Page 1

It’s A Family Affair

Maximize Medical

by Pat Mc Bride, BA, RDA, CCSH

by Rose Nierman

Parental resistance

Insurance Benefits

Building Your Sleep Practice? SleepArchiTx is your design-build solution WINTER 2017 PLUS

Continuing Education

Evolution

of the Human Oral Airway and Apnea Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Allen J. Moses, DDS, Elizabeth T. Kalliath, DMD, and Gloria Pacini, RDH


Your Sleep Solutions Partner from patient screening The Great Lakes George Gauge™

Apnea Guard®

to bite records to appliance selection

Narval™ CC

New! Nonin WristOx2® Model 3150 Wrist-worn Pulse Oximeter

MediByte® Lite Kit

Hard Telescopic Sleep Herbst®*

NEW! dreamTAP™ Rhea®

to achieving optimal outcomes

Every step...we’re here for you Dentists have trusted Great Lakes for effective screening devices, sleep appliances, and technical support for over 25 years. Whether you are new to dental sleep medicine or a veteran, we will partner with you to provide the best solutions for your patients with sleep disordered breathing.

*Herbst is a registered trademark of Dentaurum, Inc.

SMBP628Rev080217

Call our Sleep Specialists today at 1.800.828.7626 or visit GreatLakesSleep.com


INTRODUCTION

Togetherness

R

esolution 17, the result of a two-year, open-process task force of the American Dental Association’s House of Delegates, was passed during the meeting in Atlanta in October. Resolution 17 is a set of statements guiding member dentists in the treatment of airway problems in collaboration with physicians. During the reference committee hearing, there were a dozen dentists lined up to state their support of Resolution 17, with some speaking how this will impact their practice in a positive way, others encouraging inclusion of related health issues, some defending the process of writing the document, and a plea to maintain the reference to treating children’s airways during the debate over the wording in the House. One person spoke in opposition, but that statement represented our 10,000 American Academy of Sleep Medicine (AASM) colleagues. Happily, the opposing points were not exclusionary – the physicians do not want to keep us from treating airway problems, but they strongly feel the diagnosis and management of the patients falls fully within their purview. The statement further offered to work together with dentists and the ADA to define these roles more clearly, if Resolution 17 was not made the guiding principles of the ADA. Since it was passed, what happens next remains to be seen. There are not many innovative ways of treating airway health on the horizon. There are glimmers of change in areas of pharmaceuticals, airway muscle training, or even breathing pattern coaching to affect the stability of the oropharynx, but keeping the adult airway open will for some time remain in the hands of PAP and oral appliance providers and surgeons. We know how to treat sleep breathing disorders; what is in conversation is how to identify who needs treatment. What is rapidly expanding is awareness of the health effects of even mildly disordered breathing and how many people in our community are affected by it. Just this year, papers have been published and editorials written about the increasing preva-

lence of airway health problems and position statements have been made about diagnosis and management options, including several by the AASM and its member physicians. Dentists have had no statements by a widelyrepresentative membership organization that promote a bigger responsibility for us in this field. The American Academy of Dental Sleep Steve Carstensen, DDS Medicine (AADSM) did authorize one of their Diplomate, American Board of Board members to speak in favor of Resolution Dental Sleep Medicine 17, but they did not send their President nor have they published an official paper about dentists’ role since a joint position paper with the AASM in 2015. The ADA has heretofore been silent, and the Academy of General Dentistry has not taken an official position on the subject. Walter McNicholas, MD, in a well-written opinion, questions “Obstructive sleep apnea of mild severity: Should it be treated?”1 He writes about the difficulty of diagnosis of mild SDB and the lack of research that shows increased comorbidities or early death for those so diagnosed. He points out how many millions of people around the world have some form of obstructive sleep apnea syndrome. The conclusion he comes to I think is powerful: The management of mild OSAS represents a greater clinical challenge than severe OSAS, in which CPAP therapy is the most appropriate option. Successful outcomes require careful clinical assessment of the individual patient and a personalized approach to treatment, especially as a wide range of therapeutic choices are available in mild cases. Although the clinical significance of mild OSAS is questioned, each patient who presents to the sleep clinic seeks a solution and a successful outcome requires an expert approach to the diagnosis and management. If there are fewer clinically significant details associated with mild OSAS, do those patients need highly-trained specialist physicians to manage them? Yet, they want answers, they want solutions, and they want to feel better. Tens of millions of them do. There are not resources to waste on inappropriate treatments – the faster experts can employ the best option for the individual patient, the more efficiently they can reach their health goals. The biggest question is how do we satisfy the people who seek solutions by experts and look to their medical providers, whether they be physicians or dentists, to show that their doctors are working together, truly to keep their best interests in mind. Having the ADA take a stand for dentists and step forward to engage in a professional dialog with AASM physicians is an excellent way to improve the health of our communities, together. 1.

Curr Opin Pulm Med 2017, 23:000–000

DentalSleepPractice.com

1


CONTENTS

14

Cover Story

Building Your Sleep Practice? SleepArchiTx is your design-build solution Every service you need in one place.

10

Communications

It’s a Family Affair: Parental resistance – a communication dilemma

by Pat Mc Bride, BA, RDA, CCSH You have to treat the whole family. From left: Payam Ataii, DMD; Lou Shuman, DMD, CAGS; Alice Limkakeng, SleepArchiTx CEO; Jerald Simmons, MD, D.ABPN, D.ABSM, D.ABCN; Marco Navarro, DDS, MS; Sal Rodas, SleepArchiTx Chief Product Officer; and Rob Veis, DDS

20

32

New Thinking

We Are Not Our Symptoms by Barry Raphael, DMD Think dynamically to offer solutions.

30

Practice Management

Maximize Medical Insurance Benefits by Rose Nierman, CEO Nierman Practice Management The right code is the thing.

2 DSP | Winter 2017

Continuing Education

Evolution of the Human Oral Airway and Apnea by Allen J. Moses, DDS, Elizabeth T. Kalliath, DMD, and Gloria Pacini, RDH You can’t separate the function from the anatomy.

2 CE CREDITS


The Reliability You Expect With ProSomnus The ProSomnus® [IA] Sleep and Snore Device with Compliance Sensor offers a more reliable way to track patient behaviors and compliance. This customizable, iterative advancement sleep device delivers results beyond predicate devices. • 97.5% serviceability at 6 months • Precision manufacturing • Engineered pocket design to protect sensor • Durability and performance

ProSomnus [IA] ®

PRO_DSP_Oct17

ITERATIVE ADVANCEMENT DEVICE WITH COMPLIANCE SENSOR

Leader in Precision OAT™

Join the growing number of dentists who are dedicated to 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


CONTENTS

6

Ortho Connection

Teledontic, Pharyngorofacial Orthopedic Treatment for OSA by Dr. Joseph Z. Yousefian The right orthodontist can help at any age.

24

Team Focus

What We Know Now – A Team Approach by Glennine Varga, AAS, RDA, CTA Patients have history – we can help them have a better future.

26

Product Spotlight

What Does Neuroscience Have to Do with Dentistry? A Lot! by Sandra Marlowe A method of achieving a profound mental state of peak performance.

40

Laser Focus

Superpulse 10,600 nm CO2 Laser Revision of Lingual Frenum Previously Released with a Diode Hot Glass Tip by Karen Wuertz, DDS, and Peter Vitruk, PhD Once may not be enough.

44

Product Spotlight

Patient Centric Design Helps Collaborate with Medicine by Reza Radmand, DMD, FAAOM We know our doctors, but it’s all about our patients.

46

TMD Screening

Exploring TMJ Symptoms as a Result of MAD for Sleep Apnea by Mayoor Patel, DDS, MS Not all symptoms result in long term problems.

4 DSP | Winter 2017

50

Clinician Spotlight

Fresh Eyes and New Technology – People are Getting Healthier The enthusiasm of a young dentist’s approach to solving problems.

53

Practice Growth

Did You Hear the One About the Dentist...? by Chris Bez, opportunity engineer Bring your team along for best results.

56

Product Spotlight

BluePro® Temporary Appliance: Clinical Profile Temporary or Interim – useful for your practice.

58

Winter 2017 Publisher | Lisa Moler lmoler@medmarkmedia.com Editor in Chief | Steve Carstensen, DDS stevec@medmarkmedia.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com Editorial Advisors Steve Bender, DDS                           Ken Berley, DDS, JD Howard Hindin, DDS                          Ofer Jacobowitz, MD                       Christina LaJoie Steve Lamberg, DDS, DABDSM Dale Miles, DDS                                  Amy Morgan                                      John Remmers, MD                        Rob Rogers, DMD                            Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS   Jason Tierney    Glennine Varga, AAS, RDA, CTA

Practice Development

SEO: Scam or critical marketing service? Part 1

National Sales Director Kristin Sammarco | kristin@medmarkmedia.com

Ian McNickle, MBA Defining SEO and discussing its importance.

Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com

60

Office Manager/Executive Assistant Mystey Helm | mystey@medmarkmedia.com

Legal Ledger

Need to Know Medicare Guidelines for Oral Appliances for OSA: Friend or Foe? Part 4 by Ken Berley, DDS, JD, DABDSM and Courtney Snow, Medical Insurance Consultant Part 4 of the series.

64

Seek and Sleep

DSP Word Search

Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2017. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.


ORTHO connection

Teledontic, Pharyngorofacial Orthopedic Treatment for OSA by Dr. Joseph Z. Yousefian

A

lex was devastated. His best friend Brandon invited him and couple of other friends to go to Disneyland with his family. He and Brandon were inseparable at school, even over the weekends. But Alex was afraid and decided not to go. If he went on the trip and shared one of the double beds in the hotel with Brandon, Alex knew he’d probably wet the bed while sleeping. Alex’s story has a happy ending. Although he missed the trip to Disneyland, his mom found out through me – I was treating her obstructive sleep apnea (OSA) – that Alex’s problem with bed-wetting is curable. I explained to mom that Alex’s recent diagnosis of ADHD, metabolic syndrome, overweight, high blood pressure, high cholesterol, high blood sugar, and poor school performance, along with snoring and restless sleep, were most likely related to airway complications.1,2

6 DSP | Winter 2017

I noticed this problem when Alex was brought to our office to wait during her orthodontic appointments. He was seven years old but unusually short and chubby for his age. He always behaved out of control, all over the place, climbing the chairs and disturbing other patients, unable to sit quietly or watch TV. When I asked his mom about his sleeping behavior, the answer was that he slept restlessly, but was also hard to wake in the morning. His mom said that Alex’s tooth grinding keeps the whole family awake. Mom was very surprised when I told her that his primary teeth were worn significantly. Mom also described that their precious only child was failing first grade for the second time. Indeed, little Alex was disruptive, unable to focus on his work, and unable to get even one gold star on his papers, which he rarely completed. His parents were devastated when told that their son would have


ORTHOconnection

Connections of airway condition to other health issues

to leave the traditional public school and go to the alternative school. They knew this signaled the end of hope for their son to live a normal life. Even his four psychotropic medications were not helping. The pediatric psychiatrist held out no hope either. Later mom admitted that she and her husband had made a difficult decision not to have any more children, with the bleak future they saw for their little boy. I diagnosed Alex with constricted jaws, crossbite, large tonsils, adenoids and considering his other symptoms, recommended a sleep study, something none of the other doctors had brought up. I explained to mom the possible connections of Alex’s airway condition to his other health issues. Alex’s mother called the pediatric psychiatrist. “Sara, I know you are desperate and looking for anything you can find,” he said, “But I wouldn’t hold out any hope for a solution as simple as airway diagnosis and treatment.” The sleep test was done shortly after my consultation appointment. Alex was diagnosed with severe obstructive sleep apnea, AHI of 17. To make it easier for Alex to breathe, the sleep doctor referred him to an ENT specialist to get tonsillectomy and adenoidectomy. Although after surgery his snoring was reduced, he did not stop wetting the bed. A second sleep test showed that Alex still suf-

Dr. Joseph Z. Yousefian obtained his degree in Dentistry from Washington University, in St. Louis, in 1987, and completed three years of post-graduate training in orthodontics at the Ohio State University in 1991. He also received Master of Science degrees in biology and physical anthropology. He is a diplomate of the American Board of Orthodontics and has been in private practice in Bellevue, Washington since 1991. Dr. Yousefian has served as a Clinical Assistant Professor and Orthodontic Research Associate at the Ohio State University and the University of Washington, Department of Orthodontics. He is an active lecturer nationally and internationally and has contributed as a main author to numerous publications in orthodontics as well as dental journals and textbooks.

DentalSleepPractice.com

7


ORTHOconnection

Your

fered from OSA, with minimal reduction of AHI to 13. The sleep specialist referred Alex back to our office to proceed with expansion of his jaws and airway. This protocol combined with proper nutrition, physical referral can change activity, and avoidance of processed the course of that food and sodas gradually helped him lose weight. child’s life. The third sleep test, after completion of his treatment, showed complete relief of the OSA with an AHI of 1. He stopped snoring and started sleeping well. Alex invited Brandon over for a sleepover, and Alex didn’t wet the bedthat night, or ever again! He now sits quietly watching TV in the dental chair. Tooth grinding has stopped and he sleeps peacefully. In fact, the whole family is sleeping better! A few months after the completion of his treatment, Alex’s teacher asked the parents, “What did you do? This is a different child.” And sure enough, Alex was bringing home gold stars on completed, beautiful school papers. He is off all but one of the psychotropic

1. 2. 3. 4. 5.

8 DSP | Winter 2017

meds, and weaning off that one, giving his parents hope again. Can you even imagine that a child who has behavioral and emotional problems, and cannot live life as most children, could perhaps avoid being medicated and become “normalized” just through interventions that allow good nasal breathing? You, too, can provide that miracle to your child patients and their families! It’s a lot easier to “see” the problem in a child who has snoring, loud mouth breathing and what seem to be obvious signs of airway dysfunction. But indeed, often children only exhibit one or two symptoms, and they may be symptoms like behavioral problems, bedwetting, and/or bruxism.3 Your referral can change the course of that child’s life. Whether the symptoms of the patient are typical or atypical, large or small, it is possible that your referral to a medically knowledgeable orthodontist specialized in treatment of OSA may give the child his or her future. In my experience, children with airway pathology require a treatment protocol significantly different than traditional orthodontic treatment to create straight teeth. Improvement of the whole pharyngorofacial complex, not just correction of crossbites or a narrow palate, is required to have an impact on the airway.3 While oral surgeons are rethinking their approach from ‘orthognathic’ to ‘telegnathic’ to reflect the forward positioning of the maxilla and mandible, orthodontists with a medical focus are providing ‘teledontic therapy’ – a medically necessary therapy for a diagnosed medical problem.3,4 With the right documentation of disease and the structural reasons for that diagnosis, teledontic therapy should be reimbursed under medical coverage, like telegnathic surgery or even oral appliances.5 As the value of choosing an airway-focused orthodontist providing teledontic therapy becomes more appreciated, this trend to treat the whole pharyngorofacial complex will continue.3

Van Eyck A, Van Hoorenbeek K. Sleep-disordered breathing, systemic adipokine secretion, and metabolic dysregulation in overweight and obese children and adolescents. Sleep Med 2017;30:52-56. Won D, Guillminault C. It Is Just Attention-Deficit Hyperactivity Disorder…or Is It? J Dev Pedatr 2017 Feb, Mar, ;38(2):169-72. Yousefian J, Moghadam B. The role of contemporary orthodontics in the diagnosis and treatment of sleep-disordered breathing. 2nd ed. USA: Roth Williams Legacy Foundation; 2015. Prinsell J. Telegnatic maxillomandibular advancement surgery for OSA. Dental Sleep Pratice 2015 Fall(Fall):6-9. Nierman R. Dentists become durable medical equipment suppliers for sleep apnea oral appliances. Dentistry iQ. The Dentistry iQ Network: Dentistryiq.com; 2013.


Think small When we developed the first CAD/CAM oral appliance for the treatment of obstructive sleep apnea, we packed our biggest ideas into our smallest device. Today, Narval CC continues to revolutionize oral appliance therapy with its advanced technology, its proven track record of compliance and efficacy, and its compact, lightweight design. As the experts in sleep, we couldn’t be prouder to offer the very best in dental sleep.

Contact us at narval@resmed.com.


COMMUNICATIONS

It’s a Family Affair Parental resistance – a communication dilemma by Pat Mc Bride, BA, RDA, CCSH

P

arents used to bring their children to the dentist or orthodontist with a limited agenda; specifically, a cleaning, a “cavity” or misaligned teeth. Today, dentists and orthodontists trained in airway health, facial growth guidance, function, breathing, sleep and cognition have the ability to comprehensively screen and serve pediatric patients in the focused, supportive environments of their practices. Expanding your practice to include a holistic patient care model with screening and assessment protocols encourages development of meaningful relationships with your patients and their families. This article addresses the special communication needs relating to children, our most precious resources. No longer providers of a simple cleaning or cavity prep, dental/orthodontic paradigms now include assessment of the functional airway and associated problems affecting our pediatric and adult patient populations. The days where it was easier to make therapy recommendations and leave it to the parents to decide what to do, have been replaced by a driving force to act (by screening and assessment) in accordance with what is best for the child. In order to act effectively however, clinicians must learn to communicate in a way which brings the family as an entity into the conversation. 10 DSP | Winter 2017

Many current continuing education courses have some component of screening for breathing and sleep issues addressed. Some are quite specific, and others give a smattering of information and leave it to you the clinician to try and “figure it out” on Monday morning when you return to the office. Which we all know from experience, is far easier said than done. Implementation of pediatric questionnaires, screening, education and assessment tools for oral rest posture, breathing, sleep, academic and behavior issues can (and will) be met with resistance from parents unwilling to consider that there is anything “wrong” with how their child/children sleep, breathe, speak, swallow, perform in school or behave. It is all too common to hear parents state clearly to the hygienist that, “Johnny is only here for a cleaning, I don’t need to hear about anything else” when poor oral rest posture, mouth breathing, chapped lips or tongue tie are recognized and brought to the parents’ attention. Pushback and resistance to new assessment measures is often based on parents’ perceptions of their child, and their own inability to cope emotionally with the stresses surrounding any new revelation


COMMUNICATIONS about their child’s health condition (Menahem and Halasz, 1998). Parents are vulnerable to psychological reactions which inhibit rational thinking and decision making especially when it concerns the welfare of their child. Social constructs such as denial serve to protect parents from overwhelming fears and anxieties, and if addressed with good communication and empathy may transform parental defensiveness to co-operation. Adopting a holistic (whole person) clinical approach for assessment and management of pediatric patients in the general practice affords clinical observation of dysfunction and other issues over and above any presenting problem(s) (Menahem, 1983). As an example, non-presenting symptoms include unrecognized or ignored abnormalities such as maxillary insufficiency, retrognathia, tongue tie, snoring, swollen tonsils, nasal congestion, allergic shiners, inability to attend, poor sleep, school and behavior issues. How parents respond to questions regarding these issues however can range from grateful acceptance of your observations and clinical advice at one extreme to one of anger and total rejection on the other (Melton, 1996). You as an effective communicator can make or break the opportunity to change the life and health trajectory of every child in your practice. Good communication is good medicine. Take time to learn to talk with parents. Not to parents, or at parents, but with them. Listening is an essential part of a two-way process, especially one where the parent is the consumer, and the child the patient. You must be able to communicate sufficiently well with the children themselves. It is absolutely not acceptable to talk over a child, especially if

they are required at some point to buy into and participate in a proposed therapeutic protocol. Facial growth guidance, myofunctional therapy, breathing retraining and expansion therapy all require very high levels of patient and parental participation and cooperation for success. Can you dissect the child’s issues into digestible pieces for the less dentally knowledgeable parent or care giver? All explanations you give must be clear, complete, and in a language that the parents can easily understand. Relying on your assistant who took high school Spanish for three years will not guarantee that the rationale for a sleep study referral is actually comprehended by the parents. Any and all therapy or treatment options must be explained clearly Good communication and completely in order for informed consent to be obtained; which means giving is good medicine. the family time to absorb the content of the conversation and ask questions without being rushed or directed (Settledge, 1991). Parents like knowing the truth, but sometimes, it is harsh and can be shocking, so delivery must be tempered with common sense and empathy (Metha, 2008). You must be patient and supportive when delivering information parents may not want to hear. You and your team must also be prepared at some point to deal with emotional outbursts such as blame, anger and grief as normal parental reactions. As you try and temper a potential blow to a family, remember, you cannot hedge around a serious health concern such as sleep apnea. Procuring necessary referrals for appropriate definitive diagnosis and treatment followed by reassurance that you will continue to monitor the child’s progress closely is imperative to building trust and a safety net for the entire family. Many of the

Pat Mc Bride, BA, RDA, CCSH, has spent 38 years as a full time clinician and educator in the fields of dentistry, respiratory medicine and dental sleep medicine. Her extensive experience in clinical, laboratory, research and educational arenas has led to the development of interdisciplinary care model delivery systems used by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. She sits on the Board of Directors for the American Academy of Physiological Medicine and Dentistry in New York. Pat continues to work hands on with patients while lecturing internationally on subjects relating to breathing and sleep medicine, dentistry and precision medicine systems to best benefit all patient populations. Serving the underserved and marginalized patient remains a passion and priority for her. She is a Ph.D. candidate at Fielding Graduate University. She has one grown daughter who shares her passion for social justice and education, serving as a fifth grade teacher in the inner city Oakland, CA.

DentalSleepPractice.com

11


COMMUNICATIONS issues screened for are quite literally, family affairs. Helping the family relate what is going on with this child to perhaps a father, grandmother, aunt or other child brings stability and relevance to the situation. The family needs reassurance that they are not alone in this and you are there to help. The psychosocial adjustment to having a child with a potentially life long chronic disorder such as sleep apnea is daunting, and parents will need all of the support you and your team can provide. Do you have the ability to convince a patient and their parents to follow a treatment plan? We are not talking about selling a two stage serial extraction ortho plan here, but real ongoing cross disciplinary healthcare with longitudinal expectations and goals for the child. If parents are resistant to screening, what makes you believe they will accept your proposed therapy? This is especially important embarking on prolonged, exCreating a pathway for when pensive, difficult, or alternative/ada healthier and happier junctive therapy. Facial growth guidand expansion therapy have next generation. ance multiple phases, and at any given point a family may falter if they believe the child suffers psychologically due to peer reactions that are unsupportive of temporary facial changes. Can you and your staff effectively support this situation? Ongoing self-esteem promoting dialogue and support for both parents and child are critical especially for example, when a child must wear a reverse pull headgear all day long at school. Your commitment to the process, the patient and the family unit is paramount. This may mean numerous “support” calls after hours, but ultimately those few minutes on the phone serve the child’s best interests for improved compliance and clinical outcome. In the end, a few moments of reassurance to stay the course provide a scaffold and foundation for the establishment of a solid relationship based on mutual respect and trust 1. 2. 3. 4. 5. 6. 7.

with the parents and the child. Their confidence in you and your commitment guarantees that they will tell other people about what you are doing to help their child. Being able to put all classes of parents at ease and converse with them regarding non-medical issues also creates an atmosphere of comfort and concern, allaying many of the fears and anxieties parents have regarding their child and the treatment they may be needing. No matter how busy your schedule, or how far “behind” you are, these families need your attention at that moment, and that should be the priority. The time you spend on the front end will more than take care of everything else as treatment moves along. As more providers embrace holistic care models to better serve our patients and their families, we accept the challenge and responsibility of service to all strata of society, especially our cherished kids. The community of our peers is stepping in to fill an ever expanding gap in coverage of essential care for people. Dentists spend, typically, 60 minutes with families, far more than a routine pediatrician visit. This statistic is incredibly important to keep in mind as dentistry is expanding to fill an essential healthcare need and provide a higher standard of global screening and assessment for our patients. With our faltering managed care health system, you and your team may very well be more heavily invested in that child’s health and wellbeing than their own doctor. According to a recent study, the average well child pediatric appointment is <10 minutes. Visits of short duration are associated with reductions in content and quality of care, and parent satisfaction with care (Halfton et. al, 2011). Your commitment to screening every patient in your practice including special attention directed towards the pediatric patient population followed by effective communication and appropriate therapy interventions when necessary can and will create a pathway for a healthier and happier next generation.

Halfon, N., Stevens, G. D., Larson, K., & Olson, L. M. (2011). Duration of a Well-Child VAssociation With Content, Family-Centeredness, and Satisfaction. PEDIATRICS, 128(4), 657-664. doi:10.1542/peds.2011-0586 Mechanic, D. (1962). The concept of illness behavior. Journal of Chronic Diseases, 15(2), 189-194. doi:10.1016/0021-9681(62)90068-1 Melton, G.B. (1996). The child’s right to a family environment. American Psychologist, 51, 1234-1238 Menhem, S. (1983). Therapeutic concern for the ‘non-presenting symptom’ in paediatric practice. Child Psychiatry and Human Development, 14,87-91 Mehta, P. (2008). Communication Skills- Talking to Parents, Pediatrics in Practice, 45,300-304. Settlage, C. F., Bemesderfer, S., Rosenthal, J., Afterman, J., & Spielman, P. M. (1991). The Appeal Cycle in Early Mother-Child Interaction: Nature and Implications of a Finding from Developmental Research. Journal of the American Psychoanalytic Association, 39(4), 987-1014. doi:10.1177/000306519103900406 Tates, K. (1998). Doctor-parent-child communication over the years. Patient Education and Counseling, 34, S11. doi:10.1016/s0738-3991(98)90017-9

12 DSP | Winter 2017


COVERstory

Building Your Sleep Practice? SleepArchiTx is your design-build solution

I

s it frustrating to know that your patients are suffering from sleep disorders but you can’t help them because of obstacles that exist? SleepArchiTx™ has put together a solution that helps you overcome those obstacles. Turnkey 360° Solution

Instead of point solutions that require your practice to coordinate different service providers for billing, appliances, home sleep testing, etc., SleepArchiTx brings you an all-in-one solution with a single point of contact for you to overcome obstacles and build your sleep practice. The offering includes: • Education and Training – For both doctor and staff. • Home Sleep Testing – Takes the burden off you. Fully coordinates with patients. No investment in equipment. • Turnkey Medical Billing – Experts working full-time to get you paid for your dental services. • Treatment Planning – Multi-disciplinary expertise to help dentists with each case. • Portfolio of Sleep Appliances – Because one appliance does not fit all patients. • Ongoing Support – Critical focus of SleepArchiTx. Will even help chairside when the patient is with you.

Building your sleep practice with a unique 360° turnkey solution. Support

Expertise

• Dedicated Support Team • Communication with Patient’s Physicians

• Comprehensive Education • Sleep Physician Expertise • Diagnostics and Treatment Planning

Growth

Technology

• Turnkey Billing Service • Marketing Support

• Workflow Guiding Web Portal • Portfolio of Innovative Appliances

14 DSP | Winter 2017

These services are not merely a collection of separate companies. Instead, SleepArchiTx developed an entire service offering in-house to give you a truly seamless experience, and all efforts are aligned to make your dental office successful in building your sleep practice without any competing objectives.

Obstacle 1: Education Alone Isn’t Enough

Tired of weekend courses that go nowhere? Have you tried weekend courses that get you excited about serving more patients only to get bogged down in the day-to-day when you return? SleepArchiTx does not believe in “weekend warrior” education models that claim to set doctors up for success. Instead, the company’s education program is provided in more bite-sized pieces over several weeks to give you and the team time to learn, absorb and apply the learning. The SleepArchiTx education program is required for doctors and all staff to get everyone on the same page. Participants are given assignments to gain knowledge with practical experience. Leveraging the knowledge and experience of the SleepArchiTx’s Advisory Board in sleep medicine, diagnostics, orthodontics and general practice, the education curriculum is truly unique and designed to drive a deeper un-


COVERstory

From left: Marco Navarro, DDS, MS; Jerald Simmons, MD, D.ABPN, D.ABSM, D.ABCN; Payam Ataii, DMD; Alice Limkakeng, SleepArchiTx CEO; Lou Shuman, DMD, CAGS; Rob Veis, DDS; Sal Rodas, SleepArchiTx Chief Product Officer

derstanding of how multiple clinical factors impact patients with sleep disorders.

Obstacle 2: Getting the Patient Properly Diagnosed Home Sleep Testing – Do you have diagnostic units sitting unused in your closet? Throughout the years, multiple attempts have been made to push dentists to dispense home sleep testing devices from their practices, resulting in many of these diagnostic recording units sitting unused in dental office closets. As a response to this, SleepArchiTx has incorporated home sleep testing services seamlessly within its holistic offering. SleepArchiTx therefore does not require dentists to make any investments in testing equipment and the company does all the hand-holding with the patient to ensure the test is done correctly. Importantly, the company works with board-certified sleep physicians to ensure that your patients’ sleep disorders are diagnosed appropriately. These sleep physicians can also help you talk to your local sleep physicians when in-lab sleep testing is needed.

Obstacle 3: Getting Paid for Your Services

Turnkey Medical Billing – Are you afraid of billing medical insurance? Sleep dentistry can be a source of growth

for dental practices. However, SleepArchiTx understands that medical billing for dental sleep services requires full-time focus to be effective because it takes time to develop the knowledge needed to work with medical insurance companies and “speak their language.” SleepArchiTx has formed a dedicated team armed with deep medical billing experience and incorporated this service as an integrated component of its total offering. When necessary, SleepArchiTx further leverages their medical clinical staff to explain medical justification to insurance companies – a differentiating factor that drives reimbursement success.

Obstacle 4: Overcoming Challenging Cases

Working with SleepArchiTx gives you access to a panel of experts in malocclusion, TMJ contraindications, dental co-morbidities, compromised airways and sleep issues to help you on a case-by-case basis.

Treatment Planning – Who can help you with tough cases? Gain the peace of mind and confidence you need to succeed. Working with SleepArchiTx gives you access to a panel of experts in malocclusion, TMJ contra-indications, dental co-morbidities, compromised airways and sleep issues to help you on a case-by-case basis. With all this expertise, your treatment planning is

DentalSleepPractice.com

15


COVERstory more comprehensive than ever and you always have dental, medical, diagnostics and dental lab experts with which to consult.

Obstacle 5: Choosing the Right Appliances

Portfolio of Sleep Appliances - Unsure about which appliance works best for each patient? Do you wonder which appliance is right for each situation? SleepArchiTx knows that each patient has a unique set of challenges that contributes to his or her sleep disorder. These cannot be ignored when considering treatment options. For instance, different appliances may be needed for bruxers vs. edentulous patients. Therefore, SleepArchiTx provides a wide portfolio of sleep appliances designed to meet a variety of patients’ needs. Importantly, all these appliances are FDAcleared devices and manufactured to the highest quality standards.

Obstacle 6: Getting Enough Support

Ongoing support – Who will help you when training is done? SleepArchiTx recognizes that doctors and staff need repetition and practice to learn concepts. Because of this, SleepArchiTx’s support services do not end when training ends; in fact, quite the opposite – support is even more important after the initial training

Our Lifetime Customer Support Program is serviced by full-time representatives who support the office with every single case on an ongoing basis.

16 DSP | Winter 2017

and implementation. Therefore, the company provides a Lifetime Customer Support Program that is serviced by full-time representatives who support the office with every single case on an ongoing basis. The representatives will even assist chairside when you are with the patient. “SleepArchiTx is here for you. We have created a comprehensive service designed to overcome obstacles and ensure that dentists achieve success.” says Sal Rodas, Chief Product Officer.

Innovation – Introducing the Aligner Sleep Appliance®(ASA)

From the start, SleepArchiTx has focused on bringing innovation to dentists. Given the deep experience of the team, the company is continually working on new solutions to overcome obstacles in the dental sleep market. One example is the Aligner Sleep Appliance®(ASA), which was co-invented by two members of the SleepArchiTx Advisory Board, Dr. Payam Ataii and Dr. Rob Veis. SleepArchiTx is proud to be the exclusive provider of the ASA, which is the only FDAcleared sleep appliance that can be used in combination therapy with clear aligners. The ASA is a true game changer for clinicians who are increasingly seeing patients who suffer from malocclusion and sleep disorders concurrently. SleepArchiTx is working on several other innovations for screening and monitoring that it plans to bring to market in the near future.

Expert Advisory Board

The company recognized that the complexity of sleep requires experience from many fields. Therefore, SleepArchiTx was founded from the beginning by bringing together the brightest minds from all the relevant disciplines. Members of this “Sleep Leadership Advisory Board” include: • Sleep Medicine – Jerald Simmons, MD, D.ABPN, D.ABSM, D.ABCN, is a triple board-certified neurologist specializing in sleep disorders and epilepsy who completed his Fellowship training at the birth place of sleep medicine in the US, Stanford University Medical Center. • Dental Sleep – Lou Shuman, DMD, CAGS is CEO of Cellerant Consulting Group, Managing Editor of Dental


COVERstory

Sleep Practice, a Board Director of Foundation for Airway Health and on the Advisory Board for Seattle Sleep Education. Orthodontics – Marco Navarro, DDS, MS is a practicing orthodontist renowned for sleep appliance and TMJ therapy and early development intervention. General Dentistry – Payam Ataii, DMD is a practicing general dentist who has been treating sleep patients for over 10 years and has treated nearly a thousand clear aligner cases using the Invisalign® system. He also serves on the Faculty of Align Technology and is co-inventor of the Aligner Sleep Appliance® (ASA). Dental Lab Appliances – Rob Veis, DDS, is CEO of the renowned Space Maintainers Lab (SML) and a general dentist serving sleep patients for over 15 years. He is co-author of The Principles of Appliance Therapy for Adults and Children, which is considered one of the definitive texts on the subject. He is also co-inventor of the Aligner Sleep Appliance® (ASA). Training & Education – Max Schulze, MDT, CDT is an internationally recognized technical clinician who runs Straumann’s educational training for key opinion leaders and clinicians nationwide.

Harvard Business School comes to Dentistry

Alice Limkakeng, CEO of SleepArchiTx comes from the healthcare executive and venture investing world where she has worked for over 20 years. Most recently she was Chief Business Officer of Boston Heart Diagnostics and helped lead the cardiovascular services company from early stage to over $100 million of profitable revenue through organic growth and innovation. She attained her undergraduate degree at the Wharton School of Business and did her masters at Harvard Business School (HBS) where she graduated with High Distinction as a Baker Scholar, a designation given only to the top 5% of each graduating class. She has extensive experience with medical doctors, medical billing/reimbursement and the healthcare field generally. “SleepArchiTx is a

perfect opportunity to apply my healthcare business experience to overcome the obstacles in bringing dental sleep therapy to dentists and their patients,” says Limkakeng. As the Executive Director of the Foundation for Airway Health, Sal Rodas, Chief Product Officer of SleepArchiTx, has committed to airway health as one of his life missions. Most recently he led a sleep diagnostics company as Chief Operations Officer and Chief Strategic Officer, so Rodas is perfectly positioned to support SleepArchiTx in the dental sleep industry.

National Launch – Solving a National Crisis

Having spent much of the past several years investing, refining the offering, and working with select dental practices, SleepArchiTx launched nationally on September 1. Limkakeng and the SleepArchiTx team are excited to bring the offering to dentists and their patients nationwide. The statistics are alarming: About 70 million Americans suffer from sleep problems, with approximately 60% of these having a chronic disorder as published by the National Center on Sleep Disorders Research (NCSDR), an organization within the National Institute of Health (NIH). This problem is a major driver of healthcare costs too. “Sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national health care bill,” quotes NCSDR.1 The industry estimates that nearly 80% of patients who have the serious condition of sleep apnea are undiagnosed.2 This leaves millions of people walking and driving around who are at risk and potentially pose a risk to others. The importance that sleep plays on whole body health and the exacerbation that lack of sleep can have on major diseases such as diabetes, cardiovascular disease, obesity and depression cannot be ignored. It is with this sense of urgency that SleepArchiTx is driven to support dentists in solving our national sleep crisis. Limkakeng confirms, “Given the frequency of visits and strong relationships with patients, I am convinced that dentistry is the perfect profession to lead the charge.”

1. 2.

The ASA is a true game changer for clinicians who are increasingly seeing patients who suffer from malocclusion and sleep disorders concurrently.

https://www.nhlbi.nih.gov/about/org/ncsdr https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/

DentalSleepPractice.com

17


NEWthinking

We Are Not Our Symptoms by Barry Raphael, DMD

Static Thinking

Despite the fact that orthodontic training programs have been teaching about growth and development ever since the beginning of the profession and the relationship between breathing behavior and facial growth has been written about for equally as long, once an orthodontist gets into practice much of that training gets set aside as an intellectual maxim but has very little influence on real-world diagnostics and treatment planning. For example, when an orthodontist first sees a patient, the first thing we do is look at the teeth and describe the malocclusion by the Angle classification. I might describe a case to a colleague like this: “This 9-year-old girl comes in, Class II, 7mm overjet”. We can all imagine what that girl looks like from that simple description, right? Or I might say, “I had this div 2 case with an impacted canine” and any orthodontist can see the central incisors tipped back and the primary canine still in place with a bulge on the palate. And we can imagine a treatment plan that would go with that description as well. In other words, the Angle Classification is not only the phenotype, it is also the diagnosis and the basis for the treatment plan.  When a patient walks in the door and is described, classified, and planned this way, the underlying assumption is that her classification is a personal characteristic: a description of who this person is. Everything about

20 DSP | Winter 2017

this person is known from what can be seen at that moment in time, either clinically or through radiographs, and what is seen is all there is to be seen. It is a static way of looking at a patient. Static and simple and direct. It also assumes that whatever this person presents with was this person’s destiny. Most often, malocclusion and facial deformity (called “skeletal patterns”) are written off to genetics and familial traits. If the child happens to look like one of the parents – even to the extent of having the same overlapping central incisors – then no further questions are asked: it’s a genetic trait. If both parents are beautiful with nice teeth and the kid looks a mess, then it’s either an uncle’s fault or it was a funny admixture of traits, ie: the Dad’s big teeth and the Mom’s small jaws. In any case, it was an outcome that could not have been avoided. This is who this person is.

Dynamic Thinking

There is a completely different way of thinking that has always been part of orthodontic pedagogy but is finally finding it’s way into clinical practice. The assumption in this model is that the way a patient presents herself in front of you now is NOT who they ARE but what they have BECOME...and are still becoming. That Class II with 7mm of overjet


NEWthinking bodies have all changed in response to a very different way of life than the one our bodies were developed in. The mismatch between our genetics and the the modern environment is not only the origin of malocclusion but of all the chronic non-communicable diseases of modern life. This includes all the metabolic diseases (cardiac disease, diabetes, hypertension and obesity), all the immune diseases (autoimmune, inflammatory, cancer), behavioral issues (neurocognitive, autism, ADHD, addiction), and more. This also includes periodontal disease, caries, malocclusion, and importantly, breathing-disordered sleep (sleep disorders, flow limitation, Upper Airway Resistance Syndrome, and sleep apnea).

Dynamic Treatment

Most malocclusions in humans are actually a distortion of the genetic process triggered by some chronic stressor of the modern environment.

that you see in front if you is IN PROGRESS. And though there may be a genetic influence and familial traits involved, the actual malocclusion has almost NOTHING to do with genetics at all. In fact, what we have learned from the relatively new science of epigenetics is that most malocclusions in humans are actually a distortion of the genetic process triggered by some chronic stressor of the modern environment.   The anthropologists tell us that the “genetic” standard for the human dentition is room for 32 teeth in a wide arch. They say that because that’s the way it’s always been, up until the modern era anyway. Just as surely as a zebra has stripes, a pre-modern human has straight teeth with only minor exceptions. Anything other than that is a distortion – a compromise – of the ideal. These distortions are the result of compensatory behaviors we make in response to the chronic stressors of the modern environment. The way we breathe, the way we eat, the way we sleep, the way we use our

Barry Raphael, DMD, is a practicing orthodontist in Clifton, New Jersey, for over 30 years. His transition to airway thinking came 25 years into practice so as he says, “I know what it takes to make the transition.” He teaches these concepts at the Mt. Sinai School of Medicine in New York City. He is the owner of the Raphael Center for Integrative Orthodontics and the founder of the Raphael Center for Integrative Education.

22 DSP | Winter 2017

The prospect of the environment being the etiology of most chronic disease is somewhat overwhelming to practitioners who have been trained only to take care of the symptoms. CPAP, MADs, and even braces are merely ways to help a person compensate for the problem but do nothing to effect a cure (hence, lifetime retention and management). Changing from a static to a dynamic view of human biology not only requires a change in thinking, but a change in treatment approaches as well. The good news is that dynamic treatment approaches are available that address the three major aspects of physiology: Structure, Function and Behavior. Helping the face, jaws, and airway grow optimally helps reduce flow limitation and gives teeth plenty of room to erupt. Optimizing the functions of sleep, nutrition and posture lessens the swelling, inflammation, and obstruction of the airway. And training proper breathing mechanics, tongue posture, and swallowing mechanics eliminate the soft tissue dysfunctions. Above all, educating and training four basic competencies of airway physiology can make a difference for people of all ages. Nasal, diaphragmatic breathing, lip competence, tongue-to-palate resting posture, and swallowing without using facial muscles can help an adult sleep better and can help a child grow up with straight teeth. You CAN optimize the outcome of growth and development for your patients and help overcome the symptoms by curing what ails modern man.


TEAMfocus

What We Know Now – A Team Approach

by Glennine Varga, AAS, RDA, CTA

G

raduation photos and thank-you cards covered the cork board next to the receptionist desk. There was a large sliding window behind the check-in clipboard. Once your name was called you walked thru the door and after two short steps you were in a massive room with what seemed like 20 dental chairs abuzz with women in matching scrubs hovering over their chair’s occupant, elastics and wires flying. There was energy and conversation in the air until we walked into the consultation room, suddenly quiet, with shiny white models of my teeth sitting on the table. We were told my 4 bicuspid teeth and impacted wisdom teeth were to blame for my teeth crowding. I wish we knew then what I know now… In 2017, we understand our airway anatomy can collapse easily during sleep. The collapse impacts our quality of sleep and interferes with essential tasks such as cleaning our brain, regulating hormones and boosting cardiovascular health. We understand that form follows function – swallowing and how we hold our tongues shapes both the maxilla and mandible during growth. We know the shape and position of the jaws will influence airway function. Do we know if the extractions impacted my airway? No, unfortunately this not something we can revisit and analyze. However, personally I would like my bicuspid space back which I feel would

24 DSP | Winter 2017

give my tongue more space and make my face more symmetrical. The conversation between parent/patient and doctor regarding airway deficiency is not always easy. Some people do not appreciate bringing habits, allergies, genetics or whatever into the picture. After all, “There is nothing wrong with my child.” The younger the age that airway problems start, the more influence they have on growth and development. It’s not only the growing bone – the shaping of the child’s personality, mood and intelligence can be affected as well. I believe I was 14yrs old when I was sitting in that consultation office. I was terrified about the wisdom teeth extractions; I figured the bicuspids were no big deal. NO ONE considered that by reducing the size of this child’s mouth her airway volume was also going to be smaller. There was no chance my mother would ask such a thing, and the thought wasn’t in the orthodontist’s head, either. I simply had too many teeth. I wish we knew then what I know now… As team we can educate our patients and it’s one of the most rewarding things we can do. Most people do not understand the relationship between sleep and breathing let alone how childhood growth and development plays a role. Here are some simple steps to help you find opportunities to com-


TEAMfocus municate and educate patients by simply sharing What We Know Now. Parents/patients want facts about sleep and breathing if it doesn’t feel that you are directing the information toward them. Remember, they don’t want to be told something is wrong with them or their child. Clinical team members can ask ‘Did you know’ questions during a new patient interview or while taking x-rays to break the ice. I like to always start with… • Did you know prior to 2013 we did not know why we sleep? What we know now is we sleep to clean our brain! • Did you know sleep disordered breathing can result in bed wetting in a child? I don’t know if you have ever experienced this but what we know now is it is very common and typically resolves when the child breathes better. • Did you know adults need 4-5 90 minute cycles of sleep a night? What we know now is any interruption in sleep can reset the cycle and makes it start over. Therefore, it’s very important to limit the number of times you wake up. Sleep breathing can impact this dramatically. Get together as a team and come up with 3-4 great “Did you know” questions, then practice on each other so your patients hear a consistent message. If your practice is starting to become more airway focused, your onsite and online presence should reflect this. It is important patients have materials to read and information to reference. The DSP Patient Education Guide was created for them to take home – it’s a perfect item to share. Create fact-filled, fun, and interesting videos to run in reception. Joining social media groups affiliated with Healthy Start or Myofunctional Orthodontics allows your office to participate with other offices and communities dedicated to helping children with sleep disordered breathing. The more you can learn the more you can help by teaching. Every patient/parent makes the final decisions about how to feed their infant, what habits should be broken and which should be enforced, and whether or not to remove their child’s bicuspids. It’s our job to make sure they have facts and ways to identify if there may be an issue.

As our dental profession learns more about sleep and breathing, it will become more important that each office integrates these services into practice. This is my 20th year in dentistry and my favorite communication opportunity tip is one I’ve seen used with some of the greatest dental mentoring groups like The Pankey Institute and The Dick Barnes Group of Arrowhead Dental Lab: The New Patient Encounter. Use this time to get to know your patient. Team interviews patient or parents to find out what prompted them to come in. At some point in your conversations your patient will need to decide a course of action. This interview will allow you to find out more about why the patient feels it’s important to do something. Knowing why will make all the difference. For the past 4 years I’ve seen more and more information on sleep and airway become news and noteworthy for our profession. I feel like we are at the time when measuring blood pressure was first discovered. Sphygmomanometers were not available to everyone, never mind knowing what the numbers mean or how to use them to make decisions toward therapy. Now everyone can do that and I feel measuring sleep is catching up quickly. In no time, we be able to purchase something that will measure our breathing and sleep staging and patients will be able to measure sleep quality, identify disruptions and make decisions toward therapy. Let’s be a team that is ready to answer questions about diagnostic protocols and therapy options.

Most people do not understand the relationship between sleep and breathing let alone how childhood growth and development plays a role.

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

Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain. She has been employed in dental education for over 19 years. Glennine has been a TMD/Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and a trainer of electrodiagnostic equipment for five years. Glennine is CEO of Dental Sleep Medicine Boot Camp and a Total Team Training instructor for Arrowhead Dental Lab. For more information, visit www.dsmbootcamp.com or email g@dsmbootcamp.com.

DentalSleepPractice.com

25


PRODUCTspotlight

What Does Neuroscience Have to Do with Dentistry? A Lot! by Sandra Marlowe

I

magine a new way to practice dentistry – where your patients look forward to visits and arrive calm and relaxed. Where you are far more to your patients than just a way to prevent or get out of pain or have a more attractive smile. At your practice, patients are discovering a healthier, happier life in ways they never dreamed possible. Some patients have lost weight, others have found relief from anxiety and fear, and some even have you to thank for lower golf scores. Imagine, in this new dental practice, patients schedule recommended treatment because they trust you. They complete treatment plans because they feel safe in the office, and they regularly refer friends and family because you are more than just their dentist, you are their hero. How do you create such a practice? The surprising answer for a large and growing number of dentists has been found in the burgeoning field of neuroscience and new discoveries in brain wave entrainment. These methods work by balancing and harmonizing the brain in a way that creates a profound mental state of peak performance. BrainTap Technologies is leading the charge in delivering brain wave entrainment technology in an easily consumable manner. The benefits of braintapping include relaxation, stress reduction, restorative sleep, and lifestyle improvements that directly contribute to an enhanced patient experience.  BrainTap uses five mind technologies that, combined, create a powerful tool for you to use both in-office and for home care to help improve quality of life for your patients in every aspect of their lives. • Beats and Tones – Imbedded tones emulate relaxed brain waves, guiding the brain to an extraordinary level of focus and performance that would otherwise take years of practice to achieve. • Audio Library – Patrick K. Porter, PhD, BrainTap’s founder, created guided visualization audio-sessions to help people

26 DSP | Winter 2017

become the designers of their own lives. With a selection of more than 700 titles – all encoded to work with the BrainTap headset – users learn how to focus on everything they want out of life. • 10-Cycle Holographic Music – The music on the Audio Library audio-recordings is designed to create a full 360-degree experience that delights the mind with calming thoughts and images. • Light Frequencies – The BrainTap headset adds the dimension of light pulses that train the brain to produce a healthy balance of brain wave activity, transforming the listener into a mental powerhouse with the right mindset to accomplish just about any goal. • Auriculotherapy – The BrainTap headset also delivers light frequencies through the ears. There are specific points in the ears, called meridians, known to directly affect the body’s organs and systems. These are typically activated using acupuncture needles, but light frequencies are known to have the same effect. The headset’s earphones are uniquely equipped with nine LED lights set at the optimum frequency for providing a sublime feeling of serenity and balance, all without needles. The benefits to patients are innumerable, and can be immeasurable. Virginia Beach homecare provider Carol Hooper is a great example. “I had been overweight nearly my entire life,” Hooper says, “Food was my comfort when I was sad, tired or happy. In 1996, I met Dr. Patrick Porter (BrainTap’s founder) and my life changed forever. Dr.


PRODUCTspotlight

Patients feel the results in a short amount of time, allowing them to recognize the longterm benefit.

Porter taught me how to balance my brain, visualize my goals, and stay motivated for life. I took off 95 lbs. and, best of all, I kept it off for twenty years.” Stories like Hooper’s are not uncommon. But how do dentists benefit from providing BrainTap in their practices? By becoming licensees of the BrainTap system, any dentist can have the ability to increase income and build a more varied practice in at least five different ways: 1. BrainTap services can be offered to patients in the dental practice for profit. Now dentists can offer programs for sleep, weight loss, smoking cessation, stress reduction, pain reduction, or choose a more unique route of care by choosing from any of 700 single audio sessions offered on the BrainTap mobile app. You can also use BrainTap to add value (and higher fees) to some or all of your existing practice’s services. 2. Offer the BrainTap Headset in office as a retail item. BrainTap offer the dental professional a generous wholesale rate. Dentists who retail just one BrainTap Headset a week can drop an additional $12,500 to their bottom line. And, once clients own their own BrainTap headset, they will likely opt for the mobile app membership, which adds to monthly income as well. 3. Sell the membership service to clients for added monthly revenue. For every client set up for membership, dentists earn 30 percent of the $30 monthly payment. Which means, if just four patients a week become members, this alone can add $7,000 to the bottom line with virtually no effort. And dentists who prescribe the membership service to stressed-out clients for home care, see a growing residual income. 4. Use BrainTap Technology products and services as your entrée for drawing in new patients, conducting training sessions, demos, seminars, and shows. Free

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.

28 DSP | Winter 2017

demonstrations of the BrainTap headset provide you a unique way to introduce prospective new patients to your practice. They experience an immediate shift in how they feel and function, making it easy to convert them for long-term care. 5. Improve retention and increase referrals. Patients experiencing brainwave entrainment through the BrainTap headset and the membership tend to respond better to care and overall are happier and more compliant – which translates to patients that stay and refer. To make it simple for the practitioner, BrainTap allows dentists to gift patients a 15-day trial for FREE. Getting brainwave patterns back to normal, or closer to normal, during that 15-day free trial allows patients’ brains to start self-regulating and the autonomic nervous system to balance, helping all unconscious activity to function optimally. This helps regulate the functions that have been under control of the Central Nervous System (CNS). Patients feel the results in a short amount of time, allowing them to recognize the long-term benefit. So how do you apply this neuroscience to the real life dental practice? Consider for a moment how many dentists are now offering and profiting from treatment for sleep apnea, a disorder that causes breathing to frequently stop and start that has been associated with significant health risks including high blood pressure, diabetes, obesity, and heart disease. In the national effort to understand, diagnose and treat this disorder, dental professionals have emerged as an important part of the community aimed at alleviating human suffering due to sleep apnea. This specialized area of practice has become a rewarding and highly profitable part of those dental offices. Now, thanks to new advances in neuroscience, BrainTap is providing dentists unique and specialized tools for branching out into other arenas such as weight loss, stop smoking, stress management, chronic pain, and may more. And, for the dental sleep practice, BrainTap is the logical complement to existing treatments for sleep apnea. The first step in discovering all that BrainTap can do for you and your practice is to try braintapping for yourself. Simply sign up for a complimentary trial here: www. mybrainoffer.com.


PRACTICEmanagement

Maximize Medical Insurance Benefits by Rose Nierman, CEO Nierman Practice Management

I

f you have medical billing mastered for Obstructive Sleep Apnea (OSA) cases, it’s time to consider billing other procedures to medical insurance. Once you discover that medical billing success revolves around documentation, you can explore what’s needed to bill medical for other services such as TMJ treatment, CBCT (cone beam), medically necessary exams and oral surgeries. More states are now mandating that health plans must cover TMJ treatment and accidents to teeth. In some instances, dental plans instruct dental offices to first bill a patient’s medical insurance for oral surgeries (this can maximize benefits and end up saving the dental benefits for restorative dentistry). And yet another billing scenario involves clearance exams (and radiographs) to rule out oral infection before a medical surgery or chemotherapy. Many medical insurance policies are now paying for these clearance exams with ICD Code Z01.818: Encounter for preprocedural examination NOS Encounter for examinations prior to antineoplastic chemotherapy Services to consider for Medical Billing

• Exams • Panorex, CBCT • TMJ Disorder, Craniofacial Pain Services • Sleep Apnea Therapy

30 DSP | Winter 2017

• Bone Grafts & Implants • Impacted Teeth Removal • Frenectomies, Biopsies and other Dental Surgeries including Anesthesia • Clearance Exams • Accidents to Teeth • Botox injections for “Painful Bruxism” Whether billing for OSA or other procedures, preparatory steps include asking the right questions and creating the patient’s story in SOAP reports. When reviewing medical history focus on the loss of function, pain or infection to help determine if services are medically necessary. When you learn the ropes for cross-coding (billing medical insurance in dentistry), you’re focused on navigating claim form boxes and connecting ICD-10 codes (diagnosis) to the appropriate and corresponding CPT codes (procedures). A new biller has all the ICD, CPT, and claim form fields correct but may forget the one thing that could make all the difference – documentation. Accurate documentation for oral appliances includes a sleep study and or CPAP Intolerance Affidavit. Subjective symptoms such as morning headaches and the score from an Epworth Sleepiness Scale (higher than 10) also need to be documented in S.O.A.P. reports. S.O.A.P. reports are your


PRACTICEmanagement decisive advantage with medical insurance. Still not sure if documentation is that important? Keep reading and you’ll find out shortly why this could be your downfall.

What needs to be in an S.O.A.P. report?

S. – Subjective Complaints of the Patient. Use a Patient Questionnaire unique to TMJ disorder, loss of function or obstructive sleep apnea screening. Report your Review of Systems (ROS) which is a verbal medical history summarizing organ systems which documents the level of medical history taking. O. – Objective Findings of the Provider. In addition to a dental screening for OSA, perform an airway exam. It’s also important to rule out if the patient has been diagnosed with TMJ disorder or periodontal disease since some insurance companies exclude a patient as a candidate for oral appliance therapy when these conditions are present. When there is no clear-cut diagnosis of periodontal disease or TMJ disorder, include this fact in your SOAP reports. These baselines often need to be stated upfront to prevent preauthorization and claim delays. A. – Assessment by the provider with ICD diagnosis codes included. Having a SOAP report with the codes printed leads to approvals in the preauthorization phase and documentation which conforms to claims submitted. P. – Plan The plan outlines what services are in the treatment plan moving forward for this patient and includes recall and referrals. Since you will be generating a SOAP report for medical insurance, be sure to forward the reports to the other healthcare providers the patient sees. Sending reports to medical providers, whose care the patient is under, is respectful and spreads the word that you are the leading sleep apnea, TMD or surgical dentist in your area. Avoid submitting medical exams without knowing the documentation required to support the exam code levels. Insurers may request this documentation in post-payment reviews. Post payment reviews ensure that providers do not perform up-coding on these codes. For example, a Level 4 evaluation and management code is typically 45 minutes but time alone is not the determining factor. It’s essential to also document that the presenting problems are of moderate to high severity, the history taking and exam are com-

prehensive, and the level of decision-making is moderate to high. SOAP reports are typically one-half to two pages and provide the documentation that medical insurance and the patient’s other providers want and need. Taking a little extra time to SOAP up the patient’s story ensures that you don’t take a bath with medical insurance and physician referrals.

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

Express 4 Sleep Semi-custom oral appliance to treat snoring and sleep apnea It is the first adjustable, customizable device that can be delivered chairside in 5 - 10 minutes. Available to dentists for in-office fitting or to dental labs as a sellable kit.

express4sleep.com | 708-207-0007 Don’t miss the CE article by Dr. Moses on page 32

DentalSleepPractice.com

31


CONTINUING education

Evolution of the Human Oral Airway and Apnea by Allen J. Moses, DDS, Elizabeth T. Kalliath, DMD, and Gloria Pacini, RDH

Introduction

Educational aims

This article intends to present human evolutionary development in a different way to engender a better understanding of why humans are the way they are, to challenge the validity and rationales of some established treatment methods and perhaps shed light other more comfortable, effective and less invasive therapies.

Expected outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader will: • Have a better understanding of the influence of evolution on the nervous system, structural and regulatory integrity of human function. • Understand that evolution is random, opportunistic, unpredictable, strange and not logical. • Appreciate that a unique relationship results from the small dimensions of the human birth canal mandated by the survival requirements of upright bipodal locomotion and the evolutionary advantages of developing progressively larger human brains. • See that it is the unique evolutionary history of human facial development that results in swallowing and breathing operating by different anatomic details at the newborn stage and during adulthood.

32 DSP | Winter 2017

Overwhelmingly, patients diagnosed with obstructive sleep apnea (OSA) receive treatment with continuous positive air pressure (CPAP), a pneumatic stent for maintaining airway patency during sleep. A significant problem is that patients do not comply at a rate substantial enough to indicate anywhere near universal acceptance of CPAP. The compliance rate reported in the literature is 40%. There are a multitude of reasons for CPAP noncompliance with the chief one being that OSA is an extremely complex malady. Treatment of OSA requires a thorough understanding of the biomechanics, biochemistry, pathophysiology and morbid consequences of this complex phenomenon1, but more than that, the human airway is part of our complex evolution. Evolution can be illogical and evolution is often quite strange. It is not always predictable. The thought is that understanding the history of what was may lead to clues to cope better with what is. There has always been a common sense assumption that everything about homo sapiens must be a great improvement over any-


CONTINUING education

Figure 1: Examples of snout fetishes Source: The Moses Collection

thing evolved by other animals. This may be totally irrational in terms of evolution of the head and will be a part of this discussion. The evolution of human beings is in fact a work in progress that is far from perfect, and understanding some of these imperfections may shed light on alternative treatments for OSA2. Some cultures seem to decry this evolution – snout fetishes are still found today and they may not be as ethologically baseless as it seems, and will be discussed.

Figures 2A and 2B: Illustrate evolutionary changes from quadripodal to bipodal mobility; and cantilevered horizontal head posture to vertical, balanced head posture.

Structural Changes

In lower animals the spinal column comes out the back of the head, is oriented horizontally and parallel to the ground. The head is cantilevered off the spinal column. Humans have evolved to an erect posture and the spinal column is vertical to the ground. The head is balanced on top of the spinal column. Humans are bipodal – walk on two legs. The reorientation from quadripodal to bipodal came with many structural changes, including a change in position of the foramen magnum which moved from being in the back of the head to the center at the bottom of the skull. Also the human head, in proportion to the rest of the body, is much larger than that of other animals. The most important function of the back and neck in humans is to balance the giant human head on the spinal column. Humans have bigger heads for accommodating bigger brains than other primates; the switch to bipodalism required a great amount of neurological development. Numerous adaptations of the head had to occur to accomplish the increased cranial size. The evolutionary changes that occurred encompassed modularity, integration and multifunctionality of existing parts3. In all mammals the head emerges first from the birth canal. The snout being parallel

Figures 3A and 3B: It is normal for all mammalian newborns to emerge from the birth canal snout first or head first.

Figure 4: Head sizes at birth relative to size of birth canal. Source: Rosenberg, K. & Trevathan, W. (2002). Birth, obstetrics and human evolution. BIOG: an Internatlional Journal of Obstetrics and Gynecology, 109, 1199-1206.

Dr. Allen Moses has had a dental practice in Sears/ Willis Tower for over 25 years and was assistant professor at Rush University for 15 years in the department of sleep research and clinical practice. He is the inventor of The Moses® intraoral sleep appliance distributed worldwide by Modern Dental Lab, and the Express4Sleep™. He has four US patents and has written more than 30 articles on sleep dentistry, facial pain and temporomandibular disorders.

DentalSleepPractice.com

33


CONTINUINGâ&#x20AC;&#x160;education

Figure 5: Illustrates large size of human head at birth. Source: "Textbook of Obstetrics and Obstetric Nursing" Bookmiller, MM, Bowen, GL; section on the newborn by Bakwin, H. With original drawings by Frank Netter. Public Domain, https://commons.wikimedia.org/w/index.php?curid=30361510

to the spinal column, lower animals come out snout first. Human heads emerge from the birth canal crown first as a logical evolutionary development so that human necks not break as infants emerge from the human birth canal4. The human birth canal must undergo a huge dilation during labor and5 delivery to accommodate emergence of the jumbo human head crown first. In humans, a flat face is also a necessity for getting the head out of the birth canal but ultimately compromises nasal function, airway size, olfaction and condylar position6. It also reduces space for the tongue in the mouth. The birth process would be virtually impossible if human newborns had a snout. Major structural changes occurred for human faces to eliminate the snout. As it is, human birthing is difficult7, but definitely facilitated by the soft fontanelles that allow a reshaping of the head during the birth process. The fontanelles also allow for brain growth to occur post-partum and remain soft to allow brain growth for a number of years.8

Functional Adaptations

Significant evolutionary changes to the human head are flat face, smaller chin, shorter oral cavity, changes in jaw function, repositioning of ears behind jaws, ascent of the uvula and descent of the epiglottis, right

Figure 6: Fontanelles and soft sutures allow for a reshaping of the head during the birth process. Source: Graham JM, Sanchez-Lara P. Vertex birth molding. In: Graham JM, Sanchez-Lara PA, eds. Smiths' Recognizable Patterns of Human Deformation. 4th ed. Philadelphia, PA: Elsevier; 2016: chap 35.

34 DSP | Winter 2017

angle bend in tongue, creation of compliant, combined, flexible airway-foodway, and speech.9 Humans, by virtue of their upright posture, bipodalism, big heads and larger brains to facilitate functional balance, speech and reasoning must try and orchestrate their survival as a species with repositioned, reconditioned, rebuilt, redesigned miniaturized and in many cases, parts of inferior design for olfaction, mastication swallowing, hearing, breathing and conditioning of inspired air.10 Lower animals have evolved structures of nearly perfect design for their particular function for olfaction, mastication, swallowing, hearing, breathing, and conditioning of inspired air. This optimal design observed by primitive cultures in lower animals might be a reason for the shamanic veneration of the snout. The adult human pharynx is made up of a short oral cavity and an upright neck combined with a rounded tongue that has a 90 degree bend so 2/3 is horizontal and the posterior 1/3 is vertical. Lower animals have a horizontal tongue and a throat arrangement referred to as an intranarial or locked epiglottis. The intranarial epiglottis diverts food around the trachea and into the esophagus during a swallow. This arrangement of parts deflects swallowed food over the tracheal airway and into the esophagus. It is beneficial because the animal can swallow and

Figures 7A and 7B: The yellow outlined rectangles define the area of tongue collapse on the distal of the pharynx during sleep, called Obstructive Sleep Apnea (OSA). This open area of throat between soft palate and epiglottis defines non-intranarial airway is unique to humans makes it possible to choke to death on aspirated food and is essential to forming vowel sounds in speech. OSA does not happen the same in adults and children. Source: "Atlas of Human Anatomy" 2nd ed. Netter FH; Novartis E. Hanover, NJ, 1997


CONTINUINGâ&#x20AC;&#x160;education breathe at the same time. Human newborns, until the age of 3 - 4 months, have this same intranarial arrangement.11 The tongue first appears in embryological development at approximately six weeks. It develops from swellings in the first four branchial arches, hence innervations from XII, X, VII, and V cranial nerves. The entire tongue is within the mouth at birth. It doubles in length and thickness between birth and adolescence, and always stays entirely within the mouth. The tongue position, swallow, as well as breathing modes influence development of the palate, the face and eruption of the teeth12. With no snout and a short, flat face the human tongue is not proportionately larger than other primates, but it must fit in a smaller space and allow a patent airway for breathing. Newborn human babies suck only to attach to the breast.13 They nasal breathe as they nurse and because of the locked epiglottis, they can swallow and breathe simultaneously. As the human infant grows the epiglottis descends and the uvula ascends with the soft palate to which it is attached. The descent of the epiglottis is not complete until about 15 years of age, or when the vocal cord is fully matured. In adult humans separation of the epiglottis from the uvula allows mouth breathing, necessary when the nasal airway is obstructed. In mouth breathing the nasopharynx and the oropharynx are in open communication. The only bone intimately connected to the pharynx is the hyoid. It is literally a floating bone that lies at the base of the tongue, suspended by a series of muscles and ligaments.14 It is the center of action for most movements of the pharynx. The position of the hyoid changes during speech, swallowing and particularly in mouth breathers with their low tongue position. The lower the hyoid the more forward is the head position on the spinal column and the lower the tongue, the smaller the pharyngeal airway. The largest oropharyngeal airway is created with the person nose breathing, the lips sealed, dorsum of the tongue as far forward as possible and sealed against the hard and soft palate.1 In the newborn human the muscle fibers in the entire tongue are horizontally oriented. As the epiglottis descends and the uvula ascends, the pharynx grows vertically and

Figure 8: Frontal, open mouth view of a newborn. Interlocking of soft palate and epiglottis illustrates intranarial airway. Breast milk flows through faucium channels, infant's lips are sealed on breast and child can breathe and swallow at same time. Source: Crelin ES. Development of the Upper Respiratory System, Clinical Symposia, Vol. 26, No. 3, 1976

Figure 9: Sagittal section just lateral to midline showing infact suckling on mother's breast. Note: flat infant face from not having a snout, position of nipple just anterior to soft palate, lips sealed on nipple, nose breathe shape of mother's breast allows now breathing so infant can nose breathe and swallow simultaneously (intranarial arrangement). Tongue is all horizontal. Source: Michael Woolridge, The 'Anatomy' of infant sucking. Midwifery, 1986 (2) 164-171

Figure 10: Chimpanzee demonstrates the intranarial airway arrangement. Chimp can swallow and breathe at the same time. Adult human on the right cannot breathe and swallow at the same time, demonstrating a non-intranarial airway. Source: "An Introduction to Human Evolutionary Evolution"; Atella L, Dean, C; Academic Press, 1990. "The Ontogenetic and Phylogenetic Development of the Upper Respiratory System and Basicranium in Man". Laitman JT; PhD Dissertation, Yale Univ. 1977

the posterior one-third of the tongue simultaneously grows vertically as well. The elongated oropharynx has no bony or cartilaginous support to maintain patency. Longitudinal and circumferential muscles constitute the sides and posterior pharyngeal walls. The vertical portion of the tongue occupies the anterior wall of the pharynx. The oropharynx and tongue create a flexible, compliant, combined airway-foodway. DentalSleepPractice.com

35


CONTINUINGâ&#x20AC;&#x160;education Consequences of Rebuilt, Reconditioned, Repositioned, Redesigned Parts

To avoid choking, human swallowing requires more neurologic precision and coordination than in lower animals. As humans sleep, flaccidity of the tongue can bring about collapse of the tongue on the soft palate or flexible, compliant walls of the oropharynx, causing obstructive sleep apnea (OSA) and/ or snoring. A very positive evolutionary development resulting from the flexible, compliant adult human airway is the capability to create formant sounds, instrumental in the articulation of speech.15 In adult humans the pharynx remains open for passage of air at all times except during swallowing, and regurgitation. Breathing cannot occur simultaneously with swallowing. The good news is speech. The negative consequences are choking, snoring and obstructive sleep apnea (OSA). OSA occurs when the luminal cross-sectional area of the upper airway collapses during inspiration, at or below the level of the soft palate and above the epiglottis.

Young children do not experience Obstructive Sleep Apnea at the same site or sites as adults.

An apneic event is created in adults by either the tongue or soft palate or both together collapsing on the back of the airway during sleep. The collapse can be caused by muscle flaccidity, negative airway pressure brought about by increased nasal airway resistance, or a combination of both. It can be predisposed by muscle fatigue, CNS misfiring or incoordination, pulmonary diseases or neuromuscular diseases. Combinations of the following can also contribute to the airway blockage: swollen, hyperplastic or redundant tissue, large tonsils, obesity, nasal obstructions, deviated septum, dysphagia, broken nose, long soft palate, large uvula, macroglossia, edentulous collapse, iatrogenic micrognathia (otherwise known as four bicuspid extraction orthodontics).

36 DSP | Winter 2017

Young children, with the intranarial or locked epiglottis do not experience OSA in exactly the same way as adults. Young children most commonly experience what is called Upper Airway Resistance Syndrome (UARS). UARS is not so much a collapse of the tongue, as a distinct airway obstruction by inflamed, edematous tissue. UARS in juveniles occurs at the level of the tonsils and adenoids. The immune systems of young children have not yet developed to the advanced status of adults. These lymphoid tissues can proliferate to obstruct airflow due to environmental irritants, allergic rhinitis, asthma, viral infections or genetic factors. This tissue enlargement can obstruct air flow to various extents that rarely result in overt OSA but most commonly in UARS, snoring or just mouth breathing. If undiagnosed or just left untreated, under-development of facial structures, adult OSA and serious other adult morbid consequences can result. Most mammals ventilate almost exclusively through their noses. Mouth breathing usually only occurs in mammals when suffering from hyperthermia. Human children with enlarged tonsils and adenoids however, usually become mouth breathers. Kids who chronically mouth breathe experience reduced nasal cavity growth, developing smaller midfaces, narrower maxillae, smaller noses and narrower nasal cavities. After surgical removal of the tonsils and adenoids, young children rapidly undergo a catch-up period of growth, developing wider, longer, deeper nasal cavities and maxillae as well.17 Obese children are also at risk for sleep disordered breathing (SDB) and OSA. Fatty infiltration of subcutaneous anterior neck tissue and cervical structures can exert collapsing forces on the pharynx. Obesity and fat buildup can also cause mass loading of the respiratory system in the chest wall and abdomen forcing reduced diaphragm movement in breathing. Gozal proposes that these are two distinct types of OSA in children.15

Concluding about evolution and airway development

Evolution is not the same as biologic engineering, where a designer has a goal in mind and tools or components are created to fulfill the new function. Evolution is random


CONTINUING education

Figure 12: Sectioned skulls demonstrate that the roof of the mouth is contiguous to the floor of the nose, the lateral wall of the nose is contiguous with the maxillary sinus and the medial wall of the eye. The tops of the nose and eye border the brain. The roof of the mouth is contiguous to the floor of the nose. Evolutionary changes involve integration, modularity and multifunctionality of parts. Bone growth in one area may stimulate or retard other areas from developing. Source: "Essentials of Human Growth" 2nd ed. 1996, Enlow D, Hans M, Saunders Pub, Philadelphia

and opportunistic. Bones in the skull share walls, so that bone growth in one region accomodates growth in an adjacent area.18 Evolutionary changes in the head encompass modularity, integration and multifunctionality of existing parts. The roof of the mouth is the floor of the nose. The lateral wall of the nose is contiguous to the medial wall of the eye. The top of the nose and eye border the floor of the brain. The chewing muscles and TMJ attach to the skull. Tongue movement, nose breathing, mouth breathing, swallowing, speaking and OSA are complexly integrated in terms of development, structure and function so that new and different function in one part may stimulate or retard others from developing as growth continues. The only bone intimately connected to the flexible, compliant oropharynx is the hyoid, which lies beneath the base of the tongue. Positioning and coordination of the hyoid, the tongue, jaws, cervical vertebrae and larynx requires frequent intermittent changes during breathing, speech, swallowing, mandibular function and apnea episodes. Maintaining head balance during this nearly constant repositioning and coordination of changing function requires the involvement of tremendous neurologic circuitry. Humans need all the brains they can get to survive and function with all their redesigned parts and no snout. This concludes Part 1 of a four part series.

1.

"Principles and Practice of Sleep Medicine", 4th ed. Kryger, MH; Roth, T; Dement, WC. Elsevier Saunders, Philadelphia, 2005

2.

"Orofacial Myology: International Perspectives", Hanson ML, Mason RM;Charles C. Thomas, Pub. Springfield, IL 2nd ed. 2003

3.

"Evolution of the Human Head", Lieberman, DE; Harvard UniversityPress, Cambridge MA, 2011

4.

Lothian JA, McGrath K; Your step by step guide to giving birth. www.Lamaze.org

5.

“Textbook of Obstetrics and Obstetric Nursing“ Bookmiller MM, Bowen GL; section on the newborn by Bakwin, H. With original drawings by Frank Netter., Public Domain

6.

Rosenberg, K. & Trevathan, W. (2002). Birth, obstetrics and humanevolution. BJOG: an International Journal of Obstetrics and Gynaecology, 109, 1199-1206.

7.

Wittman, AB, Wall, LL; The Evolutionary Origins of Obstructed Labor:Bipedalism, Encephalization and the Human Obstetric Dilemma. Obstetrical and Gynecological Survey 2007; 6(11): 739-748 Graham JM, Sanchez-Lara P. Vertex birth molding. In: Graham JM,Sanchez-Lara PA, eds. Smiths' Recognizable Patterns of Human Deformation. 4th ed. Philadelphia, PA: Elsevier; 2016:chap 35

8.

9.

"Reconstructing Human Origins", Conroy, GC; 2nd ed. WW Norton, NewYork, 2005.

10. "The Human Vocal Tract: Anatomy, Function, Development andEvolution", Crelin, ES; Vantage Press, New York, 1987. 11. "The Comparative Anatomy and Physiology of the Larynx" Negus VE;Hafner Publ Co. New York, © 1949 12. "Development of the Upper Respiratory Tract ", Crelin, ES; in CibaClinical Symposia; V26, (3) 1976, Ciba Pharmaceutical Company, New Jersey 13. Woolridge, M. The ‘Anatomy' of infant sucking. Midwifery, 1986 (2)164-171 14. “An Introduction to Human Evolutionary Development”; Aiello L, Dean,C; Academic Press, Cambridge MA. 1990 15. “The Ontogenetic and Phylogenetic Development of the UpperRespiratory System and Basicranium in Man”. Laitman JT; PhD Dissertation, Yale Univ, 1977 16. "The Unpredictable Species: What Makes Humans Unique". Lieberman,P; Princeton University Press, New Jersey, 2013. 17. Dayyat E, Kheirandish-Gozal L, Gozal D. Childhood Obstructive SleepApnea: One Disease or Two Distinct Disease Entities?", Sleep Med Clin. 2007 Sept; 2(3):433 - 444 18. "Essentials of Facial Growth", 2nd ed. Enlow D, Hans M; Saunders Publ.Philadelphia 1996 19. "Sicher's Oral Anatomy" DuBrul EL; 7th ed. CV Mosby Co, St Louis MO1980

DentalSleepPractice.com

37


CONTINUINGâ&#x20AC;&#x160;education

Continuing Education Test

CE CREDITS

Certificate Details

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 1/1/2016 to 12/31/2017 Provider ID# 356023

REF: DSP Winter 2017

__________________________________________________________________________________ FULL NAME __________________________________________________________________________________ AGD REGISTRATION NUMBER

CONTINUING EDUCATION BROUGHT TO YOU BY MEDMARK AND SEATTLE SLEEP EDUCATION

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 8 CE credits for only $129. To receive credit, complete the 10-question test by circling the correct answer, then either:

__________________________________________________________________________________ LICENSE NUMBER __________________________________________________________________________________ ADDRESS __________________________________________________________________________________ CITY, STATE, AND ZIP CODE

n Post the completed questionnaire to: Dental Sleep Practice CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

__________________________________________________________________________________ EMAIL

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

__________________________________________________________________________________ TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted. Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkaz.com to your Approved Senders List in your email account.You may need to check your junk/spam folder for your certificate email.

Evolution of the Human Oral Airway and Apnea Allen J. Moses, DDS, Elizabeth T. Kalliath, DMD, and Gloria Pacini, RDH 1. Post-partum brain growth in humans is made possible by: a. no snout b. fontanelles c. flat face d. bipodal posture 2. Reshaping of the head during birthing is made possible by: a. flat face b. no snout c. female hormone release d. fontanelles 3. Ascent of the uvula and descent of the epiglottis results in the consequence of: a. right angle bend in tongue b. flat face c. ability to create vowel sounds d. repositioning ears behind jaws 4. Locked (intranarial) epiglottis in human newborns confers: a. attach properly to motherâ&#x20AC;&#x2122;s breast

38 DSP | Winter 2017

b. ability to swallow and breathe simultaneously c. suck on a pacifier d. bottle feed 5. A consequence of ascent of the uvula and descent of the epiglottis in adult humans: a. ability to mouth breathe b. generate consonant sounds c. right angle bend in tongue d. possibility to choke on food 6. The bone most closely connected to the adult oropharynx: a. maxilla b. mandible c. hyoid d. atlas 7. Obstructive sleep apnea in newborn children can result from: a. collapse of tongue on compliant airway during sleep b. sleeping with a pacifier c. nasal obstruction from allergies

d. obstruction of the oral airway by enlarged tonsils 8. In evolutionary reorientation from quadripodal to bipodal posture: a. human head became cantilevered to spinal column b. foramen magnum moved distal on skull c. diameter of foramen magnum decreased d. head got larger relative to body size 9. Evolutionary changes to human head: a. more acute olfaction b. better hearing c. improved visual acuity d. bigger brains 10. Pediatric sleep disordered breathing: a. has same biomechanics as adult OSA b. never involves mouth breathing c. has no adult consequences d. inflamed, edematous tissue causes severe restriction of airflow


䐀䔀一吀䄀䰀

匀䰀䔀䔀倀  䴀䔀䐀䤀䌀䤀一䔀 吀甀昀琀猀 唀渀椀瘀攀爀猀椀琀礀 䐀攀瀀愀爀琀洀攀渀琀 漀昀  䌀漀渀琀椀渀甀椀渀最 䔀搀甀挀愀琀椀漀渀 椀猀 瀀氀攀愀猀攀搀 琀漀  愀渀渀漀甀渀挀攀 椀琀猀 渀攀眀攀猀琀 搀攀渀琀愀氀 猀氀攀攀瀀  洀攀搀椀挀椀渀攀 瀀爀漀最爀愀洀⸀ 吀栀椀猀 瀀爀漀最爀愀洀 椀猀  椀渀琀攀渀搀攀搀 昀漀爀 搀攀渀琀椀猀琀猀 氀漀漀欀椀渀最 琀漀 琀愀欀攀 琀栀攀  ǻ爀猀琀 猀琀攀瀀猀 琀漀眀愀爀搀猀 氀攀愀爀渀椀渀最 愀渀搀  甀渀搀攀爀猀琀愀渀搀椀渀最 琀栀攀 瀀爀愀挀琀椀挀攀 漀昀 搀攀渀琀愀氀  猀氀攀攀瀀 洀攀搀椀挀椀渀攀Ⰰ 愀渀搀 眀椀氀氀 猀攀爀瘀攀 愀猀 愀渀  猀氀攀攀瀀 洀攀搀椀挀椀渀攀Ⰰ 愀渀搀 眀椀氀氀 猀攀爀 攀砀挀攀氀氀攀渀琀 瀀爀攀挀甀爀猀漀爀 琀漀眀愀爀搀猀 愀渀 攀砀琀攀渀搀攀搀  瀀爀漀最爀愀洀 ⠀猀甀挀栀 愀猀 琀栀攀 吀唀匀䐀䴀 䐀攀渀琀愀氀  匀氀攀攀瀀 䴀椀渀椀ⴀ刀攀猀椀搀攀渀挀礀⤀⸀

䐀攀渀琀愀氀 匀氀攀攀瀀 䴀攀搀椀挀椀渀攀㨀  䄀 䌀漀洀瀀爀攀栀攀渀猀椀瘀攀  䤀渀琀爀漀搀甀挀琀椀漀渀 䘀攀戀爀甀愀爀礀 ㄀ ⴀ㄀㄀Ⰰ ㈀ ㄀㠀

䴀愀爀挀栀 ㄀ ⴀ㄀㄀Ⰰ ㈀ ㄀㠀

䄀瀀爀椀氀 ㄀㄀ⴀ㄀㈀Ⰰ ㈀ ㄀㠀


LASERfocus

Superpulse 10,600 nm CO2 Laser Revision of Lingual Frenum Previously Released with a Diode Hot Glass Tip by Karen Wuertz, DDS, and Peter Vitruk, PhD Lingual Frenectomy and Significance of OMT

Frenectomy utilizing scissors or a scalpel is associated with several drawbacks, such as intra-operative hemorrhage (which impedes the visibility of the surgical field and may ultimately lead to scarring); the need for sutures; post-surgical pain and discomfort; and the potential for infection.1,2 Electrocautery and dental diode hot glass tip may result in notable thermal injury3 and consequent prolonged healing. Erbium laser frenectomy necessitates the need to manage intra-operative bleeding, due to the inefficiency of the erbium wavelength for coagulation.3 The 10,600-nm CO2 laser provides effective and spatially accurate soft-tissue incisions, with excellent coagulation ability due to close match between photo-thermal coagulation depth and the diameters of oral soft tissue blood and lymphatic capillaries.1,3 As a result, good visibility of the surgical field is maintained and the risk of postoperative edema is reduced. After the removal of the lingual restriction, oro-myofunctional therapy (OMT) is crucial1 to re-establish the swallowing, chewing, speaking and breathing patterns developed as a consequence of ankyloglossia. Without such therapy, the deviant swallowing, speech impediments, compensatory tongue posture and improper breathing habits persist, which eventually entails the relapse of airway problems, sleep disorders and other preoperative issues.

Patient

22-year-old healthy male presented for consideration of a revision of a healed lingual frenum (Figures 1A-1B) released 1.5 years prior with a 940 nm diode hot tip (Biolase®, Irvine, CA). He did not do OMT exercises post-release and his tongue felt tight again. He experienced headaches, bilateral TMJ tenderness, pain and tightness in his neck and between the shoulder blades. The patient reported a history of sleep issues. His symptoms included excessive daytime sleepiness and fatigue, low energy, moodiness, and restlessness. He had no history of drug or alcohol use and was currently taking no medications. The patient had a sleep study performed (WatchPat Home Device) and was diagnosed with a sleep disorder. Childhood history of symptoms: Born a healthy male with difficulty breastfeeding, a

40 DSP | Winter 2017

A.

B. Figure 1: A. View prior to CO2 laser frenectomy. The lingual frenum was previously revised with a diode hot tip, but the restriction returned. B. Tongue-toSpot distance preoperatively – 27 mm.

history of severe reflux with projectile vomiting, colic and inconsolable crying. Mother reported that as an infant, he failed to sustain latch while she experienced pain at latch that persisted throughout the feeding. The mother reported cracked, bruised and bleeding nipples, plugged ducts and mastitis and eventual decrease in milk supply, despite pumping. The patient was placed on formula but continued projectile vomiting, had blood in stool and experienced weight loss. He had frequent ear infections, placed on multiple antibiotics and at 6 months of age had ear tube placed by the ENT. Adenoids and tonsils were removed at two years old due to persistent ear infections and recurrent strep throat. He was subsequently placed on soy formula which helped to resolve the vomiting. He received speech therapy at age 9, and by age 11 resolved most of the speech issues. Intraoral clinical exam and history: Patient had had routine dental hygiene care and required no restorative dentistry. Moderate occlusal wear revealed a history of bruxism, and non-extraction orthodontic therapy involving maxillary palatal expansion and mandibular advancement with a fixed Herbst appliance was also reported. Prior to his diode frenectomy, the patient presented with bilateral TMJ tenderness, asymptomatic bilateral subluxation of the condyles, lateral excursions of 10 mm bilaterally with poor lingual-mandibular differentiation. No nasal deviation was noted, nasal airway was patent. The intraoral exam revealed a restricted lingual frenulum after the previous frenectomy was completed with a 940 nm diode hot tip. There was a decrease in the elevation of the tongue and tongue-to-spot (TTS) placement. At the time of his appointment for the second frenectomy, the patient’s Mallampati score was 2.


LASERfocus

A.

B.

C.

D.

E.

Figure 2: A. Grooved tongue director is used to maintain tension. Frenal tissue is “etched” by zigzagging the CO2 laser beam. B. After surface tension started to release, a horizontal incision is made half-way between the frenal insertion into the tongue and the floor of the mouth. C. Vaporizing fibers and releasing tension. D. Patient is asked to open his mouth wide with tongue anchored to the incisive maxillary papilla. E. The remaining restriction is removed horizontally.

Laser Surgery

After baseline re-assessment/measurements, local anesthesia (4% Articaine hydrochloride with 1:100,000 epinephrine) was administered by infiltration. The LightScalpel laser surgery was performed (see Figures 1-3) with the assistance of the grooved retractor. LightScalpel CO2 laser with 0.25mm focal spot size laser handpiece (see Figure 4) was utilized, delivering 2 Watts SuperPulse laser beam gated at 70% duty cycle at 20 Hz (average power to the tissue 1.4 Watts). Similarly gated non-SuperPulse settings for defocused beam is used for enhanced hemostasis without cutting, if needed. To facilitate the laser procedure, gentle tension was applied to the tongue during the lingual frenectomy. At first, the handpiece was held approximately 4 millimeters away from and perpendicular to the target tissue; a zigzagging vertical motion was used to “etch” the tissue (Figure 2A) (“etching” was done to “tenderize” the tissue, where the scarred tissue that

After the removal of the lingual restriction, oro-myofunctional therapy (OMT) is crucial to re-establish the swallowing, chewing, speaking and breathing patterns developed as a consequence of ankyloglossia.

resisted cutting was present). As the tissue began to respond to the laser energy, the zigzagging vertical motion was continued until the frenal tension began to release. A horizontal incision at approximately 1 mm handpiece-to-tissue distance was made in the midline, half-way between the frenum insertion to the tongue and the floor of the mouth (Figure 2B); vaporization of fibers continued (Figure 2C). The patient was then asked to place his tongue to spot (the maxillary incisive papilla) and open the mouth as wide as possible and continue to open, while the tongue remained anchored (Figure 2D). This provides the opportunity to watch the increase in opening and further functional elevation resulting from the laser release. This also enables the surgeon to observe and evaluate if tension remains on the floor of the mouth. The tongue director was removed and with the tongue anchored, the noted frenal restriction was further removed in the horizontal direction (at a 1 mm tip-to-tissue distance) (Figure 2E).

Karen Wuertz, DDS, is a Diplomate of the American Board of Craniofacial Dental Sleep Medicine and a Fellow in the American Academy of Craniofacial Pain. She is passionate about treating and coordinating care for patients as it relates to Oral restrictions, Oral function and Airway management during Sleep. She is an Assistant Adjunct Professor, UNC Dental School, Chapel Hill, a Member of the North Carolina Dental Society, American Dental Association, American Association of Dental Sleep Medicine and the American Association of Sleep Medicine, Fellow in the American Academy of Craniofacial Pain, Diplomate American Board of Dental Sleep Medicine, and a Clinical Evaluator for Dr. Gordon Christianson’s Clinician’s Research Foundation. She holds active dental licensure in Virginia, North Carolina, and Texas. She has written and published numerous papers on restorative & cosmetic dentistry. Peter Vitruk, PhD, is a founder of LightScalpel, LLC in Woodinville, WA. He is a member of The Institute of Physics, a Diplomate of the American Board of Laser Surgery, USA, and its current Director of Laser Physics and Safety Education, and a founder of American Laser Study Club. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@ lightscalpel.com.

DentalSleepPractice.com

41


LASERfocus When the fascia overlying the genioglossus muscle was observed, a finger dissection of the remaining frenal fibers completed the procedure. During the frenectomy, a large sublingual blood vessel was encountered; precise laser cutting and shallow penetration depth allowed the surgeon to remove the tissue around it, while leaving the blood vessel intact. After the tension was released, the patient was asked to extend the tongue and to lateralize it in each direction, with the chin stabilized. This also helps to determine if lingual mandibular differentiation can be observed. Measurements were then re-assessed and recorded at the maximum opening and TTS (Figure 3A) shows that the TTS distance increased by 11 mm to reach 38 mm).

adjusted to the new appliance and soon reported improvements in his sleep quality and restfulness. During the visit to his chiropractor within the first week after the laser release, he noted that his neck adjustment, unlike all of the prior ones, was “as smooth as butter”. With the combination of his post-release OMT and wearing the MAD, the patient reported the resolution of pain in his TMJ and neck. Six months after the surgery the MAD is still necessary for maintaining quality of life (and differences are seen when the appliance is not worn). The patient was highly compliant with the OMT and the surgical site healed without complications (Figure 3B). A.

Postoperative Care and Healing

Ten minutes after his CO2 laser frenum release, the patient reported that tightness in his neck and shoulders immediately disappeared. 800 mg Ibuprofen was recommended postoperatively, but the patient did not need it as the surgical site was only mildly sore. Soft diet was advised for the first 24 to 48 hours with the recommendation to avoid spicy, caustic, crunchy or sharp foods. To achieve the maximum range of motion and optimal function, regular OMT was an important part of postoperative protocol. For five weeks after the surgery, five times a day, the patient performed five sets of eleven exercises (the routine adapted from the Myo Manual). He was also instructed to wear his new sleep appliance, mandibular advancement device (MAD), nightly to keep his oropharyngeal airway patent. He quickly

B. Figure. 3: A. Immediately after the tongue tie release, the tongue-to-spot distance has increased from 27 mm to 38 mm. B. 6 months post-frenectomy, regular OMT and wearing MAD.

Summary

The proper orofacial function in patients can be restored through an extensive functional release1 of restrictive lingual frenum. The functional release is achieved through a) the SuperPulse CO2 laser frenectomy accompanied by the tongue mobility assessment to ensure optimal function; and b) mandatory OMT. Due to reduced wound contraction, minimal thermal tissue damage, less traumatic surgery, precise depth of incision and hemostatic efficiency, the SuperPulse 10,600 nm CO2 laser presents an effective alternative to scalpel, electrocautery, diodes and erbium lasers.

Acknowledgement

The authors greatly appreciate the support and contribution from Anna “Anya” Glazkova, PhD, in preparing this material for publication.

1. 2.

3.

4.

Figure 4: Laser incision/coagulation with focused (250-µm spot size) and defocused (500-800-µm spot size) laser beam delivered from a pen-sized, autoclavable handpiece.

42 DSP | Winter 2017

Fabbie P, Kundel L, Vitruk P. Tongue-tie functional release. Dent Sleep Pract. 2016 winter;40-5. 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. Vitruk P, Levine R. Hemostasis and Coagulation with Ablative Soft-Tissue Dental Lasers and Hot-Tip Devices. Inside Dentistry. 2016 Aug;12(8):37-42. Holtzman SR. Orofacial myology: From basics to habituation: A treatment manual. 2nd ed. Orlando, FL: Neo-Health Services, Inc.; 2014.


A complimentary copy of Tony Robbins best selling new book,

UNSHAKEABLE & a free review of your 401(k) plan

#1 Best Seller

#1 Best Seller

#1 Best Seller

HOW IT WORKS 1. Visit FreeCopyPlease.com and give us the details of your 401(k) plan. We will uncover all layers of hidden and unnecessary fees. 855.905.4015

2. After a brief call to review the results, we will send you a complimentary copy of UNSHAKEABLE.


PRODUCTspotlight

Patient Centric Design Helps Collaborate with Medicine by Reza Radmand, DMD, FAAOM

A

s “oral physicians”, we have an opportunity and obligation to reach across the aisle to our medical colleagues and collaboratively address systemic health issues. Looking past the teeth, gums and temporomandibular joints, we can observe the patient more comprehensively and use the oral cavity as an important health indicator. In the words of one of the founding father of Johns Hopkins Hospital, Sir William Osler, “The good physician treats the disease; the great physician treats the patient who has the disease.” Osler called the oral cavity a mirror of the rest of the body.1 As a hospital-trained dentist and medical school faculty, I have learned, taught and crossed the aisle with this discipline. The field of sleep medicine has provided a platform for a unique collaboration between dentists and sleep physicians. The diagnosis and treatment of sleep disturbed breathing typically resides within medicine. This most often results in a CPAP (continuous positive airway pressure) solution. The attractiveness of CPAP’s 100% efficacy can blind providers to the poor compliance and compromised MDA (mean disease alleviation)2. The dental team, led by “oral physicians”, however, has the best vantage point for screening and recognizing the

Which Would You Choose?

ProSomnus Appliance

44 DSP | Winter 2017

Typical CPAP Machine

anatomical variants, phenotypic expressions, and other patient centric circumstances as contributors to successful treatment. This collaborative dialogue could further improve the effectiveness of treatment modalities that are available. Individualizing treatment and matching appliance type and design features, improves the efficacy, efficiency and ultimately the effectiveness of treatment. Imagine the following: During a routine dental visit, the dentist identifies a patient at risk for sleep related breathing disorder who also reports history of chronic sinus congestion, hypertension, lightheadedness and occasional episodes of skip beats in his pulse. The dentist initiates a referral to a sleep physician colleague for further testing and diagnosis, emphasizing the potential associated comorbidities. The sleep specialist, using this screening results as a jumping off point, orders a sleep test and determines the patient has a sleep disorder which could also be contributing to the other reported health concerns. The patient does not qualify for the standard CPAP therapy, due to the chronic sinus congestion and therefore receives a prescription for oral appliance therapy. The sleep specialist refers this patient back to the dentist for oral appliance fabrication with design specification to include advan-


PRODUCTspotlight Clinical Presentation Large Tongue / Small Arches / Gagger

Lingualess Hooks

Lateral Play

Reinforce

X

X

X

X

Mouth Breather

X

Airway

X

X

X X

Clenching / Bruxism

X X

X

X

X

X

Nasal Blockage Crowding / Malposition

Discluder Lingual Coverage

X

Compliance Risk

Promote Nasal Breathing

Compliance Sensor

X

Extensive Range of Motion

Claustrophobic

70’ Posts

X X

Anterior Open Bite

X

Partially Edentulous / Retention Concern

tages for their chronic sinus congestion. In this scenario, the dentist not only initiated an impressive preliminary screening observation for a sleep related problem, but also made a point of the associated comorbidities to the referring physician. The subsequent prescription for an oral appliance provided an opportunity for the dentist to customize the choice, design and therapy to meet the patient’s expression and condition, because, one size or design does not fit all. The ProSomnus [IA] device has a myriad of features that can be applied to offset anatomical variations, circumstances, and phenotype expressions that a patient may present with. The chart above shows some of the Monogram features available and the clinical presentations they support. There are many oral sleep appliance manufacturers, but few have been able to be as responsive to the rate of change in medical science and have the necessary platform

X X

to accommodate design features addressing discoveries as they are made in the field of sleep medicine as ProSomnus Sleep Technologies. Their proprietary, patented system allows for the precise digital fabrication of a customizable device, which drives improved patient compliance, efficacy, efficiency and outcomes3,4. The future is undoubtedly bright, exciting and rewarding. Through new technology, proven science and acceptance of multidisciplinary collaboration among experts in the field such as sleep medicine, the odds of success will inevitably rise, as new opportunities for collaborations are already here and gaining traction.

1. 2. 3. 4.

JAMA. 1957;165(2):159. Osler Quote New Eng. J Med. McEvoy et al 2016; 375: 919-931 – SAVE Trial WSS Poster, Stern et al 2017; EFFECTS Study AADSM Poster, Vranjes et al. 2016; New Oral Appliance Titration and Results

“Oral physicians” have the best vantage point for screening and recognizing the anatomical variants, phenotypic expressions, and other patient centric circumstances as contributors to successful treatment.

Reza Radmand, DMD, graduated with a BA in Biology from Hofstra University in Hempstead, New York, and received his dental degree from Tufts University Dental School in Boston, Massachusetts. He then attained a Residency Certificate in Hospital Dentistry at UCLA Medical Center, Los Angeles, California. Dr. Radmand is an American Academy of Dental Sleep Medicine Research Committee Member, has Dental Sleep Medicine Facility Accreditation, and is a Diplomate with the American Board of Dental Sleep Medicine. He is a Fellow of American Academy of Oral Medicine and Associate Fellow of American Head and Neck Society. He also has received the Dental Radiology High Achievement Award from the American Academy of Dental Radiology. Currently, Dr. Radmand is a Clinical Assistant Professor in the Department of Surgery at Yale New Haven Health-Bridgeport Hospital. He is in private practice and is an active member of the medical staff at Yale New Haven Health-Bridgeport Hospital, as well as a clinical instructor at the Yale School of Medicine. Dr. Radmand is a member of the American Head and Neck Society, American Academy of Oral Medicine, and the American Academy of Dental Sleep Medicine and has served as treasurer on the board of the New Haven Dental Association. Dr. Radmand has served as a presenter at many conferences and has published articles in dental and medical journals.

DentalSleepPractice.com

45


TMDscreening

Exploring TMJ Symptoms as a Result of MAD for Sleep Apnea by Mayoor Patel, DDS, MS

I

n recent years, dental devices have taken an increasingly important role in the treatment of snoring and obstructive sleep apnea (OSA). Increasing evidence suggests that mandibular advancement devices (MAD) improve sleep-disordered breathing.1

The acceptance rate of MAD after one-year ranged from

55% 2 % 8 to

MAD is the most common class of oral appliance used to treat snoring and OSA. While there are several MAD designs, all devices protrude the mandible and induce changes in the anterior position of the tongue, soft palate, lateral pharyngeal walls, and mandible, resulting in improved airway patency.2 Response to MAD is variable and normally depends on the design and patient characteristics. The acceptance rate of MAD after one-year ranged from 55% to 82%, and there was a declining trend over time.2 The most common reasons for discontinuing MAD use are lack of efficacy, side effects, and complications.3

Side effects disrupt care

Subjective side effects are common, and the most frequently reported include temporomandibular joint (TMJ) pain, myofascial pain, tooth pain, salivation, TMJ sounds, dry mouth, gum irritation, and morning- after occlusal changes.4â&#x20AC;&#x201C;7 Most of these side effects

are minor, well-tolerated and tend to be resolved in a short period of time. Objective side effects such as tooth movement, skeletal changes, and occlusal alteration have also been reported.5,8â&#x20AC;&#x201C;10 Temporomandibular disorders (TMD) have also been associated with the use of MAD in some patients. TMD is a cluster of heterogeneous disorders of the masticatory muscles and TMJs. The myogenous and arthrogenous disorders may be further subclassified into myofascial and arthrogenous pain, disc displacements, and degenerative joint disease as the most common conditions.

Occlusal changes in patients

Although many patients report that TMD symptoms are significantly reduced following MAD treatment, the development of some problems is not surprising, given the significant forces applied to the teeth and temporomandibular joints during jaw repositioning. In many cases, occlusal changes are minor and not noticed by the patient. This is typical because the majority of patients do not have a loss of posterior occlusion or experience TMJ pain. Understanding the various pain conditions the patient may experience and their clinical characteristics will allow you to formulate a treatment strategy. Most pain conditions as a result of MAD are also self-limiting. Sharpening your understanding and receiving education in TMJ disorders will allow you to better manage your patientsâ&#x20AC;&#x2122; health and well-being.

Explore common examples

Myogenous pain over the masseter/temporalis muscle can be experienced in some patients once the appliance has been removed in the morning. This condition can be managed conservatively using temporary cessation of the MAD or reduction in the use of the device in combination with remedial jaw exercises each morning following the removal of the appliance.

46 DSP | Winter 2017


Only 15% of airway/

BECOME INVOLVED

sleep disorders are diagnosed. Help address this major unrecognized public healthcare crisis by joining thought leaders, academies, organizations and corporations to bring a unified message of awareness to the public.

â&#x20AC;˘ Attend Foundation Events

Airway Summit @ The Greater New York Dental Meeting November 25, 2017 in New York, NY

â&#x20AC;˘ Complete the Foundation for Airway Health Pledge (below) and be listed as a resource for those seeking care for airway/sleep problems.

For more information, visit www.foundationforairwayhealth.org Foundation for Airway Health Pledge We want to fill our pledge rolls with practitioners of any modality that believe in the importance and priority of airway. Those interested can use this form or visit the Foundation website and find the pledge under the Healthcare Professionals tab. Thank for your support and partnership in our airway mission.

o

I am committed to championing the recognition, diagnosis and treatment of airway disorders through collaboration, awareness, research and education, and access to care. I pledge all patients seen in my office will be screened for airway/sleep problems and will be provided resources for diagnosis, treatment and referral.

o

I wish to be listed on the Foundation for Airway Health website as a referral resource for those seeking care for airway/sleep problems. Airway is a priority.

Name ____________________________________________________ Email ____________________________________________________________ Send to Foundation for Airway Health, 355 Lexington Ave., 5th Floor, New York, NY 10017 or pledges@airwayhealth.org


TMDscreening

Critically, prior to MAD therapy, completing a comprehensive screening and workup can prevent complications from arising.

Moist heat application with stretching (opening mouth and holding it for 5 seconds and repeating for a couple minutes) may also be a simple yet effective treatment option. This is considering that the mandible is not being held in an eccentric position or that heavy contacts of the posterior aspect of the appliances are not causes. If occlusal changes are noticed upon awakening, they can, in most cases, be resolved by morning jaw exercises or ceasing MAD use for 1-2 weeks. It is important to demonstrate and have the patient show understanding of the exercises you suggest. Prevention of occlusal changes is maintained by further instruction to the patient about an ongoing exercise regimen after removal of MAD and careful monitoring by the clinician. We consider it reasonable to persist with treatment in the presence of occlusal change, providing that it is regularly monitored (by at least 6-month clinical reviews), not associated with unacceptable symptoms, not progressive, and that there is adequate posterior occlusal support.

Further modifications and adjustments

Pain in the TMJ can be a result of capsulitis, synovitis, osteoarthritis or a variant of some form of internal derangement. Soft diet and identifying the etiology of these symptoms are critical for resolution and prevention of further pain. It is important to determine if the mandible is being held in an eccentric position or heavy contacts of the posterior aspect of the appliances are present. If so, address and make appropriate modifications to return the mandible to a more neutral position or reduce the heavy occlusion on the posterior aspect of the appliance. Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP, serves as a board member with the American Board of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain (ABCP), American Academy of Craniofacial Pain and the British Society of DSM. He also has taken the role as examination chair for the ABCP. Having a limited practice to Craniofacial Pain and DSM, Dr. Patel utilizes his experience and expertise to help dentists across the country excel within their dental practices. As Clinical Education Director with Nierman Practice Management, Dr. Patel develops up-to-date curriculum for their sleep apnea and craniofacial pain programs. To register for a seminar, contact Nierman Practice Management through Contactus@dentalwriter.com or 800-879-6468.

48 DSP | Winter 2017

In the acute stages, nonsteroidal anti-inflammatory drugs (NSAIDs), which are effective analgesics and anti-inflammatory agents, can be prescribed. Care must be taken to evaluate for gastrointestinal irritation and bleeding, which is a major risk of this class of medications. Critically, prior to MAD therapy, completing a comprehensive screening and workup can prevent complications from arising. Many times, if a pre-existing condition is present, addressing it prior to treatment with MAD can prevent many of the symptoms experienced by patients. Many medical insurance policies now require documentation showing that there is an absence of a TMJ disorder prior to initiating oral appliance therapy so TMD screening and management becomes even more important than ever to retain insurance payments. It is beyond the scope of this article to address all the possible treatment choices, but I do encourage you to understand the functionality of the TMJ and the various conditions that produce pain in the TMJ. Courses are available for TMD and dental sleep medicine to become familiar with the many ways you can help your patients when symptoms or side effects develop. 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev. 2006 Jan 25;(1) Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repositioning appliances. Sleep Med Rev. 2004; 8:443–457. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244–262. Shadaba A, Battagel JM, Owa A, Croft CB, Kotecha BT. Evaluation of the Herbst mandibular advancement splint in the management of patients with sleep-related breathing disorders. Clin Otolaryngol Allied Sci. 2000;25:404–412. Fritsch KM, Iseli A, Russi EW, Bloch KE. Side effects of mandibular advancement devices for sleep apnea treatment. Am J Respir Crit Care Med. 2001;164:813–818. de Almeida FR, Lowe AA, Tsuiki S, et al. Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea syndrome. J Clin Sleep Med. 2005;1:143–152. Marklund M, Franklin KA. Long-term effects of mandibular repositioning appliances on symptoms of sleep apnoea. J Sleep Res. 2007;16:414–420. Pantin CC, Hillman DR, Tennant M. Dental side effects of an oral device to treat snoring and obstructive sleep apnea. Sleep. 1999;22:237–240. Bondemark L, Lindman R. Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splint: a 2-year follow-up. Eur J Orthod. 2000; 22:53–60. Fransson AM, Tegelberg A, Johansson A, Wenneberg B. Influence on the masticatory system in treatment of obstructive sleep apnea and snoring with a mandibular protruding device: a 2-year follow-up. Am J Orthod Dento-facial Orthop. 2004;126:687–693.


CLINICIANspotlight

Fresh Eyes and New Technology – People are Getting Healthier

S

ee if this sounds familiar: A young-50’s male, with a snoring history that includes his children begging for separate hotel rooms during family trips so they could get some sleep. The family says they considered Dad’s snoring to be funny and annoying, but not dangerous. The man has been observed falling asleep at his keyboard in the afternoon, and admits to being awakened by the bumps on the side of the interstate on long trips. DSP readers who have begun talking with their patients about airway health have met this man. Probably won’t surprise you to hear that he had never visited a sleep physician, much less been diagnosed, in no small part because the man refused to consider using a PAP device and he was convinced that would be his only treatment option. Seeing doctors was never on his ‘to-do list,’ and, besides, he felt fine. Richard “Sully” Sullivan, IV DDS, a new graduate, joined his father’s practice and soon invested in a Galileos CBCT from Sirona. Wanting to learn about their new fascinating tool and maximize their ROI, they attended SIROWORLD in Orlando in September of 2016. One of the featured speakers there was Tarun “T-Bone” Agarwal, DDS,

50 DSP | Winter 2017

with a talk about airway health and dental sleep medicine. Sully’s training in sleep had included only a brief talk during undergraduate dental school and a little bit of clinical practice in a residency, enough to be interested to sit in on that class, thinking he would find out more about what the Galileos could do. Little did he anticipate that the dots would start to connect – the patient profile T-Bone presented was every bit his father! That family was his, and Sully knew immediately that he wanted to do something to help his Dad. They bought a Braebon HSAT device – the Medibyte Jr. – and tested his father as soon as they could. The diagnosis, using Braebon’s portal, came back from the board-certified sleep physician as “one of the worst we’ve ever seen.” The AHI was 78, with oxygen levels dipping into the 70’s, over and over through the night. That funny, annoying, snoring suddenly took on a whole new level of importance. Sully knew two things immediately: he wanted to get his Dad treated as soon as possible, and he wanted to learn more about how dentists can help people. Using his Galileos and Cerec technology, he sent digital records to Sirona and soon his Dad was


CLINICIANspotlight using an OptiSleep dental device. The precision technology allowed the device to ‘drop in’ with no adjustments whatsoever, and Sully says “Dad was really shook up. Immediately he was able to sleep through the night without multiple bathroom breaks, something he had not enjoyed, well, ever. Mom even checked on him with a flashlight to make sure he was still breathing!” The crazy part is this medical professional had, up to then, no clue he had any breathing problem. Understandably thrilled with this result, Sully set out to fulfil the second part and signed up for sleep training in Raleigh with T-Bone and Dr. Erin Elliott, a dentist from Post Falls, Idaho, who complements T-Bone well with her fun, patient-centered and technologically adept style of teaching. Sully didn’t want to see more patients without learning more about what he was doing; what he learned there allowed him to see his practice with entirely new eyes. Adding fuel to this passion was the realization that those improved symptoms were not enough to know that Dad was OK. A repeat test with the Medibyte showed an AHI of 6 and no time spent with an oxygen level below 90% – they are sure they’ve added years to Dad’s life; certainly, the improvement in lifestyle is worth everything they’ve invested so far. No more falling asleep in the afternoon and everyone feels safer with Dad at the wheel now. The kids, now adults, still get separate hotel rooms, but not as a means of escape! Turning to the 3,000 patients in their practice of nearly 30 years, screening tools revealed many patients showing signs of sleep disorders that they’ve never noticed before. ‘Connecting the dots’ with their entire team during morning huddles, patients of the day that they thought might benefit from some directed conversation, such as those with nightguards, began to include more and more of the daily schedule. The hygienists, using the intraoral camera, pointed out pitted molars and scalloped tongues and talked with their patients about airway health. Galileos images showed compromised airways in detailed, color-coded pictures using Galileos software that showed the sometimes-dramatic compromises in airway present in their patients. Sully talked with colleagues in town – his passion for this new service meant he pushed for quick solutions for his patients. What if there were more like his Dad in his chairs? With his limited training came fewer limits on

possibility thinking – and he knew he wanted to establish some credibility as a young, passionate dentist. He saw 3 month waits for appointments with the sleep physicians as a barrier to healthy outcomes. His Sully wanted to get dental friends with more experience told tales of referrals and reports back of his Dad treated as only PAP being presented as treatment soon as possible, choice – exactly what had kept his Dad and he wanted to from seeking diagnosis for many years. “What if, instead of going to sleep learn more. physicians and primary care docs as an inexperienced, hopeful young dentist, I went with proven results? Can I expand to more than a case study of one? What would that mean to the patients I choose to help? I’ll have to come up with a plan to prove what we can do’ were some of the considerations Sully thought through, and decided to take action.

DentalSleepPractice.com

51


CLINICIANspotlight

They’ve made screening for SDB part of their office culture – it is simply what is done at Sullivan Dental Care.

Using their modern Sirona technology, they were able to use CBCT and Omnicam to identify patients at risk for sleep disordered breathing. They’ve made using the Braebon HST part of their office culture – screening for sleep disordered breathing is simply what is done at Sullivan Dental Care. In just over four months, they’ve delivered over 50 OPTISLEEP appliances, using a totally-digital workflow. Sully says, “I’ve yet to have to adjust the fit in the mouth.” From the time the patient discusses risk with a dentist, hygienist, or team member in the practice to the first night of airway support with the OPTISLEEP is about three weeks. Compared to the 90-day wait just for an appointment with the sleep physician, Sully’s confident he’s providing significantly better health for his patients. “It also means a lot when my partner and Dad walks in and tells them how its changed his life. In fact, we have had our entire team tested and two of our hygienists are also wearing optisleeps.”

Left: Dr. “Sully“ Sullivan discusses the OPTISLEEP with hygienist Kyndall. Right: Dr. Richard Sullivan, III DDS with son Dr. Richard “Sully“ Sullivan, IV DDS

Focusing on time to treatment involves some compromises that Sully is aware of – in no small part due to the prompting by his mentor Dr. Elliot. Medical insurance billing is limited by those policies that require pre-authorization of benefits or a specific prescription from a local sleep doctor. While all the Medibyte tests are read by a board-certified sleep physician, often Sully proceeds to make the devices from that diagnosis alone.

52 DSP | Winter 2017

This is legal in his state, but he’s learning that there is a better protocol recommended by most sleep experts that he will be addressing soon. ‘But think about this,” says Sully, “when I go in to meet the local physicians, if I can bring in dozens of patient reports that have been successfully treated, won’t that mean more to those docs than if I just offered myself up as ‘ready to get started’?” His intention is to work out arrangements with physicians so they can evaluate the patient during the workflow and still maintain a fast time-to-treatment while incorporating the physician’s expertise for optimum patient care. With over 150 other mandibular advancement devices available for use, he’s also curious about using some others, but those perfect-fit OPTISLEEP devices are hard to beat, he says. “The next step in my education is definitely involving the primary care doctor more. I think it’s hypocritical of us as dentists to be annoyed when they don’t communicate, yet here I am doing the same thing. Its just better for the patients to have more providers involved.” One thing he says about starting out without a lot of preconceived ideas is that he and his team feel sleep disordered breathing is not limited to older, overweight males – they consider it for every patient. It’s just part of their culture. One man, 27 years old with a host of symptoms you wouldn’t immediately associate with SDB such as dentin hypersensitivity and enamel erosion, and other complaints more commonly found such as tiredness and depression, was evaluated in the practice and found to have an AHI of 54. Having some other medical conditions, his mother stays involved in his health care and talked with Sully about how frustrated she was – that no one on his medical team had ever asked about, much less tested him for, sleep problems. She worries that he wouldn’t be able to tolerate a PAP to begin with and is beyond excited that treating his sleep disordered breathing could have a domino effect on some of the daily things he struggles with. Sully is on his way to a major impact on his community health. More education, a better connection with physicians, and some office system developments will only improve his ability to help other people’s fathers and sons (and mothers and daughters, too!) enjoy a healthier, happier life.


PRACTICEgrowth

Did You Hear the One About the Dentist...? by Chris Bez, opportunity engineer

M

arketing for a Dental Sleep Medicine practice, as we all know, is at a right angle to marketing for a general dentistry practice. While the marketing vehicles may be the same, the target audience is multi-pronged and the messages for each aspect of your marketing strategy are very different. There is also the added dimension of being invisible. Perhaps less so in recent years, but still, dental sleep medicine is seldom a topic that makes the top 10 list at any gathering. Despite that, as marketing strategies are worked, most of us experience campaign wins and watch the practices we are affiliated with, grow. Some grow geometrically, some gradually, but still the trend continues upward to the point where dental sleep medicine becomes one of the practiceâ&#x20AC;&#x2122;s reliable profit centers. Or so I thought. Iâ&#x20AC;&#x2122;ve been marketing for DSM practices for over a decade, and have enjoyed success on behalf of my clients helping them build and grow their practices, providing all the good

stuff we marketing types are supposed to provide to deliver patients to the door. Recently, however, I was reminded of Marketing 101 and appreciated the refresher course enough to believe it worthy of sharing. Most successful marketing is fairly straightforward â&#x20AC;&#x201C; familiarize with your market, learn about the available vehicles, define the practice vision/message, create the strategic plan, add market-friendly creativity, work the plan, evaluate results, adapt and persist. The variations to the plan come from creativity, implementation and sometimes, dumb luck. Tactics vary from urban to suburban areas, are impacted by social and political environments and demographic specifics but, if attention has been paid to those pieces, and messages have been well crafted, absent acts of God, for the most part a sound program provides favorable results.

Be careful what you promise... Marketing 101 begins with an old story as told by office staff. DentalSleepPractice.com

53


PRACTICEgrowth When I was in the evaluation stage of one such “sound program,” I received the following exasperated explanation from “Amy” (not really her name), “Did you hear the one about the dentist who went away to a seminar and came back and expected things to automatically change? Well we have, more than once. Each year it’s a new direction, a new gadget, a new survey or whatever the flavor of the month might be. We don’t know the details, don’t know what’s needed, should get that through osmosis and the fallout is simple, we eventually get tired (sick and tired!) of dealing with Dental sleep medicine patients who are irritated by more is really a very different forms, longer waits, and truthfully in case, we’re not sold on the valcreature from general this ue of oral appliances. In fact, when practice or most a patient asks about oral appliances specialized dental now, we just try to discourage them. Most patients just stick with their regspecialties. ular appointments but leave the appliance stuff alone. At any rate, we don’t have to deal with it here and it makes it easier. Those appointments always run over, making schedules impossible, the phone calls beforehand asking about the insurance and insurance itself, which is a nightmare and takes way too long to process, well we just got tired of it.” I could hear the screeching of brakes in the background, followed by the sounds of crashing and burning. She was 100% correct if not addressed immediately, this would be a fatal error for future of dental sleep medicine in that office. Dental sleep medicine is really a very different creature from general practice or most specialized dental specialties. Insert schedules that go sideways, quickly, appliance re-

pairs that must ship to labs, follow up tracking, exhausted patients who often present with short tempers and bad moods; having to convince “cured” patients to return for recall appointments they don’t believe are required, and medical insurance claims that require more, new codes and often, resubmission. Early on staff must be educated, informed, invited into a discussion about dental sleep medicine. Being able to emotionally connect to the struggle of patients who suffer from obstructive sleep apnea and the hope that oral appliances offer them, understanding the overall health imperative of sleep, relating on a real level with the vast impact to the quality of life provided by healthy sleep – for the patient and often their grateful families, is essential to development of the empathy that can fuel willingness to deal with disrupted appointment flow, procedures and DSM patients. They need to be allowed to ask questions, push back and get more than a, “because I said so,” response. Taking time to bring on board, those who will be responsible for additional work, new training, basically for being the face of your DSM sales team, can be the difference between delivering a successful offering to your patients or being stealthily sabotaged. The attitude that persists – positive or negative, is supported with every phone call, every interaction and every patient file. A sound program must begin with the buy-in of those who are charged with the task of implementation – from the ground up. Deterrent behaviors can be far more successful than any marketing plan. Never promise what you can’t deliver: Marketing 101, as taught by Amy. Thanks, Amy.

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.

54 DSP | Winter 2017


PRODUCTspotlight

BluePro® Temporary Appliance: Clinical Profile

F

rench manufacturer BlueSom first launched BluePro® in Europe in 2014 and then received FDA clearance in December 2016 for the treatment of snoring and mild to moderate OSA. After launching in USA at AADSM/ Sleep 2017 and receiving an encouraging response from US dentists, this same-day temporary appliance is now available nationwide. Place in therapy

A closer look at the design features and evidence reveals wider opportunities for use beyond the traditional role of a temp.

BluePro is prefabricated, adjustable and thermoplastic; a category increasingly termed ‘PAT-MAD’ in the literature. It is fitted chair-side by the dentist within a few minutes by immersing the two splints in boiling water, molding them directly on the arches, assembling to form a monobloc, protruding as tolerated to a comfortable starting position and then locking in position for patients to begin same-day treatment. It plays a role comparable to other temporary appliances i.e. professional same-day transitional treatment, a way to affordably trial the patient’s response to mandibular advancement and a way to find an optimal level of titration comfortably through incremental adjustment. Indeed BluePro has demonstrated its suitability to this task in published studies and in European clinical practice. However a closer look at the design features and evidence reveals wider opportunities for use beyond the traditional role of a temp.

Retention

Professor Marc Braem evaluated this appliance in 2014 with a mechanical study to assess its retentive capability1. When molded to the teeth, the splints are designed to guide the pre-lined thermoplastic into the interdental spaces, creating a precise and durable impression. Professor Braem found the resulting mean force of retention to be around 26N, sufficient “to resist initial jaw opening as well as full mouth opening forces” over the equivalent of 1 year’s use.

56 DSP | Winter 2017

Loss of retention is therefore rarely a problem for this device. It is more likely that patients will feel some tightness or dental discomfort, but this can be addressed during fitting by removing interdental material from the splint with a sharp knife.

Efficacy

Two independent studies, first a pilot in 24 patients2 and then a larger comparative study3 have confirmed the efficacy of BluePro in treating OSA. The second study analysed treatment results for two patient groups over six months; one group wearing BluePro (n = 86) and one group wearing custom devices AMO® or SomnoDent® (n = 72). In their analysis, after adjusting for differences in the groups at baseline, the investigators observed no statistically significant difference between the groups in: • Primary outcome measures of sleepdisordered breathing symptom relief (AHI, AI, ODI, T90); • Mean measures of self-reported treatment satisfaction and compliance and; • Overall side-effect scores calculated from self-reported measures (despite reports of greater dental discomfort in the BluePro group). Of course BlueSom does not claim this to be evidence that the device can replace custom-made devices. However, the data shows that BluePro can provide equivalent efficacy to custom devices in suitable patients over a period of 6 months.

Wider role

In USA this device will be used mainly


PRODUCTspotlight

Case Study

by Dr. Kent Smith DDS, D-ABDSM, ASBA; Owner, Sleep Dallas and 21st Century Dental and Sleep Center; President, American Sleep and Breathing Academy; and Diplomate, American Board of Dental Sleep Medicine

M

y passion is helping patients get a better night of sleep, which affords them a day void of nodding off at the wheel and a healthier relationship with their partner. However, with the constraints of medical insurance, the delivery of these custom-made devices is often delayed for months. This reality is not welcome by many patients, and without a quick and comfortable way to ameliorate the sleepiness and unwelcomed angst, they would leave my office discouraged. A typical example of this scenario is our patient Leah. She presented on Tuesday, desperate for a solution to her strained relationship with her fiancé. They were sleeping in separate beds, as the noise that accompanied her severe sleep apnea was not allowing him to sleep. As usual, the custom device would take a few months before delivery would be allowed by her insurance. Enter BluePro. We have used many temporary appliances over the last 20 years, but my entire team loves the ease of fabrication, the unique adjustment mechanism and the fact they do not have to use any extra material. It appears to be the best complement to bridge the gap between custom and expediency.

as a trial or transitional appliance and its durability allows it to be kept as a robust spare after the custom device is delivered. In Europe it has been frequently used as a pragmatic therapy device in settings where custom devices are not available. This has been made possible thanks to a relatively sleek design, low price, simple adjustability, and (with regular cleaning) an achievable product life of 1 year. In USA it may similarly provide a pragmatic therapy option for patients without access to custom devices or those needing an affordable complementary device for nights away from CPAP.

Patient selection

All prefabricated appliances have limitations and BluePro’s one size does not fit all. It will flex to fit most arch sizes but it can be difficult to achieve a good fit in patients with irregular occlusion, especially cross bites, large open bites or a significant curve of Spee. Patient selection and hands-on practice are therefore key to successful adoption in clinical practice.

Specifications Device name

BluePro®

Manufacturer

BlueSom, Paris, France

Category

Professionally fitted, prefabricated, adjustable, thermoplastic (PAT-MAD)

Indication (510k)

Snoring and mild to moderate OSA in adults 18+

Adjustability

10mm in 1mm increments; Self-adjustable

Retention

High, confirmed at c.26N

Durability

1 year expected product life. No limitations on duration of use in 510k

Roles

1. Temporary, trial, transitional 2. Complementary, spare, back-up, emergency 3. Pragmatic 1-year therapy

For more information please contact hello@bluepro.pro or visit the website at www.bluepro.pro.

1.

2.

3.

Braem M. In vitro retention of a new thermoplastic titratable mandibular advancement device. F1000Research [Internet]. 2015 Feb 26 [cited 2017 Feb 14];4. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4392831/ El Ibrahimi M, Laabouri M. Pilot Study of a New Adjustable Thermoplastic Mandibular Advancement Device for the Management of Obstructive Sleep Apnoea-Hypopnoea Syndrome: A Brief Research Letter. Open Respir Med J. 2016;10:46–50. Gagnadoux F, Nguyen X-L, Vaillant ML, Priou P, Meslier N, Eberlein A, et al. Comparison of titrable thermoplastic versus custom-made mandibular advancement device for the treatment of obstructive sleep apnoea. Respir Med. 2017 Oct 1;131:35–42.

DentalSleepPractice.com

57


PRACTICEdevelopment

SEO: Scam or critical marketing service? Part 1 by Ian McNickle, MBA

T

he world of online marketing can be quite confusing, if not downright aggravating. It can be challenging to know what to do, how to do it, and who should do it for you. One of the most popular services discussed these days is “Search Engine Optimization” (SEO). Most people understand that SEO is a sort of mysterious service that somehow gets you ranked highly on Google and the other search engines. “What exactly is SEO?”

SEO can be defined as a set of ongoing monthly activities that must be performed in order for your website to rank highly on Google and the other search engines. SEO includes both “on-page” optimization and “off-page” optimization. On-page optimization includes items done on the website itself (code, content, images, videos, sitemap, blogs, etc). Off-page optimization includes items that are on the Internet, but not the website (online reviews, social media, directories, backlinks, etc). So in a

nutshell, SEO is some combination of all these things performed each month. Determining which items should be done and how much of each item should be done depends on your goals and local competition.

“I’ve tried SEO and got ripped off!”

I frequently lecture all over North America about SEO and many other online marketing topics. If I had a dollar for every time I’ve heard a doctor complain about getting ripped off, I could probably retire. I feel their pain and frustration. It’s real. Hiring an SEO company is kind of like taking your car to the mechanic. You hope they are honest and good at what they do so you’ll get value for your money, but it is difficult for you to assess that ahead of time (or even afterwards). In my estimation, SEO is indeed one of the most misunderstood services, and therefore, a lot of doctors get taken advantage of when hiring an SEO company. My goal with this article series is to educate doctors and staff to prevent you from getting ripped off, or at least from making bad decisions.

“How does it work?”

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com

58 DSP | Winter 2017

In order to understand why SEO needs to be done a certain way, it is important to first understand a little bit about how search engines operate. For most average websites, the search engines review your website about every 30 days. When a search engine reviews your website, it actually indexes (reads and stores on its servers) every line of content and code on your website. Each time it does this, it compares all of your code and content to what it indexed 30 days prior and looks for improvements, new content, etc. Search engines also take into account your online reviews (Google, Yelp, Healthgrades, Facebook, etc), as well as social media activity and engagement (Facebook, Instagram, Pinterest, Twitter, You Tube, etc). A well-designed SEO program will involve some combination of many of these activities every month so that each time the search engines index your website and online activity,


PRACTICEdevelopment your practice will be rewarded with higher rankings (or at least by not dropping in the rankings). SEO takeaway No. 1 — SEO activities must be done every month in order to be rewarded by search engines. If not, your search rankings will plateau or decline.

“How can I tell if I’m getting real SEO?” Google has over 200 variables it evaluates when assigning search rankings to websites. I normally group the most important variables into five major categories: 1) website code, 2) website content, 3) incoming links to the website, 4) online reviews, and 5) social media. In part 2 of our SEO series, we will explore these five major categories, so practices will be able to understand what they need to do (or what their SEO company should be doing) in order to rank highly on Google and other search engines. In part 3 of our series, we will

discuss questions to ask when interviewing SEO companies and how to spot scams (and low-end SEO services).

Marketing consultation

If you have questions about your website, SEO, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication.

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or call 888-246-6906. For more information, you can visit online at www.weodental.com.

1-888-751-1121

What is HindexRV™ & How does it work? Visit us at www.physiologicaldentistry.com Learn the basics of our technology and see how you can implement it in your practice.

Physiological Monitoring for Dentistry and Medicine HindexRV™ is an FDA approved cutting-edge physiological monitoring system for collecting and transmitting multiple measurements. The HindexRV™ system monitors the autonomic nervous system using accurate recordings of multiple physiological parameters and statistical data which the clinician can use to make a clinical assessment of medical, dental, or peak performance interventions.

DentalSleepPractice.com

59


LEGALledger

I

n this edition, I have asked Courtney to outline the Medicare rules and guidelines that dental offices MUST know in order to file Medicare. This is vital information! I encourage you to keep copies of this article for a quick reference for you and your employees. I want to thank Courtney for her commitment to the advancement of Dental Sleep Medicine.

Need to Know Medicare Guidelines for Oral Appliances for OSA

FRIEND OR FOE? Part 4

by Ken Berley, DDS, JD, DABDSM and Courtney Snow, Medical Insurance Consultant

60 DSP | Winter 2017

It is crucial that dental practices understand the guidelines when billing Medicare DME. The importance is two-fold; first to ensure that your practice is protected in the event of an audit from Medicare, and second to ensure that your Medicare patients receive the coverage that is available to them. Frequently, we find practices that have billed Medicare for years are violating guidelines. In this article, we will discuss the need to know guidelines when billing Medicare for custom made oral appliances for Obstructive Sleep Apnea (OSA). So how is a dental practice supposed to know the guidelines? It’s simple: get to know and love the Medicare Local Coverage Determination (LCD) and the related policy article. Sure, it may not be the most exciting read in the world, however, familiarity with this document could save your practice thousands of dollars in the long run. Each of the four Medicare DME Jurisdiction (A, B, C & D) have their own LCD; currently the language in all four is the same. You can locate your Jurisdiction’s LCD online from your DME Medicare Administrative Contractor’s (MAC) website, under the “Local Coverage Determinations” option. The LCD is titled Oral Appliances for Obstructive Sleep Apnea (L33611). The related policy article is titled Oral Appliances for Obstructive Sleep Apnea – Policy Article (A52512).


LEGALledger Without further ado, let’s explore some main points to be aware of when billing Medicare for oral appliances for OSA.

The practice location must be enrolled as a Medicare DME supplier, either participating or non-participating

Currently, custom made oral appliances for OSA are categorized as Durable Medical Equipment (DME) under Medicare. DME is a broad range of items that are used by a patient in a home setting to serve a medical purpose, such as wheelchairs, positive airway pressure devices, canes, the list goes on. To bill Medicare for DME items, a practice (or company) must enroll as a DME supplier using the 855s application. While this is not a quick process, it can be well worth it as Medicare is the largest medical insurer in the United States.

The coverage criteria is different for mild, moderate and severe OSA The Medicare LCD for oral appliances for OSA states the coverage criteria for mild, moderate, and severe OSA as follows: The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3): 1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or, 2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, b. Hypertension, ischemic heart disease, or history of stroke; or, 3. If the AHI> 30 or the RDI> 30 and meets either of the following (a or b): a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, b. The treating physician determines that the use of a PAP device is contraindicated. An important point to understand on the coverage criteria above: do not let the inclusion of “RDI” fool you! Later in the policy, RDI is defined: The respiratory disturbance index (RDI) is defined as the average number of apneas

plus hypopneas per hour of recording without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type IV, and other home sleep studies. Without RERA’s being considered in the calculation for RDI for Medicare, many of the RDI’s listed on the sleep testing reports are inaccurate...in Medicare’s eyes.

The patient must have a face to face evaluation by a physician prior to undergoing the sleep study, and a physician must write an order for the oral appliance

Currently, custom made oral appliances for OSA are categorized as Durable Medical Equipment (DME) under Medicare.

In the LCD, included in the coverage criteria, it is stated: The beneficiary has a faceto-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea testing. Additionally, DME suppliers are responsible for collecting documentation of this evaluation! The LCD states: Upon request by a contractor, all DMEPOS suppliers must provide documentation of the face-to-face examination.

Dr. Ken Berley is a practicing general dentist with over 30 years of private practice experience focusing on complex reconstruction and 20 years of experience as an attorney licensed to practice law in Arkansas and Texas. He has extensive experience as a litigator and was a full partner in Travis, Borland and Berley, Attorneys’ at Law before moving to Northwest Arkansas. Dr. Berley is a Diplomate of the American Sleep and Breathing Academy and a Diplomate for the ABDSM. He lectures in the area of sleep medicine risk management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years. As Director of Training and DentalWriter™ Software Implementation at Nierman Practice Management, Courtney Snow is well known in the Dental Sleep Medicine industry for her work with medical insurance reimbursement for Oral Appliance Therapy for Obstructive Sleep Apnea. She is also an excellent resource for medical billing for Temporomandibular Disorders (TMD), oral surgery services, and other medically necessary services performed in the dental practice setting. Courtney can be reached at 1-800879-6468 and through Courtney@DentalWriter.com.

DentalSleepPractice.com

61


LEGALledger Highlights • The practice location must be enrolled as a Medicare DME supplier, either participating or non-participating • The patient must have a face to face evaluation by a physician prior to undergoing the sleep study, and a physician must write an order for the oral appliance • Only a DDS/DMD can provide and bill for the oral appliance • Each claim must be submitted with modifier NU, and either modifier KX, GA or GZ • The oral appliance must be approved by Medicare Pricing, Data Analysis & Coding (PDAC) for HCPCS code E0486 • Medicare DME suppliers cannot administer home sleep testing (HST) • The patient must sign a proof of delivery form when the appliance is received • Follow up care 90 days from the delivery date are included in the reimbursement

62 DSP | Winter 2017

The good news here, is that the physician who performed the evaluation prior to the sleep test does not necessarily have to be the same physician who writes the order (a.k.a. prescription) for the oral appliance to the dental practice. The LCD states: The device is ordered by the treating physician following a review of the report of the sleep test. (The physician who provides the order for the oral appliance could be different from the one who performed the clinical evaluation in criterion A.)

Only a DDS/DMD can provide and bill for the oral appliance

That’s right! The LCD clearly states as part of the coverage criteria: The device is provided and billed for by a licensed dentist (DDS or DMD). So if you have a physician or lab in your area providing custom made sleep appliances to their Medicare patients – you may want to show them a copy of the LCD!

Each claim must be submitted with modifier NU, and either modifier KX, GA or GZ

Many practices do know they must submit a modifier or two on the claim – but understanding what these modifiers represent is extremely important. Modifier NU stands for “New durable medical equipment purchase”. This indicates the item has been purchased new, and it not refurbished or a rental item. When a claim is submitted to Medicare DME for an oral appliance for OSA, modifier KX, GA or GZ must also be present or the claim will be rejected. It is important that practices do not simply use the KX modifier on every claim because they know it will be paid. Modifier KX stands for “Requirements specified in the medical policy have been met”. Modifier GA stands for “Waiver of liability statement issued, as required by payer policy”. Modifier GZ stands for “Item or service expected to be denied as not reasonable and necessary”. So when to use the different modifiers? The Medicare LCD clarifies: Suppliers must add a KX modifier to a code only if all of the criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD have been met. If the requirements for

the KX modifier are not met, the KX modifier must not be used. If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for the oral appliance. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN. Claim lines billed without a GA, GZ, or KX modifier will be rejected as missing information.

The oral appliance must be approved by Medicare Pricing, Data Analysis & Coding (PDAC) for HCPCS code E0486

HCPCS code E0486 stands for: oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment. Most custom made oral appliances on the market today meet this definition, of course. However, Medicare PDAC has a set of criteria the appliance must meet to be PDAC approved for E0486. The related policy article states: • Code E0486 may only be used for custom fabricated mandibular advancement devices. To be coded as E0486, custom fabricated mandibular advancement devices must meet all of the criteria below: • Have a fixed mechanical hinge (see below) at the sides, front or palate; and, • Be able to protrude the individual beneficiary’s mandible beyond the front teeth when adjusted to maximum protrusion; and, • Incorporate a mechanism that allows the mandible to be easily advanced by the beneficiary in increments of one millimeter or less; and, • Retain the adjustment setting when removed from the mouth; and, • Maintain the adjusted mouth position during sleep; and, • Remain fixed in place during sleep so as to prevent dislodging the device; and, • Require no return dental visits beyond the initial 90-day fitting and adjust-


LEGALledger ment period to perform ongoing modification and adjustments in order to maintain effectiveness (see below) A fixed hinge is defined as a mechanical joint, containing an inseparable pivot point. Interlocking flanges, tongue and groove mechanisms, hook and loop or hook and eye clasps, elastic straps or bands, mono-block articulation, traction-based articulation, compression-based articulation, etc. (not all-inclusive) do not meet this requirement. If the appliance that is used is not listed on the PDAC list for E0486, you must use a different code when submitting the claim to Medicare! The policy article states: The only products, which may be billed using code E0486, are those for which a written Coding Verification Review has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the appropriate Product Classification List. All custom fabricated mandibular advancement devices that have not received a written PDAC Verification Review must use HCPCS code A9270 (NON-COVERED ITEM OR SERVICE).

Medicare DME suppliers cannot administer home sleep testing (HST)

This one is simple. The LCD states: No aspect of a HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.

The patient must sign a proof of delivery form when the appliance is received

For an oral appliance that is delivered to the patient in the dental practice, the proof of delivery form must include: • Beneficiary’s name • Delivery address • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered • Quantity delivered • Date delivered • Beneficiary (or designee) signature

Follow up care 90 days from the delivery date are included in the reimbursement Follow up care for 90 days being included in the reimbursement for E0486 is not a foreign concept, as most medical insurers follow this guideline. However, it is important to know that the related policy article states: Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period in order to maintain fit and/or effectiveness are not eligible for classification as DME. These items are considered as dental therapies, which are not eligible for reimbursement, by Medicare under the DME benefit. They must not be coded using E0486. While this article is not intended to be a replacement guide for the Medicare LCD and related policy article for oral appliances for OSA, we hope it helps clarify some of the common questions we get, as well as correct some of the incorrect coding and documentation practices we see in the field today. If any dental sleep practices out there need assistance locating the link to the LCD and related policy article for your Medicare DME jurisdiction, please feel free to contact Nierman Practice Management at contactus @dentalwriter.com and the Nierman team will be happy to assist you. Currently, Medicare audits and reviews of dental practice protocols are rare. However, as more dentists incorporate DSM into their practices, Medicare audits may increase. Now is the time to ensure that your protocols are compliant with Medicare rules and regulations. If you need our help, please contact us to assist you.

As more dentists incorporate DSM into their practices, Medicare audits may increase.

DentalSleepPractice.com

63


SEEKandSLEEP WORD SEARCH A

D

Q

Y

R

T

E

M

P

O

R

A

R

Y

Z

M

R

P

O

K

L

A

Y

F

P

H

J

V

X

N

Y

R

A

H

P

D

U

A

C

O

E

C

O

N

U

A

G

H

S

A

T

D

E

V

I

C

E

I

Y

N

V

W

D

F

A

E

R

N

M

Z

P

S

B

M

F

T

O

S

M

F

G

M

O

T

D

M

E

E

F

E

O

E

A

U

O

H

R

S

O

R

A

Y

M

A

E

D

I

V

H

A

D

L

A

N

R

Z

P

O

T

E

L

O

T

T

T

L

Q

C

P

T

O

I

G

S

Y

A

U

L

C

N

I

G

L

E

J

S

E

P

T

C

O

U

C

L

A

K

L

G

E

E

L

E

A

R

O

B

I

D

C

R

E

L

N

A

N

L

B

O

L

C

E

N

D

C

B

C

T

L

O

C

E

O

U

D

R

U

J

L

L

T

O

O

O

J

A

O

U

T

O

N

I

A

X

C

K

E

M

Y

I

O

S

U

P

N

I

S

I

L

Y

T

T

U

T

C

I

F

T

K

S

M

A

S

I

S

I

Z

L

O

U

F

E

I

N

M

W

R

B

N

N

Y

G

P

B

O

R

A

X

L

B

H

J

A

C

L

E

R

U

A

O

G

I

A

N

Q

P

F

O

P

T

I

S

L

E

E

P

N

E

A

T

R

H

I

H

S

T

V

E

L

C

Y

C

P

E

E

L

S

T

X

V

U

A

N

E

R

E

F

D

T

O

A

I

S

U

N

M

O

S

O

R

P

L

A

I

C

A

F

O

R

O

G

N

Y

R

A

H

P

X

Q

U

T

L

R

E

S

A

L

R

Y

M

O

T

C

E

D

I

O

N

E

D

A

D

M

V

R

Q

T

E

E

Z

G

S

I

T

T

O

L

G

I

P

E

WORD LIST ADENOIDECTOMY AHI ANKYLOGLOSSIA ASA AURICULOTHERAPY BIPODAL

64 DSP | Winter 2017

BLUPRO CBCT DME DYNAMIC TREATMENT EPIGLOTTIS EVOLUTION FRENECTOMY GALILEOS HSAT DEVICE LASER LCD MALOCCLUSION MEDICARE

MYOGENOUS PAIN OMT OPTISLEEP PHARYNGOROFACIAL PHARYNX PROSOMNUS IA SLEEP CYCLE SOAP TELEDONTIC TEMPORARY TMJ TONGUE COLLAPSE TONSILLECTOMY


“Wow! This is awesome. What a gem!”

8perCEUs year

“It is so refreshing to see a publication that is devoted to the practitioner. Well done!”

Brad Eli, DDS

Steven Bender, DDS

The word is out... DSP is a huge success! Dental Sleep Practice magazine is the sleep apnea publication for dentists — encompassing everything they need to know to properly treat this condition. And subscribers will be able to earn up to 2 hours of AGD PACE CE in every issue by completing questions about an article and submitting to our website. Sponsored by MedMark, LLC, and Seattle Sleep Education.

Subscribe Today Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 1/1/2016 to 12/31/2017 Provider ID# 356023

YES, sign me up for o 1 year for $129 o 3 years for $349 Dr/Mr/Mrs/Ms Full Name:________________________________________________________ Address:_______________________________________________________________________

Medical Maximizeranc e Benefits ily Affair Insu an It’s A Famntal by Rose Nierm resistance Pare

, BA, by Pat Mc Bride

RDA, CCSH

City:________________________________________ State: _______ ZIP:_________________ Phone:____________________________ Fax:_______________________________________ E-mail:_______________________________________________________________________ I have enclosed a check payable to Dental Sleep Practice for $_______ Please charge my:

ur Building cYtioce? ra P p e Sle ution n-build sol

SleepArchiTx

PLUS

7

Continuing

o MasterCard

o AMEX

Card Number:_______________________________________________________________

is your desig

WINTER 201

o Visa

Education

Evolution

n Oral of the Huma Apnea , Airway and J. Moses, DDS

by Allen , Kalliath, DMD Elizabeth T. Pacini, RDH and Gloria

Exp. Date: ________________________ Security Code:_____________________________ Signature:__________________________________________________________________

a Education

L Sleep Apne

Supporting

PRACTICA ists Through

Dent

4 Ways

to Subscribe

Mail this form to: Dental Sleep Practice, 15720 N. Greenway-Hayden Loop #9, Scottsdale, AZ 85260 Visit: www.dentalsleeppractice.com E-mail: subscriptions@medmarkmedia.com Call: 1-866-579-9496


CERECÂŽ Integration

Diagnosis

Treatment Plan

Guided Implantology

Endodontics

Airway Analysis

Functional Occlusal & TMD

Orthodontics

Dentsply Sirona 3D puts you in control Advanced technology thatâ&#x20AC;&#x2122;s easy to use With a single 14-second scan, Dentsply Sirona 3D provides you with all the 3D images required to confidently diagnose and accomplish any procedure. With three models to choose from, each configurable with several software possibilities, Dentsply Sirona 3D provides you with a future-proof system with room for expansion as your practice needs grow.

Contact Dentsply Sirona directly 800.659.5977. sirona3D.com

Dental Sleep Practice Winter 2017