients started failing CPAP. This lack of reciprocal referrals resulted in a significant level of resentment on my part. I saw my patients who had an AHI of 7 placed on CPAP without being offered any alternatives. I purchased home sleep testing equipment with the intent of obtaining OSA diagnosis from remote sleep physicians. I was mad! I wrote an article for publication in Dental Sleep Practice magazine entitled “The Elephant in the Room” where I blasted sleep physicians for refusing to refer my patients back to me after diagnosis and interfering with the treatment of MY patients. Fortunately, my friend Steve Carstensen did not publish the article. Luckily, I never stooped to dispensing HST testing equipment out of my office for the diagnosis of SDB. I continued to refer my patients for a face-to-face examination with local sleep physicians. This is despite the many home testing companies that were encouraging me to go to the dark side. As my completed Oral Appliance Therapy patients began to return to the local sleep physicians for final titration PSGs, I began to receive some referrals. The referrals only happened


LEGALledger after the local sleep physicians were convinced that I could get good results with appliance therapy. Since that time, I have attempted to cultivate continued cooperation with the sleep physicians in my area, but establishing a referral network seems to be very difficult for most DSM providers. So, they go to the dark side. They utilize home sleep testing and maintain control of their patients. This action seems to be a direct response to sleep physicians refusing to allow dentists to participate in the treatment of the patients that they have referred. My personal experience accurately outlines the disconnect that exists between dentists and physicians. Dentists are accustomed to referring our patients to specialists and still controlling the treatment provided. In our referrals we dictate the therapy we deem necessary and if the specialist wishes to vary significantly from our treatment plan, a conference call is expected. Physicians don’t practice that way. When a referral is received, they provide treatment based on their experience. If the physicians have had little or no positive experiences with Dental Sleep Medicine practitioners or Oral Appliance Therapy, why should dentists expect patients to be referred for MAD therapy? On the other hand, dentists frequently look at CPAP therapy and wonder how any reasonable sleep medicine practitioner would chose that device as first-line therapy for patients with mild or moderate OSA. While the degree of patient compliance with CPAP can be debated, I think we can all agree the wearing CPAP is a struggle for many patients. The simple fact that 4 hours of usage per night is considered compliant speaks volumes. Therefore, many dentists do not understand when CPAP is always the only option presented for treatment OSA. I share my concern because the lack of reciprocal referral is placing dentist and physicians at legal risk for “Negligent Failure to Refer.” Negligent failure to refer is a malpractice cause of action that can apply when a reasonable and prudent practitioner should refer a patient to another healthcare professional but fails to do so. The law places a burden on healthcare practitioners to provide referrals when you are not qualified to provide certain therapy, or your therapy has been ineffective. In that case, if an alternative therapy exists, a patient should be informed of the alternative and a referral offered, even if the alternative therapy is not the most effective treatment. Generally, the decision to refer is controlled

by protocols and scope of practice. In court, evidence is introduced regarding the protocol governing the treatment in question. Juries frequently rely on those protocols to establish the standard of care. In Sleep Medicine, we now have sleep physicians and dentists refusing to refer to each other for seemingly selfish reasons and our patients are suffering because of our collective negligence. In Sleep Medicine, Question number 1: Are dentists who refuse to refer patients to sleep physicians we now have sleep for a face to face examination and diagnophysicians and sis guilty of Negligent Failure to Refer? Question number 2: Are Sleep Physi- dentists refusing cians who fail to offer oral appliance therato refer to each py to their patients and fail to refer patients who cannot wear CPAP all night guilty of other for seemingly Negligent Failure to Refer? selfish reasons and Let’s look at the law. The Supreme Court of South Dakota our patients are delivered an important decision on when suffering because a physician’s failure to refer a patient to another doctor constitutes malpractice. of our collective St. John v. Peterson, — N.W.2d —- (S.D. negligence. 2015), 2015 WL 3505401. The Court decided that a physician has a duty to refer her patient to another doctor when she is not competent to carry out the procedure the patient needs or when the referral is part of the customary practices and protocols followed by her peers. The availability of other, more experienced, better skilled and better performing doctors is not, however, a good reason in and of itself for imposing a referral obligation on the physician. The Court had very good reasons for making that decision. In South Dakota and everywhere else in the United States, a physician/ dentist commits malpractice when she fails to

Dr. Ken Berley is a practicing general dentist with over 30 years of private practice experience focusing on complex reconstruction and 20 years of experience as an attorney licensed to practice law in Arkansas and Texas. He has extensive experience as a litigator and was a full partner in Travis, Borland and Berley, Attorneys’ at Law before moving to Northwest Arkansas. Dr. Berley is a Diplomate of the American Sleep and Breathing Academy and a Diplomate for the ABDSM. He lectures in the area of sleep medicine risk management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years.

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LEGALledger conform with her specialty’s customary practices and protocols. However, juries will apply a reasonable practitioner standard to determine if a referral should have been made. Protocols are evidence of the standard of care, but juries will determine the reasonableness of any actions or omissions. Protocols are not necessarily binding on a jury. However, for a sleep physician to achieve informed consent for the treatment of OSA, the law would demand that the patient be informed of the alternatives for treatment. The simple fact that many OSA patients are not informed of oral appliance therapy before CPAP is initiated raises the question of adequate consent for treatment. Attorneys are always looking for a way to address social problems. In my home state of Arkansas, legislation has recently been passed criminalizing fatigued driving. This places renewed emphasis on controlling daytime sleepiness. With the legal principle of Negligent Failure to Refer and criminalization of fatigued driving, let’s look at the following hypothetical:

Case Number 1

Mr. Jones is a 62-year-old male, with a BMI of 38 and an Epworth Sleepiness Scale of 18. After a split night PSG, he was diagnosed with moderate obstructive sleep apnea syndrome and a prescription was written for CPAP. The diagnostic portion of his PSG showed him to have an AHI of 28. Mr. Jones attempted to wear CPAP for 6 months, trying different masks. He returned to his sleep physician for help after developing a sinus infection that he was unable to control. The sleep physician recommended that he see a surgeon for possible surgical correction of his apnea, but Mr. Jones stated that he was not interested in surgery and asked for other alternatives. The sleep physician recommended that he exercise and lose weight and continue to wear the CPAP as much as possible. No additional referrals or recommendations were made. Mr. Jones was not placed on recall to monitor his condition. One year later, Mr. Jones falls asleep while driving and hits a school bus killing 3 children and injuring 6 others. When Mr. Jones is sued by the parents of these children, could he then sue his sleep physician for malpractice? The good news is that lawsuit has not occurred in sleep medicine YET! But if the damages were significant enough, I can certainly see a personal injury attorney collaborating with a malpractice attorney to bring this lawsuit. In that situation,

62 DSP | Summer 2018

the legal principle of joint and several liabilities could place the entire economic burden on the physician. I believe this case would survive summary judgement and go to a jury.

Case Number 2

Mr. Jones is a 62-year-old male, with a BMI of 38 and an Epworth Sleepiness Scale of 18. He was diagnosed with moderate obstructive sleep apnea after his dentist provided a home sleep test that was read by a sleep physician working for the HST company. He did not receive a face-to- face physical examination by a sleep physician. He complains of restless sleep and his wife states that he moves his legs constantly during the night. He is diagnosed with moderate sleep apnea with an AHI of 28. He is fabricated a Mandibular Advancement Appliance. During the adjustment phase, Mr. Jones complains that his sleepiness is NOT improved. After the dentist titrates the oral appliance another HST is performed, which shows Mr. Jones AHI to be 16 with a nadir of 82. Mr. Jones told the dentist “I’m not going to wear a CPAP” so he is not referred for any additional care and he never sees a sleep physician. He is not placed on a recall to monitor his condition. His daytime sleepiness is never resolved. One year later, Mr. Jones falls asleep while driving and hits a school bus killing 3 children and injuring 6 others. When Mr. Jones is sued by the parents of these children, could he then sue his dentist for malpractice? The answer is YES! This type of lawsuit is called third party liability. With the introduction of Mandibular Advancement Devices as an alternative to CPAP, dentists are now an integral part of the team of professionals providing treatment for OSA. In the hands of a well-trained clinician, Mandibular Advancement Devices have proven to be an effective treatment for patients with Sleep Disordered Breathing. Therefore, dentists and sleep physicians must find a way to coexist for the good of our patients. Working together we are better. Dentists and sleep physicians should work together to improve patient compliance with therapy. This can take many forms but the most exciting is combination therapy where CPAP is utilized with a custom fabricated oral appliance. This potentially allows for reduced CPAP pressures and typically during the night if the CPAP is removed, the oral appliance may continue to be used.


LEGALledger Additionally, sleep physicians should understand that dentists generally expect their patients to be referred back to them for therapy when indicated. Sleep physicians should be aware that dentists are ticked off when patients they refer with an AHI of 7 are placed on CPAP, without being given the option of OAT. Sleep physicians should be aware that each dentist in your area likely has 250 OSA patients in their practice. If physicians want a steady stream of new sleep patients, develop good working relationships with dentists. As of October 2017, dentists are now required by the ADA to screen all patients for SDB. If sleep physicians want those patients to be referred to their offices, they must treat the referring dentists with respect and be willing to allow the referring dentist to make appliances on easy cases. Mutual respect and reciprocal referrals will solve many problems. Additionally, if sleep physicians would simply inform referring dentists why certain patients needed CPAP and not an oral appliance, dentists would then feel

like they were a part of the treatment decision and collaboration would be improved. By reciprocal referrals, dentists and sleep physicians can share liability with each other and reduce their potential risk by informing patients of all options for treatment. By referring appropriate patients, the possibility of a suit for negligent failure to refer is eliminated. If sleep physicians would just refer patients who are struggling with CPAP to a qualified dentist in your area, patients would benefit from that referral and relationships would be developed. If dentists would refer all screened patients who show signs of sleep disordered breathing to a sleep physician, patients would benefit. Severe OSA patients would constiently receive the best therapy. Together we are better, it is time we figure that out. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome to any litigation. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Children’s Airway Health A Practical Conference

August 24-25, 2018 | ADA Headquarters | Chicago, IL Join us this summer for a two-day educational summit that will bring together some of the greatest leaders in sleep medicine for a comprehensive learning experience you will not want to miss! Renowned speakers such as David Gozal, M.D., Valerie Crabtree, Ph.D. and Jill Ombrello, D.D.S. (and many more!) will deliver the tools to recognize compromised airway health in your pediatric patients. Be a part of this important work and earn CE credit while you do! For more information and to register, go to ADA.org/CELive.

August 24-25, 2018 ADA Headquarters 211 E. Chicago Avenue Chicago, Illinois

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WORD LIST ALLERGIES ARMY ASSESS CBCT CENTRAL SLEEP APNEA DME EDUCATE EMR FRENUM HMO HYPERACTIVITY IPA MAGIC MALLAMPATI

64 DSP | Summer 2018

MALPRACTICE MARKET MEDICARE MEDITATION MOUTHBREATHER MYOFUNCTIONAL NASAL STENOSIS NEGLIGENT NIGHTMARES ORTHODONTIC OSTEOPATH PCP PEDIATRIC PLMD

PROSOMNUS READINESS REM RPE TALK TEAMWORK TITRATION


Dentsply Sirona 3D puts you in control

Advanced technology with real workflow solutions With a single 14-second scan, Dentsply Sirona 3D Imaging and Sidexis 4 are our award-winning imaging products for efficient workflow, intuitive usability and excellent image quality. From upper airway analysis and treatment of obstructive sleep apnea with SICAT Air, to safe, efficient and time–saving implantology with Galileos Implant, to functional diagnosis and treatment of temporomandibular joint dysfunction therapy with SICAT Function. With Dentsply Sirona 3D and Sidexis 4, you have the ideal basis for a new dimension of success in your practice.

Contact Dentsply Sirona directly 800.659.5977 sirona3D.com

Dental Sleep Practice Summer 2018  
Dental Sleep Practice Summer 2018