Dental Sleep Practice Fall 2018

Continuing Education

Evaluating and Treating OSA

The Tools that Make a Difference

by Stephen D. Poss, DDS

by Joe Magness, DDS, and Crystal May

FALL 2018 | dentalsleeppractice.com

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INTRODUCTION

There’s More to DSM than Appliance Therapy

Y

ou’ve probably felt the rewards that come from successful oral appliance therapy for treating snoring and obstructive sleep apnea. There’s little like it in dentistry – folks coming in telling you of life changes, just because they no longer snore or wake up feeling lousy every morning.

One of the most rewarding parts of my life is leading other professionals to discover how they can make a difference for their patients and loved ones.

Congratulations to all of us who have stepped up, learned something new, and applied our knowledge to a service that has this kind of scope!

There is danger, of course, in knowing a little about a subject. The old phrase ‘enough knowledge to be dangerous’ is certainly appropriate here, because it’s not as simple as fitting temporary or custom mandibular advancement devices (MAD) to willing adults. Just the fact that the service requires informed consent is a clue to the complexities involved, but beyond the legal protection aspect, being a doctor requires thinking about how what we do ties in with the whole person.

Our American Dental Association says this: Resolved, that dentistry is defined as the evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

Adopted, American Dental Association House of Delegates, 10/21/97.

“Adjacent and associated structures and their impact on the human body.” Our colleague and legal expert Dr. Ken Berley has taught for years that this phrase is what allows airway-related therapy to be included within our scope of practice, should we

choose to embrace the necessary steps to become experts.

I’ve enjoyed Dr. Sam Higdon’s TMJ series over the past year in DSP, and now, another of my mentors, Dr. Allan Moses, has begun teaching us about the development of the upper airway. His essay in this issue is about nasal anatomy and some of the function of that ‘adjacent structure,’ so important to maintaining an open airway, every breath, every night.

Treating airway with mandibular advancement devices without being able to help patients improve their nasal breathing, both daytime and nighttime, is the same as handing them a toothbrush without any discussion of diet choices and expecting full protection from caries.

There are many ways to help someone breathe better through their nose. To begin to be effective, we must revisit the anatomy and function that we learned in dental/ dental hygiene school, supplement it with current knowledge, and effectively teach our patients something that can help them.

I hope you enjoy the journey we’ll be taking together in DSP.

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

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in each issue by completing questions about an article (see page 18) and submitting them either online or via mail. Sponsored by MedMark, LLC, and Seattle Sleep Education.

DentalSleepPractice.com

1

CONTENTS

12

Cover Story

DSP READERS

Managing the Elevated Standard of Care

by Joe Magness, DDS, and Crystal May imagn Solutions discuss why airway is not an optional service.

8 34

Medical Insight

The Nose: Anatomy, Function, and Connection to OSA

by Alan J. Moses, DDS, Elizabeth T. Kalliath, DMD, and Gloria Pacini, RDH The more you know, the more you see.

53 2 DSP | Fall 2018

Survey Results What does our readership say about themselves?

18

Continuing Education

Evaluating and Treating OSA: The Tools that Make a Difference for the Practitioner and the Patient

by Stephen D. Poss, DDS A digital workflow makes patient care more personal.

Expert View

Myofunctional Therapy

by Kristie Gatto, MA, CCC-SLP, COM MFT is a growing, vital part of airway therapy.

2 CE CREDITS

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C O N F E R E N C E

Dr. G. Dave Singh DMD PhD DDSc

Dr. Felix Liao DDS

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R. Kirk Huntsman Keynote

Dr. Martha Cortes DDS

Dr. Tammarie Heit DDS, MICCMO

Join Us October 4 – 6, 2018 This seminal event will be unlike any other conference you have ever experienced!

— October 4 Reserve your seat and get tickets at 7:00 PM - 10:00 PM BreathingWellness.org Cocktail reception Space is limited! Don’t miss out!

Discover strategies and next level leadership principles to boost your productivity and profit. Understand, learn and implement life saving science and technology for your patients and your practice.

Gain new insights and knowledge about the science behind biomimetic oral appliance therapy that is saving lives.

And much, much more...

The Breathing Wellness Conference will feature inspiring presentations by some of the world’s most powerful speakers, insightful presentations by leading scholars and clinicians, invigorating interactive discussions with two distinguished panels.

It will be an event you will never forget with entertainment and interactions with the Breathing Wellness pioneers who have paved the way for dentists and healthcare providers to lead the way and impact the lives of their patients around the world.

The Breathing Wellness Conference will feature inspiring presentations by some of the world’s most powerful speakers, insightful presentations by leading scholars and clinicians, invigorating interactive discussions with two distinguished panels.

Don’t miss the opportunity to learn from the pioneers of this exciting movement.

Tickets Only $1,999 When you use offer code PIONEER

Dr. Ben Miraglia DMD

Dr. Jerry Hu

DDS, DABDSM, DASBA, DACSDD

All access tickets include you and your spouse, a luxurious room at the Marriott Marquis Times Square and all your meals for the event!

Jonathan Bonar Keynote

Preston Pugmire Special Keynote

October 5 8:00 AM - 4:30 PM General Sessions

October 5 6:00 PM - 12:00 AM Dinner & Gala October 6 8:00 AM - 12:00 PM General Sessions — Clinical Knowledge Big Opportunities Business Acumen Effectual Training A Celebration of The Pioneers The Human Impact

Qualified attendees will receive 10 PACE continuing education credits at the Breathing Wellness Conference.

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Ed Loew

Financial Markets

D. Bryan Ferre Author & Evangelist

CONTENTS

24

Product Spotlight

AID our Children with a HealthyStart® for Life

by Leslie Stevens It’s never too early to set the health path right.

27

Starting Early

Medical Management of Pediatric Sleep Apnea and TMD in Your Dental Office

by Christine Taxin Documentation can allow coding that pays.

30

Behavioral Therapy

Behavioral Treatment of Sleep Problems for Orofacial Pain Patients

by Joshua R. Oltmanns and Dr. Charles R. Carlson Some patients require complex care.

40

Laser Focus

47

Practice Growth

Marketing in the Era of #MeToo

by Chris Bez Messages must be carefully written.

48

Fall 2018

Team Focus

Adjunctive Therapy Can Increase the Value of Your Services

by Glennine Varga, AAS, RDA, CTA Don’t let your help stop with appliances.

50

Product Profile

Choosing the Right Appliance May Reduce Side Effects

by Mark T. Murphy, DDS, FAGD There is safety in design details.

56

Case Report

Practice Management

Limiting your vision may leave questions unasked.

60

Legal Ledger

HSAT Usage: Are We There Yet?

CARVE Your Path to Social Media Success

by Ken Berley, DDS, JD, DABDSM Be sure you’re coloring within the lines.

by Sasha Thompson-Bachtold, MEd Be Consistent, Accurate, Responsible, Varied and Effective.

64

6 DSP | Fall 2018

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 Mayoor Patel, DDS, MS, RPSGT, D.ABDSM John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA

by Ronald S. Prehn, ThM, DDS Case report for a special patient.

58

44

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

OSA and Cerebral Palsy

The Importance of Orofacial Myofunctional Therapy TMD Screening Before and After CO2 Laser SDB and TMJ: Frenectomy in Achieving It’s Not One or the Other Optimal Orofacial Function by Robert M. Grill, DDS

by Karen M. Wuertz, DDS, ABCDSM, ABLS, FOM, and Brooke Petus, RDH, BSDH, COMS Mastering the surgery is only part of the solution.

Publisher | Lisa Moler lmoler@medmarkmedia.com

Sleep Humor

VP, Sales & Business Development Mark Finkelstein | mark@medmarkmedia.com National Account Manager Celeste Scarfi-Tellez | celeste@medmarkmedia.com Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Front Office Administrator Melissa Minnick | melissa@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 2018. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

SURVEYresults

DSP READERS

I

f anyone had asked me, I would have had nothing but great things to say about Dental Sleep Practice readers. Send them a survey?

Sure, they’ll send in lots of responses! Send them a really long, detailed survey? Well, let’s hope they have the patience for it.

Our readers surprised us with a robust response, to say the least! Nearly 500 of you gave us your thoughts. Special thanks to ProSomnus Sleep Technologies for providing the honoraria for completing the survey. The first 100 participants had a choice of a $20 Amazon gift card or $100 off a ProSomnus sleep device. The rest received a special surprise, $50 off a ProSomnus appliance.

Most were the intended dentists, but 13% of the respondents were physicians, hygienists, and ‘other.’

We here at DSP will spend some time sorting through all this great data and bringing out interesting information to share with you, about you. You can expect to see articles and infographics from this survey for a couple of years, then we’ll do it all again.

How much training does it take for a dentist to feel comfortable providing mandibular advancement devices? Does it surprise you that just under half of you started after just two days of training and 35% of you have not taken any courses after initial training?

Before treating my first case I had...

50% 2 days of training

8 DSP | Fall 2018

I took my first airway treatment course...

25% 1%

47%

8% % % 8 11

In dental school At a local dental meeting or study club At a regional or national dental conference

From a manufacturer at a sponsored course Online I have not taken a course

no training

3 or more days of training

22%

17% a 1-day course

11%

SURVEYresults In the future, I plan to...

51%

27%

11%

take courses at conferences and locally

enroll in a mini-residency

only use online courses

After the first course...

58% have taken additional similar courses or participated in a mini-residency

35%

have not taken any additional training

7%

have added to education through self-study

What guidelines do you pay attention to in your dental sleep medicine practice?

Here’s a surprise: Although the American Thoracic Society has only recently begun to invite dentists to their meeting and membership, over 65% of you were familiar with their position paper, while the American Academy of Sleep Medicine/American Academy of Dental Sleep Medicine garnered only a 38% share.

Are you driven to provide more treatments for SRBD in your practice? Seems so, given that 89% of you think the ADA’s Policy Statement on the Role of Dentistry in the Treatment of Sleep Related Breathing Disorders will pull more dentists to provide

36% not take any additional courses

I am familiar with the following position papers by medical societies about the treatment of OSA...

28% American College of Chest Physicians’ paper

65%

23% sign up with a multiple-service company

The ADA’s “Role of Dentistry in the Treatment of Sleep Related Breathing Disorders” policy statement will...

58%

drive more dentists to treat SRBD who have been thinking about it already

American Thoracic Society’s paper

23% American Academy of Otolaryngology’s paper

38% American Academy of Sleep Medicine’s paper

29% American Academy of Pediatric Dentistry’s paper

28%

American Orthodontic Society’s paper

32%

drive significantly more dentists to screen for or treat SRBD

not have much impact on 8% will most dentists to treat SRBD

2% Never heard of it DentalSleepPractice.com

9

SURVEYresults What is your perspective on the next 12 months in terms of patient volumes? I plan to...

22% 66%

treat about the same number of patients

treat 10% more

10% 2%

this service. You, yourselves, overwhelmingly think you will provide at least 10% more appliance therapy in the next year.

Speaking of getting started: Bite registrations were another surprise. The most popular technique was an ‘end to end’ bite at 58%. 31% use a percentage of the protrusive range. Most of those were recorded with some form of a George Gauge: 60%.

Considering how many dentists are taking up the challenge of treating sleep related breathing disorders, it comes as no surprise that there are as many approaches, commitments, procedures, and business plans as there are professionals. Next issue, we’ll explore more about the business of DSM: insurance and fees that vary so much. Stay tuned!

treat greater than 10% more patients

treat 10% less

Taking the Starting Position Bite Record, I...

Appliance Starting Position, I...

58% 31%

62% 22%

3%

14%

Take a bite at an end-to-end position of the incisal edges Use a set percentage of the protrusive range Guided by a neuromuscular approach Decide by whether patient can make a snoring sound Use a Pharyngometer

10 DSP | Fall 2018

12% 8% 12% 6%

always use a positioning device use a positioning device at least half the time

use a positioning device less than half the time always use a neuromuscular technique use a variety of methods

www.dentalsleeppractice.com

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COVERstory

by Dr. Joe Magness and Crystal May

W

hat an exciting time to be a dentist! Now more than ever before, we are being asked to participate and play a very active role in the overall health of our patients. Health is defined by Webster’s dictionary as “the condition of being sound in body, mind, and spirit.” You know the correlation between oral hygiene, inflammation, oral function, and our health, but do you know what a significant effect poor sleep has on overall health? Many, including myself, believe sleep is the foundation of health, and without quality sleep, the body cannot properly function. Dentistry has an opportunity to intervene in current sleep protocols and we can impact health in more ways than ever. I’d like to think that not only is it an opportunity, but it’s also an obligation. Dentists have always had a role in health with the treatment of periodontal disease, infection, impacted teeth, malocclusion, tooth replacement, and caries, but now the role has evolved.

• • •

The ADA released a statement in 2017 emphasizing the importance of a dentist’s role in screening for sleep-related breathing disorders for children and adults1; I believe that is just the beginning. This new standard of care supports the valuable role that dentists play in dental sleep medicine. The AADSM has stated that dentists play an integral role in reducing the public health burden of undiagnosed and untreated sleep-related breathing disorders and make an invaluable contribution in managing these disorders with oral appliance ther-

12 DSP | Fall 2018

apy2. Oral appliances stand apart from other treatment options for certain sleep disorders because of their effectiveness and high compliance. They are also both preventative and conservative. Sleep specialists are becoming more open to collaboration with dentists and recommending oral appliances.

It is estimated that over 70% of Americans saw a dentist in 20153. That puts dentists in a unique position for early detection, diagnosis, and treatment of sleep-related breathing disorders. We should view this as an untapped opportunity. We have an organic way to educate 70% of the population on the importance of quality sleep. And considering about 80 to 90 percent of adults with clinically significant sleep-disordered breathing remain undiagnosed4, that’s a pretty powerful tool.

The first step is to screen our patients by reviewing their medical history, discussing their sleep symptoms and examining their oral cavity. With the staggering numbers above, we are our patients’ best chance at health.

I personally feel an obligation to help my patients live better, with improved health.

Sleep is the key to better health. With this overwhelming opportunity and obligation, it is crucial that dentists get involved. Not only the few thousand dentists that are currently engaged in dental sleep medicine but also the

COVERstory other 150,000+ dentists in the United States alone5. Here is your official welcome to dental sleep medicine! How will your office manage the new, elevated standard of care?

You Have Options

imagn® Solutions has consulted with offices across the country, and we have seen that the doctor’s passion for educating patients and improving their overall health is the single most significant indicator of success in dental sleep medicine. Add education, a supportive, motivated team, and accountability and you will have a successful dental sleep practice.

How can you develop a passion for sleep and what sleep implementation can do for your office and your patients? Be the scientist and the subject. Get tested. Get treated. See for yourself the positive effects quality sleep can have on your life. There is no better way to fully understand the benefits that improv-

ing sleep can have, than experiencing it for yourself and helping those closest to you. As a coach, we strongly encourage you to test yourself and your team first. More often than not, if this isn’t done, an office will struggle.

Once you have that personal experience, it is effortless to sit in front of a patient with conviction and authenticity. I believe my passion from my own personal experience with sleep and health is one of the reasons my company is successful in teaching others.

Once you are positively affected by sleep treatment, there will be no stopping the wave of excitement in sharing your knowledge and passion with your patients. imagn Solutions has created a “screen every patient” protocol.

Each patient who is part of your practice should be screened for a sleep disorder. The potential this creates for growth, whether from a total health perspective, a revenue perspective or even from a referral perspective will likely exceed your expectations. One very passionate customer, who has seen sleep dentistry change his life, his practice and even his community, says “It’s everywhere, it affects everyone, and I’ve just scratched the surface.” He also says, “While this has been one of the most rewarding endeavors in over 30 years of dentistry, it also takes a lot of persistence and effort.”

Ask yourself, to what degree am I going to implement this new standard of care?

Some dentists dream of exclusively treating sleep, while others want sleep to be one of many advanced services they offer. Still, others wish only to meet the standard of care guidelines, to screen. We have identified two different categories of dental practices. You

Joe Magness, Founder and CEO of imagn® Solutions, an innovative organization dedicated to strengthening dental practices and improving patient care through dental sleep medicine and medical billing. Dr. Magness holds multiple U.S. and international patents and has used this technology to improve the lives of many. Dr. Magness is a professional speaker and educator on dental sleep medicine. He is a general dentist with over 15 years in private practice, 10 of which were focused on dental sleep medicine. Dr. Magness now exclusively treats sleep and utilizes that first-hand experience to improve and simplify the process so others can thrive in the industry.

Crystal May, Co-Founder and COO of imagn® Solutions, a company dedicated to helping dental practices be successful in dental sleep medicine through education, consulting, team training, medical billing and more. With over 17 years of medical billing experience, 10 with an emphasis on sleep treatment, she is considered a leading educator on the topic. Having owned and managed multiple dental practices, she has mastered the process of implementation, overcoming the obstacles associated with dental sleep and shares that knowledge with dental practices throughout the country.

DentalSleepPractice.com

13

COVERstory need to decide: Are you in the category of screen and refer or the category of screen and treat? One thing is certain – screening is not optional. Depending on your chosen path in dental sleep medicine, imagn Solutions will guide you.

Option #1: Screen and Refer

Take an introductory course to be trained on how to properly identify and screen for sleep disorders. Educate your team on your screening protocol and clearly define your role in dental sleep. Create a referral letter and start getting familiar with sleep labs and sleep specialists in your community to create referral relationships. imagn Solutions has created both introductory and advanced courses for dental sleep medicine. Our practical, hands-on approach has been successful in helping dental offices integrate sleep at whatever degree they choose. Each provider leaves with an understanding of sleep, health, screening protocols, sleep testing options, how to get their team involved and the basics on medical billing.

Option #2: Screen and Treat

If you want to truly impact the health of your patients and boost your practice, you will go beyond screening, and incorporate sleep treatment into your practice. This will require some additional education. Consider introductory and advanced courses, joining study clubs and forums, even university residency programs. You will need to be an expert on the topic.

Get your team involved. Success in dental sleep is not dependent only on the provider; team involvement is key. This is where we see the biggest difference between success and failure. Our most popular training program includes customized on-site team train-

“We’ve been using imagn Solutions for over a year now. imagn Sleep Software has been the key to our success. From screening, exams, treatment plans, and medical billing, it is the total package.”

Kalley B. | Todd Fincher, DDS • • •

ing and ongoing coaching. Your coach will be there for your team when the exceptions come up and when obstacles arise.

Develop protocols. You will need to develop a protocol and process for screening, testing, treating, referring, tracking and billing. imagn Solutions has developed these systems, based on input from hundreds of providers, thousands of treated patients and over a decade of tried and true practice. To streamline and manage these procedures, you need software. We have developed dentistry’s solution for both medical billing and sleep management software. Take advantage of the other technological advancements, such as digital impressions, HSATs, CBCT, and diagnostic tools available in dentistry.

Digital scanning for appliances ensures the best fit for comfort and compliance, whether you are a general practice or a sleep exclusive practice. Investment in these tools creates efficiency in the workflow and has a high return on investment when dental sleep medicine is integrated. This digital workflow is key to successfully managing dental sleep medicine and makes it more enjoyable for the provider and team.

Software

Can you imagine running a dental practice without software? Imagine scheduling, patient communication, and billing without technology. It would simply be an unmanageable task in today’s world. Current dental practice management software programs were not built to handle this new division of dentistry, and often don’t fully support medical billing. To meet the new standard of care, and the rising opportunity for medical billing in dentistry, we have developed a cloud-based software platform known as imagn®. With two modules, one for sleep management and one for medical billing, we have a software solution for every practice. Our philosophy is to create automation and efficiency, letting advanced technology do the work for you, without disrupting your day-to-day flow. imagn understands time is not something dental teams have in excess, so let imagn software do some of the heavy lifting for you.

Medical Billing

One of the most common areas of confusion and concern when incorporating sleep dentistry is medical billing. Once you un-

14 DSP | Fall 2018

COVERstory derstand the basic rules and documentation requirements, medical billing becomes more manageable. When you start to see success with cases, it becomes obvious that offering medical billing is a practice differentiator and valuable patient service. When patients and medical providers see that you have mastered this part of the equation, they will respect your role even more. And it’s not just oral appliances you can bill for! You can bill for office visits, imaging, repairs, and even testing. In fact, medical billing isn’t limited to sleep at all, and many of our customers bill for trauma, oral surgery, diagnostic “imagn Sleep Softservices, and even periodontal treatment.

Coding, submissions, and tracking is ware is an excellent the next part of the equation. To assist ofadd-on to Dentrix® fices with this, we have created a medical billing software and service, imagn Billto run your Airway ing, that’s unlike any other. Our approach starts with education and ends with autoand DSM practice. mation. We have a low cost, efficient way Demographics and to collect documentation, submit preauthorizations and claims and track each treatment plan case through the process.

Not a medical billing expert? No probsync nicely.” lem. With imagn Billing’s Smart Code Dr. Michael Gelb technology, the dental to medical cross coding is just a click away. Since the software is cloud-based, updates and coding • • • changes are always current. One of the biggest complaints we hear about medical billing companies is the lack of communication. Offices often feel like they are chasing claims, calling insurance companies and spending far too much of their own time. You will love our real-time status updates, built-in chat feature and claim tracking system. imagn Solutions also offers education and consulting services specific to medical billing, with on-site, remote and classroom CE programs.

Sleep Management

If you have chosen to incorporate sleep treatment into your practice, you need a sleep software to effectively coordinate and streamline the process.

We have found that while some offices are exclusively treating sleep, many are adding sleep as a small part of their overall practice. Your sleep protocols need to fit as seamlessly as possible into your current patient workflow, thus needing to work with your existing practice management software.

With imagn Sleep Software, you can customize almost all aspects of the software, including medical history, screening templates, intraoral exams, and referral letters. Using pipelines and checklists, pre-loaded forms, auto-generated SOAP notes and the practice dashboard, you can track and manage your sleep patients in one place. All of this, plus a seamless connection to the imagn Billing platform.

Great news for Dentrix users. imagn offers a Dentrix connection that gives you both read and write capabilities. With access to patient information, medical history alerts and even the clinical notes, dual entry is a thing of the past. The imagn module is a permanent tab found inside of the Dentrix 1.

2.

3.

4.

5.

Chart, giving you easy access to the patient’s sleep chart, without ever leaving Dentrix. You get the best of both worlds, having the convenience of the Dentrix connection and the accessibility of imagn’s cloud-based application.

Not a Dentrix user? Since imagn Sleep is cloud-based, it can work standalone with any practice management software you use.

We haven’t stopped there! imagn is continually improving imagn Sleep and imagn Billing by implementing the feedback of our users. We also offer a “Complete Sleep Solution” with on-site and remote consulting, courses, and oral appliances. Visit imagnsolutions.com or call for advice.

Stay the Course

As you elevate the standard of care in your practice there will be speed bumps. This is no different than any new procedure, product, or service you provide. I will never say it will be easy, but I will always say it will be worth it.

With the number of patients undiagnosed, and the growing evidence supporting how critical sleep is to health, dental sleep medicine is just getting started. The expectations for dentists to provide more comprehensive care coupled with patients desire for good health has accelerated the dental sleep medicine revolution. In the words of Dr. Gordon Christensen, “Joe, you realize sleep will be the savior of dentistry.”

This new division of dentistry requires passion for health and good sleep, education, technology and support to overcome the speedbumps. Embracing this new elevated standard of care will strengthen your practice and improve the health of your patients. I see a future where this new standard is integrated into every dental practice in the country.

The Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders Adopted by ADA’s 2017 House of Delegates https://www.ada.org/~/media/ADA/Member%20Center/FIles/The-Role-ofDentistry-in-Sleep-Related-Breathing-Disorders.pdf?la=en Policy Statement on a Dentist’s Role in Treating Sleep-Related Breathing Disorders https://aadsm.org/docs/Policy_statement_on_role_of_dentists_2017.pdf Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders https://www.ncbi.nlm.nih.gov/books/NBK19961/# National Center for Health Statistics: Oral and Dental Health https://www.cdc.gov/nchs/fastats/dental.htm Munson B, Vujicic M. Number of practicing dentists per capita in the United States will grow steadily. Health Policy Institute Research Brief. American Dental Association. June 2016 (Revised).

16 DSP | Fall 2018

Learn from top educators

in sleep dentistry at the Greater New York Dental Meeting Sleep Apnea Symposium brought to you by Dental Sleep Practice

K SPEA

ERS

November 25-28, 2018 | Jacob K. Javits Convention Center | New York, NY

Joe Magness, DDS

Brett Brocki

Steve Carstensen, DDS, DABDSM

Erin Elliott, DDS

Martin Kaplan, DMD, DABLS

Leonard Kundel, DMD

Crystal May

Paul M. McLornan, DDS, MS, PLLC

Mark Murphy, DDS, FAGD

Jill Ombrello, DDS

Edward T. Sall, MD, DDS, MBA

Kevin Kwiecien, DMD, MS

Jonathan S. Lown, MD

Glennine Varga, AAS, RDA, CTA

Peter Vitruk, PhD, DABLS

Reserve Your Seat Today! www.GNYDM.com Thanks to our sponsors...

CONTINUING education

Evaluating and Treating OSA The Tools that Make a Difference for the Practitioner and the Patient

by Stephen D. Poss, DDS

Educational aims

The purpose of this article is to review the tools helpful in evaluating and treating OSA – with a special emphasis on intraoral scanning.

Expected outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 22 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader will: • Understand intraoral scanners’ role in patient education.

• Realize intraoral scanners’ role in practice documentation.

• Appreciate intraoral scanners’ impact on the fit of final appliances.

• Recognize the impact of open source digital files on practice workflow in appliance fabrication.

18 DSP | Fall 2018

Introduction

When the American Dental Association released a policy in October 2017 that encouraged dental professionals to screen for obstructive sleep apnea (OSA) and other sleep-related breathing disorders (SRBD)1, it created a dramatic shift in the role dentists play in SRBD treatment. In addition, the public’s awareness of the comorbidities associated with OSA – high blood pressure, diabetes, gastric reflux, weight gain, atrial fibrillation, heart attacks and increased likelihood of cancer2,3 – has increased significantly in recent years, and patients have begun to seek solutions from their dentists. Technological advancements related to this issue are helping doctors evaluate and treat OSA more efficiently and effectively than in the past. As a result, practitioners who focus on sleep medicine are increasingly using 3D imaging systems along with intraoral scanners and cameras to not only facilitate their OSA evaluation and treatment, but also to educate their patients on their treatment options.

CONTINUING education Evaluating for OSA

When I am evaluating a patient for OSA, I look at the same things insurance companies want verification of: sound dentition (usually a minimum of seven teeth on each arch); temporomandibular joint (TMJ) health; no active decay; and the periodontal status of the patient. I could choose to take a full series of X-rays to accomplish this, which would result in approximately 24 films and significant radiation. However, a cone beam computed tomography (CBCT) system with a large field of view, like Carestream Dental’s CS 9300, enables me to capture the entire airway space – including the teeth and TMJ – all on one film. The large field of view helps me identify preexisting conditions, including current joint positioning. This information is important to collect not only for the evaluation, but also for documentation purposes.

Most obstructions are in the uppermost part of the airway, which is the velopharyngeal region.4 Mandibular advancement devices cause forward displacement of the mandible and prevent oropharyngeal airway obstruction indirectly by moving the suprahyoid and genioglossal muscles anteriorly. It was also suggested that forward and inferior displacement of the mandible decreases the gravitational effect of the tongue in the supine position and enlarges the velopharynx by stretching the palatoglossal and the patatopharyngeal arches.5 Intuitively, one would think that mandibular advancement should improve the sagittal dimension of the oropharynx. However recent studies suggest that increases in the upper-airway caliber occur in the transverse dimension at the level of the velopharynx.6 Others indicate that the changes occur in the sagittal dimension and cross sectional area.

Hence the anatomic changes induced by mandibular advancement appear to be quite complex. This could be due to the intricate linkages between upper-airway structures.

There are studies supporting that the further down the pharynx the obstruction is occurring does make it more difficult to treat with a mandibular advancement device. This is especially true if the obstruction is more in the area of the hypopharynx.7 This is not to say a CPAP intolerant patient with a constriction in the hypopharynx could

not be treated. A study done by Allan Lowe in 15 patients demonstrated that the hypopharynx did increase in cross sectional area by 18%.8 Typically I have found several factors that can influence my thoughts on the success of an oral appliance therapy. Age and BMI and the severity of the AHI are the most obvious.

The clarity of the nasal passages as well as locating the narrowing of the airway space in the pharynx is also helpful in determine a successful outcome.

CBCT technology is not for diagnosing OSA but it can assist the clinician trying to meet the expectations of the patient. CBCT along with an intraoral scanner can help determine the appropriate appliance that will best accomplish my treatment goals.

The faster the replacement, the sooner patients can resume sleeping well.

Presenting the Case

Intraoral scanner imaging assists me in educating the patient and setting treatment expectations. I can merge the files from the CBCT system and the intraoral scanner, providing a comprehensive view of the patient’s

Figure 1: Intraoral camera image representing OSA and tongue level

A graduate from the University of Tennessee College of Dentistry, Stephen D. Poss, DDS, lectures internationally on esthetic dentistry, sleep apnea and TMD. He is a Diplomate with the ABCDSM, ACSDD in dental sleep medicine and a Fellow with the American Academy of Craniofacial Pain. Dr. Poss is an active consultant to several dental manufacturers for new product development and refinement. He has had numerous articles published in most of the leading dental journals. Dr. Poss maintains a restorative and TMD practice in Brentwood, Tennessee. He can be reached at drposs@satmj.com.

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CONTINUING education clinical situation. If, for example, the airway constriction is lower in the airway, I can present the case with images that make it easier for the patient to understand why an appliance may not improve his or her OSA completely. By contrast, if I feel confident that a 70 to 80 percent improvement is more likely, then the patient has the visual information to help him or her determine if treatment is worth pursuing.

Another useful tool in case presentation is the intraoral camera, which can capture the tongue, tonsils and uvula. These photos

can be very helpful in communicating the potential effectiveness of OSA treatment.

For example, Figure 1 shows the high, enlarged tongue and narrow airway space, which would be considerably smaller when the patient is lying down.9 Figures 2, 3 and 4 are CBCT images that provide additional information about the patient. Together with his sleep test diagnosis of severe OSA (AHI 54), these images indicate that the patient's clinical situation may be difficult to treat.

Images such as these can enable the patient to make a more informed decision about treatment options.

Fitting the appliance

Once the appliance is fabricated, I fit the appliance to the patient. The accuracy of the intraoral scanner has a direct impact on the fit of the appliance: the greater the accuracy of a digital impression, the better the fit of the appliance, which allows for quicker seating and reduced chair time.

Replacing the appliance

Figure 2: Image from CS 9300 software measuring airway constriction

Figure 3: Image of narrowing that exists lower in patient’s airway space while standing with only a 7.5 mm anterior-posterior opening

20 DSP | Fall 2018

The reasons for which a patient might need a replacement appliance are many. Loss is one – a patient might leave the appliance behind in a hotel room, for example, and cannot easily return to retrieve it. Wear and tear is another reason. Over time, an appliance can become worn and ill fitting, requiring the fabrication of a replacement. Damage is yet another reason, and the family pet is very often the culprit. Pets find appliances especially enticing, even when the greatest care has been taken to prevent access.

Thanks to digital models, I can set the wheels in motion to fabricate a replacement – for any of these reasons – with just a few clicks in the software. The process can be very fast if the intraoral scanner has an open system. I can send the open source digital files from Carestream Dental’s CS 3600 intraoral scanner, for example, to the lab electronically and request a reprint of a patient’s device. The STL files arrive at the lab in minutes – and without issue of compatibility – enabling the lab to work in the design software of its choice. Patients do not have to experience the inconvenience of making a special trip to the practice and the delay in fabrication that this step causes. For many

CONTINUING education patients, the idea of spending several nights without an appliance – which has mitigated their symptoms and upon which they’ve grown reliant – can cause distress and anxiety. Consequently, the faster the replacement can be made, the sooner patients can resume sleeping at the level they’ve grown accustomed to with OSA therapy.

A side effect of oral appliance therapy is that a patient’s teeth can move. As a result, a patient’s jaw can reposition.10 Digital models are beneficial in terms of documentation, for both the patient and the practitioner. With the visual evidence, the patient can more easily understand her clinical situation before and after OSA therapy; and the practitioner has an original reference to access if a question arises in the future.

Preventing the need for a new appliance

Digital models can also prevent the need to replace an appliance. When clinical situations change due to broken teeth, cavities, implants, etc., I can provide guidance to the general practitioner and the lab on the fabrication of the restoration. An over-contoured crown, for example, may cause the oral device to no longer fit. For the existing device to continue to work, the new restoration must be the same size and shape of the original tooth. I can share images with the patient’s dentist and even print a model for the lab to use to ensure the oral device is still functional with the new restoration.

Figure 4: More detail of the airway space, extracted from the CS 9300

Conclusion

As sleep disorders – and information about them – become more prevalent among the population, dental professionals will have an important role to play in treating them. Through the use of technology, practitioners will be better able to understand potential treatment options and to present them to their patients. The benefits of using CBCT imaging, intraoral scanners and intraoral cameras are multiple; improved appliance fit, better documentation and enhanced communication are all advantages. But perhaps the biggest benefit of all is having the opportunity to improve patients’ sleep along with their overall health and quality of life.

1.

https://www.ada.org/en/press-room/news-releases/2017-archives/october/ada-adopts-policy-on-dentistry-role-in-treating-obstructivesleep-apnea.

2.

https://well.blogs.nytimes.com/2012/05/20/sleep-apnea-tied-to-increased-cancer-risk/?ref=health.

3.

Calvin, A.D., Albuquerque, F.N., Lopez-Jimenez, F., Somers, V.K., “Obstructive Sleep Apnea, Inflammation and the Metabolic Syndrome,” Metab Syndr Relat Disord, 2009 Aug: 7 (4): 271-277.

4.

Ferguson, Kathleen, “Oral Appliances for Snoring and Obstructive Sleep Apnea,” Sleep, 2006, Vol. 29, No. 2, 245-262.

5.

Three-dimensional computer-assisted study model analysis of long term oral appliance wear. Alan Lowe, Fernanda de Almeida: American Journal of Orthodontics and Dentofacial Orthopedics September 2008 393-416

6.

Three-dimensional upper-airway changes associated with various amounts of mandibular advancement in awake apnea patients.

Xiaoguang Zhao, Yuehua Liu; Am J Orthod Dentofacial Orthop 2008; 133:661-8

7.

Effects of an anteriorly titrated mandibular position on awake airway and obstructive sleep apnea severity. Satoro Tsuiki, DDS PhD, Alan Lowe, DMD, Fernanda Almeida DDS American Journal of orthodontics and Dentofacial Orthopedics May 2004 548-554

8.

Mandibular advancement oral appliance therapy for obstructive sleep apnoea: effect on awake caliber of the velopharynx. C F Ryan, LL Love Thorax 1999; 54; 972-977

9.

Cartwright, Rosalind, “Sleep Position Training as a Treatment for Sleep Apnea Syndrome,” Sleep, 1985, Vol. 8, (2), 87-94.

10.

Hui, Chen, Lowe, Alan, “Three-Dimensions Computer-Assisted Study Model Analysis of Long-Term Oral Appliance Wear,” American Association of Orthodontics, 10.2006.10.030.

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CONTINUING education

Continuing Education Test

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REF: DSP Fall 2018

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Evaluating and Treating OSA: The Tools that Make a Difference for the Practitioner and the Patient by Stephen D. Poss, DDS 1. Merging files from the CBCT and the scanner allows _________ a. preplanning of the effective jaw position b. visualization of likelihood of treatment success c. the dentist to verify that one appliance is the best choice d. the patient to appreciate the dentist being up-to-date 2. One advantage of CBCT over an FMX is _______ a. improved diagnostic detail of periodontal disease and caries b. use of a radiological wavelength less harmful to tissue c. the ability to capture a large field of view d. the ability of the patient to move during the scan to show multiple positions 3. Digital technology is allowing _______ a. patients to select which part of their oral tissues to be imaged b. ‘teledentistry,’ where a dentist can provide remote diagnostic services c. cross-platform image sharing to any physician involved in patient care d. patients to be better educated about their treatment options 4. Airway obstructions are found most often in

22 DSP | Fall 2018

the _______ a. velopharynx b. oropharynx c. hypopharynx d. palatopharynx 5. Losing a dental sleep appliance _______ a. requires new impressions to fabricate a replacement b. rarely happens due to the cost of these devices c. is less of a problem when digital files allow the lab to recreate the device d. is only temporary if the patient’s name is engraved on the device 6. When a patient requires dental restorations _______ a. the digital files can be used to template the shape of the restoration b. only certain appliances can be modified to fit c. new scans must be taken to make a new dental appliance d. they should only be done by the dentist who supplied the dental appliance 7. Using digital scanning technology to send to the laboratory _______ a. is cumbersome because the file has to be burned to a CD for mailing

b. increases costs due to model printing c. makes the outcome less certain due to inaccuracies in the scanning d. usually results in quicker seating of the dental appliance 8. Taking advantage of digital technology allows the dentist to _______ a. meet insurance company verification of health status b. certify the TMJ disk is in the proper position c. fully verify the health of all involved teeth d. know whether periodontal therapy is required prior to airway therapy 9. Digital models of the teeth _______ a. do little more than increase the cost of the case b. provide undisputable ‘before’ documentation c. can be used to upsell the case by including bleaching trays d. are best retained by the dentist, never turned over to the patient for storage 10. The public is becoming more aware of how SRBD increases the risk of _______ a. cholecystitis, heart attacks, GERD b. weight gain, sciatica, atrial fibrillation c. high blood pressure, cancer, alopecia d. diabetes, atrial fibrillation, gastric reflux

PRODUCTspotlight

AID our Children with a HealthyStart® for Life

by Leslie Stevens, HealthyStart® by Ortho-Tain® CEO/President

AID

Address Early Identify Underlying Root Causes Diagnose and Treat for Life

HealthyStart® questionnaire

24 DSP | Fall 2018

H

ow are we treating children that exhibit sleep, breathing or airway issues? In many instances we look to remove tonsils and adenoids, tape a child’s mouth, provide myofunctional therapy or possibly even expand the arches. Is this enough?

The answer lies in a uniquely multidimensional treatment system called the HealthyStart® which addresses the underlying root causes by expanding the arches, promoting growth and development, and addressing improper habits while creating proper habits simultaneously. The HealthyStart® system uses a series of oral appliances typically worn at night while sleeping.

Research involving 501 children showed that 9 out of 10 children will exhibit one or more outward symptoms of Sleep-Related Breathing Disorders. These outward symptoms can be identified through the HealthyStart® questionnaire, where parents indicate their child’s applicable symptoms and provides the degree of prevalence. On average, children will have four outward symptoms, which can include: ADD/ADHD, Headaches, Nightmares, Teeth Grinding, Bed Wetting, Difficulty in School, Chronic Allergies, Restless Sleep, Dark Circles Under Eyes, Mouth Breathing, Daytime Drowsiness, Snoring, Swollen Tonsils/Adenoids, Delayed Growth and Defiance/Aggression.

Some habits are expressed as behaviors that are either repetitive or patterns that are instigated by sleep. Examples of repetitive habits are thumb sucking, tongue thrust, mouth breathing, etc. which can be addressed with myofunctional therapy. Each HealthyStart® Habit Corrector contains myofunctional therapy built into the appliance, activated by swallowing. During sleep, we swallow one

PRODUCTspotlight

Figure 1: Initial treatment

Figure 2: In-progress

Figure 3: Final

As CEO of HealthyStart® by Ortho-Tain® and a mother of 3, Leslie Stevens’ goal and desire is to provide every advantage for children to allow them to live healthy and happy lives. There is a silent epidemic affecting 9 out of 10 children. This epidemic manifests itself in a variety of symptoms that can easily be overlooked, misdiagnosed, and most unfortunately left untreated. It is critical children are evaluated for sleep and breathing habits. Leslie lectures on this topic and trains doctors all over the world. She takes pride in leading HealthyStart® by Ortho-Tain® with over 51 years, over 4 million cases and much research to back them. Leslie’s mission is to educate both parents and oral physicians to ensure children a lifetime of health, happiness, and success.

For more information on HealthyStart, visit www.thehealthystart.com or call 844-KID-HEALTHY. Complimentary Medical CE Webinars are available at www.healthystartwebinar.com/.

26 DSP | Fall 2018

time a minute and during the day we swallow two times a minute. When a child wears the HealthyStart® appliance at night, 500 corrective repetitions occur to create a proper swallow, eliminate mouth breathing, create nasal breathing and eliminating tongue thrusts.

This assures that myofunctional therapy occurs with wear and guarantees constant reinforcement, even during sleep when it is most needed.

Other habits instigated by sleep include bruxism, fidgeting, headaches, bed wetting, allergies, asthma, etc. which HealthyStart® addresses by influencing positive changes in sleep, breathing and the airway.

The HealthyStart® System promotes growth and development by influencing jaw growth in a forward and downward direction while eliminating detrimental malocclusions and deficiencies in jaw development and growth.

HealthyStart treats any overbite, overjet, openbite, crossbite, gummy smile, Class lll and deficiencies in both the upper and lower arches. The HealthyStart® system will promote 54% growth in the mandible as compared to the control sample. The HealthyStart treatment allows maximum airway development.

The System expands arches to gain greater nasal breathing and provide an area for the tongue to position in the upper palate. The proprietary HealthyStart® technique incorporates built-in myofunctional therapy with a ramp to lift tongue and expansion tabs to flatten tongue and to add pressure for expansion of the arches. Additional expansion is gained with the eruption of teeth. The HealthyStart® system utilizes natural eruptive forces of the teeth to gain approximately 4 mm of expansion. Typically the expansion that is gained with use of the HealthyStart® system represents 77% of the needed expansion of the pediatric patients.

Learn more about the HealthyStart® technique, which addresses the underlying root causes of SRBD, creates dramatic changes in occlusions, promotes jaw growth, creates proper habits and eliminates poor habits all while expanding the arches. Complimentary educational webinars are available at www. healthystartwebinar.com/, and 1 CE credit is provided.

Make a more permanent change for your sleep patient by treating early and treating for life.

STARTINGearly

Medical Management of Pediatric Sleep Apnea and TMD in Your Dental Office A Beginner’s Guide by Christine Taxin

S

leep apnea is a growing problem for America’s children and teenagers. Researchers from the Cleveland Clinic have suggested that between 1% and 10% of U.S. pediatric patients suffer from obstructive sleep apnea (OSA), with devastating results. Sleep apnea impacts children’s endocrine systems, their growth, their behavior, their ability to learn, and their ability to resist disease. It is more common in children who suffer from obesity and children under the age of 9, but children of all ages and BMIs are at risk. Researchers have also discovered that untreated OSA can lead to TMD in up to 73% of patients with OSA. The ADA’s new SRBD Policy Statement includes an excellent point about dentist’s responsibility: In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.

Does your child snore? Does your child show other signs of disturbed sleep: long pauses in breathing, much tossing and turning in the bed, chronic mouth breathing during sleep, night sweats (owing to increased effort to breathe)? All these, and especially the snoring, are possible signs of sleep apnea, which is commoner among children than is generally recognized.

It’s estimated than 1 to 4 percent of children suffer from sleep apnea, many of them being between 2 and 8 years old. No part of medicine/ dentistry can do this alone. Sleep physicians have no clinical role in growth and development, orthodontists don’t diagnose SRBD, families require special behavioral skills, and general dentists need to know which specialists they can refer their at-risk children to. General dentists, as a whole, see more children more frequently than any other subset of medicine and dentistry for preventive services. Talking with families about SRBD opens the door to lifetime health. The treatment window for affecting the growth of the airway

is short, with 90% complete before the child reaches puberty. Identifying at-risk children early enough to intervene and set them on a path of life yime health is going to be dentistry’s greatest contribution to community health ever. Furthermore, while there is a possibility that affected children will “grow out of” their sleep disorders, the evidence is steadily growing that untreated pediatric sleep disorders including sleep apnea can wreak a heavy toll while they persist. Studies have suggested that as many as 25 percent of children diagnosed with attention deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea and that much of their learning difficulty and behavior problems can be the consequence of chronic fragmented sleep. Bed-wetting, sleep-walking, retarded growth, other hormonal and metabolic problems, even failure to thrive can be related to sleep apnea. Some researchers have charted a specific impact of sleep disordered breathing on “executive functions” of the brain: cognitive flexibility, self-monitoring, planning, organization, and self-regulation of affect and arousal. Several recent studies show a strong association between pediatric sleep disorders and childhood obesity. Judith Owens, M.D., director of sleep medicine at the National Children&’s Medical Center in Washington, DC, who is a member of the ASAA board of directors, believes that adequate healthy sleep is as important as proper diet and sufficient exercise in preventing childhood obesity.

Screening for Sleep Apnea in Pediatric Patients

Before screening a pediatric patient for sleep apnea, ask parents for a list of all curDentalSleepPractice.com

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STARTINGearly

The Salzmann evaluation index is the only test accepted by insurance to pay for treatment. It is not the best, but the only scoring system at this time.

TIP: All of the child’s doctors and therapists must be on-board with this treatment option in order for insurance to pay.

rent medications and the contact information for any doctors or therapists involved in the treatment of the child. This is very important since pediatric sleep apnea is often misdiagnosed as ADHD, since poor sleep severely impacts a child’s ability to pay attention and exercise self-control.

Use the following questions to pre-screen for OSA risk factors in your pediatric patients.

• Does the child sleepwalk?

• Does the child urinate in their sleep?

• Does the child sleep in class?

• Does the child act out in class or at home?

• Does the child tend to breathe with their mouth open?

• Does the child have breathing pauses during sleep?

• Does the child experience daytime sleepiness?

• Does the child have difficulty with concentration?

• Does the child have a poor attention span?

• Does the child have behavioral issues?

• Does the child show poor performance at school?

• Does the child wet their bed?

Christine Taxin is the founder and president of Links2 Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company, Ms. Taxin served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multi-specialty dental practice in New York. With over 25 years’ experience as a practice management professional, she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals and serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for Maimonides Hospital.

Ms. Taxin is passionate about helping dental practices reach their highest potential and increase their profitability. In her consulting work, she focuses on helping practices strengthen their communication skills, their ability to work as a team and their capacity to set goals. As a provider of continuing dental education, Ms. Taxin has been a guest speaker for Henry Schein, Kodak Dental, Sirona and Goetze Dental. She has presented programs to the American Association of Dental Office Managers, the Pennwell Dental Group and the New York Academy of General Dentistry. The AGD has approved her company Links2Success as a national provider of PACE continuing education credits.

28 DSP | Fall 2018

If a patient displays any of these risk factors, you should administer the Orthodontic Service Salesman Evaluation Index. This evaluation is essential if you plan to bill insurance for any treatments for OSA or TMD. It allows the dentist to make to diagnosis the child, bring in their other provides to collaborate with on the case. They find that many children who have sleep/OSA is a side effect of the airway restriction that dentists CAN diagnose. Most treatments are covered under medical for appliance therapy since we are opening the airway for the child to grow.

Documentation for Insurance

Insurers require specific forms of documentation and imaging before they will reimburse for appliances that treat pediatric OSA or TMD. In addition to the Orthodontic Service Salzmann evaluation index, you’ll need to provide detailed notes about the objectives for any treatment or testing.

These notes should include: • A list of the symptoms reported by the guardian and those observed in office • References to any comorbidities that have been found to cause or be caused by OSA (for instance: ADHD, cardiac issues, obesity, diabetes, daytime sleepiness) • The type of sleep study ordered (include relevant codes) and the reason for ordering the test • The Current treatment plan for the patient • The patient’s history of past treatments both for the sleep issue and any comorbidities • If a CPAP has been tried, a notation of when and why its use failed • A copy of results from the sleep study • A copy of the questionnaire about sleep habits and the Salzmann test (Must score at least 42 points) • Written reports from the pediatrician, including letters of support for this treatment option. All of the child’s doctors and therapists must be on-board with this treatment option in order for insurance to pay.

Some of these requirements may seem repetitive or redundant. However, when you’re dealing with medical insurance, it is important to make documentation as complete as possible. This will help the insurer in evaluating the claim promptly and reduce

STARTINGearly the number of hours your staff needs to spend dealing with the claim in the long-term.

Dealing with Medical Insurers

Once you’ve compiled the documentation, you’re ready to submit the claim. Each insurer has different requirements for the treatment of sleep apnea in children, what constitutes medical necessity and how to determine the severity of a given case. You should refer to these portions of the policy when submitting your claim. Remember, you are trying to make a case that a particular child’s disease and treatment should be covered by the plan.

Be prepared to receive a ‘no’ answer on your first submissions. Insurers initially deny 61% of claims that are eventually paid. They are trying to get you to give up on the claim, but you shouldn’t take ‘no’ for an answer.

For instance, there is a high rate of comorbidity between OSA and TMD. If the insurer finds that OSA treatment is not medically

necessary, you may be able to get the child appropriate treatment by submitting via the TMD route. Reversible intra-oral appliances can be considered medical treatment for TMD when there is evidence of clinically significant masticatory impairment with documented pain and or loss of function. The child must suffer this pain for 6-8 months before the application of appliance. You cannot reference bruxism or sports guards in the documentation, as these are considered dental, not medical, needs. All TMD treatment requires preauthorization.

Too Complicated? Get Help.

Do the procedures for medical billing for pediatric OSA appliances seem too complicated? You and your staff can learn to bill insurance and help patients avoid unnecessary surgeries. Links2Success can help your team get the education they need to work with medical insurers so that you can help these pediatric patients.

Drive More Patients To Your Practice Online Training and Resources Earn CE credits while you learn Digital Marketing Made Easy Designed for Your Whole Team

Learn more and sign up today at: www.stsdentalsleepmedicine.com Sleep Treatment Solutions LLC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or any other applicable regulatory authority, or AGD endorsement. The current term of approval extends from 7/1/2018 to 6/30/2020. Provider ID #384151.

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BEHAVIORALtherapy

Behavioral Treatment of Sleep Problems for Orofacial Pain Patients

by Joshua R. Oltmanns and Dr. Charles R. Carlson

O

rofacial pain often co-occurs with problems falling asleep, maintaining sleep, and waking too early that cause impairment in daytime functioning (Carlson et al., 1998; Porto et al., 2011). These problems are captured with the definition of insomnia (American Psychiatric Association, 2013; Edinger et al., 2004) and are also associated with disruptions in mood, health, social and occupational functioning (Ohayon, 2002). It appears that the relationship between pain and insomnia is bi-directional, that is, that insomnia exacerbates pain, and pain exacerbates insomnia symptoms (Smith & Haythornthwaite, 2004). Thus, insomnia is a central problem in the experience of orofacial pain, and the treatment of insomnia is an important target for orofacial pain patients.

30 DSP | Fall 2018

BEHAVIORALtherapy Pain patients are often provided pharmacological treatment for sleep difficulties.

Behavioral treatment of insomnia, however, is at least equally as effective (Morin et al., 2006; Murtagh & Greenwood, 1995; Smith et al., 2002). Cognitive-Behavioral Therapy for Insomnia (CBTI) is a fusion of empirically-supported behavioral techniques for reducing insomnia symptoms. It is a straightforward intervention that can be effectively provided by non-sleep specialists such as dentists, nurses, social workers, or other health professionals (Bothelius, Kyhle, Espie, & Broman, 2013; Espie et al., 2007; Manber et al., 2012). CBTI can be introduced in one-on-one or group settings, either in person or online (Matthews, Arnedt, McCarthy, Cuddihy, & Aloia, 2013). Manuals are available that include education about the treatment, as well as complete session-by-session guides along with examples of provider-patient dialogues (Morin & Espie, 2003; Perlis, Jungquist, Smith, & Posner, 2005). CBTI offers an opportunity for any professional healthcare provider to reduce insomnia effectively in patients.

Two simple “first-line interventions” (Perlis et al., 2005) of CBTI are stimulus control therapy (SCT; Bootzin, 1972) and sleep restriction therapy (SRT; Spielman, Saskin, & Thorpy, 1987). The bedroom can become associated, or conditioned, with non-sleep

related thoughts and activities. Thus, SCT involves re-associating the bedroom only with sleep and relaxation, and developing a consistent sleep/wake schedule. SRT restricts time in bed, which increases the homeostatic drive for sleep the following night. As sleep efficiency (i.e., the proportion of the time spent in bed CBTI offers an opportunity awake versus time spent asleep) for any professional increases, time in bed is gradually expanded, until the patient is healthcare provider to sleeping a healthy number of hours reduce insomnia effectively efficiently. CBTI includes several other components that can be used in patients. to improve sleep quality: relaxation therapy (i.e., diaphragmatic breathing and other techniques that increase relaxation and decrease physiological arousal), sleep hygiene education (i.e., education about adaptive and maladaptive sleep-related behaviors), paradoxical intention (i.e., attempting to stay awake as long as possible, thereby eliminating anxiety about falling asleep rapidly), and cognitive therapy (i.e., restructuring maladaptive beliefs about sleep) (Harvey & Asarnow, 2014).

When applied separately, SCT and SRT are each useful for reducing insomnia symptoms (Morin et al., 2006). When used together with the other components of CBTI, patients experience even greater improvements in sleep (Morin et al., 2006).

Joshua R. Oltmanns, MS, is a third-year graduate student in clinical psychology at the University of Kentucky.

He completed a clinical placement at the University of Kentucky Medical Center’s Orofacial Pain Center under the supervision of Dr. Charles Carlson from 2015-2016. His research and clinical interests include the assessment and structure of normal and abnormal personality traits, insomnia, and the treatment of insomnia. His current clinical placement is at the Harris Psychological Services Center at the University of Kentucky.

Dr. Charles R. Carlson, Ph.D., ABPP, obtained his Ph.D. in clinical psychology from Vanderbilt University and completed a clinical residency at the University of Mississippi Medical Center. Since 1988, he has been a member of the Department of Psychology at the University of Kentucky where he is the Robert H. and Anna B. Culton Professor of Psychology; he also holds joint appointments as a professor in the Colleges of Dentistry and Medicine and is currently the Director of Behavioral Medicine and Research at the Orofacial Pain Center in the University’s College of Dentistry. Dr. Carlson has been awarded the diplomate in clinical health psychology from the American Board of Professional Psychology and received the U.S. Navy’s Civism Award for service to the Naval Postgraduate Dental School in Bethesda, MD. His research and clinical interests focus on self-regulation skills training for the management of pain in areas mediated by the trigeminal nerve.

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BEHAVIORALtherapy Cognitive Behavioral Therapy for Insomnia is the most empirically supported and efficacious behavioral treatment for insomnia (Harvey & Asarnow, 2014). A review of 37 treatment outcome studies conducted between 1998 and 2004 found that individuals with insomnia who completed CBTI experienced improvements in the time it took to fall asleep, the time spent awake Sleep quality improvements after falling asleep, total sleep time, and sleep efficiency (Mofrom CBTI predict long-term rin et al., 2006). Further, studreduction in pain and fatigue ies showed that these improvements were maintained over in chronic pain patients. follow-up periods ranging from several months to years.

There have also been studies of CBTI administered specifically to pain patients. These studies have indicated that insomnia in pain patients is very similar to insomnia experienced by primary insomnia patients (Tang, Goodchild, Hester, & Salkovskis, 2012), and CBTI significantly reduces insomnia symptoms in a variety of pain patient populations (Currie et al., 2002; Jungquist et al., 2010; Pigeon et al., 2012; Quartana, Wickwire, Klick, Grace, & Smith, 2010; Vitiello et al., 2014; Vitiello,

Rybarczyk, Von Korff, & Stepanski, 2009).

Further, CBTI may have beneficial, indirect effects on pain. For example, sleep quality improvements from CBTI have also been shown to predict long-term reduction in pain and fatigue in chronic pain patients (Currie et al., 2002; Vitiello et al., 2014). While more studies are needed, these findings provide evidence of CBTI’s effectiveness for reducing insomnia symptoms, and also its potential for reducing pain and pain-related distress (Finan et al., 2014).

Pharmacological treatment is the most common sleep treatment provided to orofacial pain patients. However, behavioral treatments that are practical and effective have been shown to be at least equally effective for reducing insomnia (Morin et al., 2006). CBTI can be provided by dentists, nurses, social workers and other health professionals. CBTI is useful because it teaches behavioral skills that improve sleep quality, while at the same time removes the possibility of side effects or dependency that may result from pharmacological treatment. Implementation of this treatment in orofacial pain clinics provides patients with safer and longer-lasting behavioral skills to reduce their insomnia.

1.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

ments for insomnia: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79-89.

2.

Bothelius, K., Kyhle, K., Espie, C. A., & Broman, J. (2013). Manual-guided cognitive-behavioural therapy for insomnia delibered by ordinary primary care personnel in general medical practice: A randomized controlled effectiveness trial. Journal of Sleep Research, 22, 688-696.

13. Ohayon, M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97-111.

3.

Carlson, C. R., Reid, K. I., Curran, S. L., Studts, J., Okeson, J. P., Falace, D., ... & Bertrand, P. M. (1998). Psychological and physiological parameters of masticatory muscle pain. Pain, 76, 297-307.

15. Pigeon, W. R., Moynihan, J., Matteson-Rusby, S., Jungquist, C. R., Xia, Y., Tu, X., & Perlis, M. L. (2012). Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: a pilot study. Behaviour Research and Therapy, 50, 685-689.

4.

Currie, S. R., Wilson, K. G., & Curran, D. (2002). Clinical significance and predictors of treatment response to cognitive-behavior therapy for insomnia secondary to chronic pain. Journal of Behavioral Medicine, 25, 135-153.

5.

Finan, P. H., Buenaver, L. F., Runko, V. T., & Smith, M. T. (2014). Cognitive-behavioral therapy for comorbid insomnia and chronic pain. Sleep Medicine Clinics, 9, 261-274.

16. Porto, F., de Leeuw, R., Evans, D. R., Carlson, C. R., Yepes, J. F., Branscum, A., & Okeson, J. P. (2011). Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients. Journal of Orofacial Pain, 25, 117-124.

6.

Harvey, A. G., & Asarnow, L. D. (2014). Insomnia. In S. G. Hofmann, Dozois, D. J. A., W. Rief, and J. A. J. Smits (Eds.), The Wiley handbook of cognitive behavioral therapy (Vols.

1-3) (pp. 541-565) Wiley-Blackwell.

7.

Jungquist, C. R., O’Brien, C., Matteson-Rusby, S., Smith, M. T., Pigeon, W. R., Xia, Y., ... & Perlis, M. L. (2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep Medicine, 11, 302-309.

8.

Manber, R., Carney, C., Edinger, J., Epstein, D., Friedman, L., Haynes, P. L., ... & Trockel, M. (2012). Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. Journal of Clinical Sleep Medicine, 8, 209-18.

9.

Matthews, E. E., Arnedt, J. T., McCarthy, M. S., Cuddihy, L. J., & Aloia, M. S. (2013).

Adherence to cognitive behavioral therapy for insomnia: a systematic review. Sleep Medicine Reviews, 17, 453-464.

10. Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). SLEEP, 29, 1398-1414.

11. Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. New York, NY: Kluwer Academic/Plenum.

12. Murtagh, D. R., & Greenwood, K. M. (1995). Identifying effective psychological treat-

32 DSP | Fall 2018

14. Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. A. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York, NY: Springer.

17. Quartana, P. J., Wickwire, E. M., Klick, B., Grace, E., & Smith, M. T. (2010). Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: a crosslagged panel analysis. PAIN, 149, 325-331.

18. Smith, M. T., & Haythornthwaite, J. A. (2004). How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Medicine Reviews, 8, 119-132.

19. Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buysse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11.

20. Tang, N. K., Goodchild, C. E., Hester, J., & Salkovskis, P. M. (2012). Pain-related insomnia versus primary insomnia: a comparison study of sleep pattern, psychological characteristics, and cognitive-behavioral processes. The Clinical Journal of Pain, 28, 428-436.

21. Vitiello, M. V., McCurry, S. M., Shortreed, S. M., Baker, L. D., Rybarczyk, B. D., Keefe, F. J., & Von Korff, M. (2014). Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia. PAIN, 155, 1547-1554.

22. Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Clinical Sleep Medicine, 5, 355-362.

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MEDICALinsight

The Nose: Anatomy, Function, and Connection to OSA

by Allen J. Moses, DDS, Elizabeth T. Kalliath, DMD, and Gloria Pacini, RDH Introduction The diagnosis of obstructive sleep apnea (OSA) solely based a Poly-SomnoGraphic study (PSG) is a “rule-in” diagnosis. OSA is just one of many Sleep Breathing Disorders (SBD) that must be considered. There is more to treating OSA than Continuous Positive Air Pressure (CPAP) and intraoral appliances.1

D. A.

B.

C.

E.

Figure 1: Humans evolved to be nasal breathers. A-B: These kids are nose breathers, sleeping with their mouths closed. Their tongue is in the roof of the mouth facilitating normal growth of the palate, broad dental arches, straight teeth and beautiful smiles. C-E: These kids are sleeping with their mouths open. Nasal breathing is obstructed. They are mouth breathers. The tongue is in the floor of the mouth. This will affect their facial development and the position of their developing teeth.

34 DSP | Fall 2018

The intent of this article is to identify the integral role sleep dentists can play in improving patients’ health by understanding the mechanics and consequences of patients’ breathing and facial growth. We present some of the dynamics, chemistry, anatomy, and physiology of human respiration, mouth versus nose breathing, under-breathing as well as over-breathing and how allergies and dentistry fit in the picture.

Environmental, intrinsic and structural factors all cause resistance to proper airflow.

Humans must adapt to numerous obstacles to sustain breathing.2 Resistance to airflow in the upper airway varies over time but typically two-thirds is of nasal origin and one-third is contributed by the mouth and oropharynx.3 Human beings are designed to be nasal breathers. The union of the foodway and the airway, an arrangement unique to humans, has caused many adaptive problems. The use of the mouth as an emergency, backup airway outweighs the possible dangers of choking and infection.4 During inhalation the nose performs some important, vital functions, namely warming, humidification, filtering and cleaning of ambient inhaled air into the lungs, as well as olfaction. It also

MEDICALinsight provides the function of dehumidification of air exhaled through the nose.5,6 The nose is a highly complex organ, initiating reflexes affecting itself as well as the rest of the body, notably a sniff reflex, sneeze reflex, autonomic airway/lung reflexes and cardiovascular reflexes.

Nasal Valve Area

A.

Anatomy, Histology, Physiology

The vasculature of the nose is extensive, consisting of sinusoidal capacitance vessels, distensible venule capacitance vessels, arteriovenous anastomoses, arteries capillaries, and venules. The secretory tissue of the nose consists of epithelial cells, submucous glands, serous glands and pseudostratified epithelium. The arterial system determines blood flow. The venous system, or capacitance vessels, determines nasal patency.

The capacitance vessels are regulated by the autonomic nervous system, contain smooth muscle and are most dense in the inferior and middle turbinates.7 Sympathetic and parasympathetic nerves play critical roles in regulating glandular, vascular and other processes in airway mucosa such as allergies. Sympathetic nerve stimulation causes constriction of the resistance vessels. Nasal congestion is more a withdrawal of sympathetic discharge than over activity of the parasympathetic system. Parasympathetic nerve stimulation of the nasal vasculature causes arterial dilation and active secretion of mucous resulting in runny nose. Allergy is a histaminic reaction characterized by vasomotor rhinitis, mucosal hyperemia, vascular engorgement, hyperrhinorhea, and obstructed nasal breathing.8 Nasal airflow resistance is decreased by exercise which causes sympathetic vasoconstriction, erect posture resulting in jugulovenous distension as well as rebreathing which brings about increased blood CO2 and by nasal vasoconstriction.9 Factors increasing nasal resistance are supine posture, hyperventilation resulting from mouth breathing, allergic rhinitis, infective rhinitis, cold air, alcohol, hypertrophic turbinates and/or nasal valve collapse. The key to successful nasal breathing is maintaining a critical balance.10

Nasal Valve

The nasal vestibule, at the entrance of the pyriform aperture is the first component of

B.

C.

Figure 2: Perspective views of the nasal valves. Source for Fig 2B: Surgical Treatment of Nasal Obstruction in Rhinoplasty. Aesthet Surg J. 2010;30(3):347-378.

nasal resistance. The clinical relevance of the nasal valve is that it is the narrowest part of the nasal airway system and contributes over 50% of nasal resistance.11 The nasal vestibule is composed of compliant walls that are liable to collapse from the negative pressures generated during inspiration. The valve area is dynamic; venous erectile tissue can cause marked obstruction. The nasal vestibule is primarily supported by alar cartilage and musculofibrous attachments. The angle between the septum and the upper lateral cartilage is 10-15°. The internal nasal valve is usually located less than 2 cm distal in the nasal

A.

B.

Figure 3: Internal nasal dilators. A. Sinus Cones® B. Max-Air Nose Cones®

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.

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MEDICALinsight passageway, approximately 1.3 cm from the naris. The average cross-sectional area is 0.73 cm. Studies have shown 30 L/min is the normal limiting flow during inspiration, beyond which nasal airway collapse is likely to occur in this area. Despite the tendency, airway collapse is prevented by activation of the dilator naris muscles during inspiration. During expiration, positive pressure is the driving force for nasal vestibule dilation.12

Oral appliances contribute to reduction of pharyngeal resistance by dilating the narrowest areas of airway diameter. Clinicians trained in oral appliance therapy should be capable of identifying nasal resistance and the non-invasive tools available for reducing nasal resistance.

Types of Nasal Airflow

The biomechanics of nasal resistance relates to understanding of the two distinctive types of airflow – turbulent and laminar. Laminar airflow is not conducive to air modification, heat and mass transfer occurs slowly, contact of airborne particles and pollutants with mucosa is minimal and filtration is impaired due to less surface area to pass over. Turbulent airflow brings about better warming, filtration and humidification of air, irregular flow, exhibits differing velocities and it increases the work of breathing.

Types of Noses

Figure 4: External nasal dilator. Source: Wikivisual

SNIFF TEST

A.

Seal your lips, take a deep breath through your nose as deep and as fast as you can • Nasal obstruction – the nares constrict (see Figure 5A to left)

On the bases of two distinct types of airflow, two distinct types of noses can be characterized – leptorhine and platyrhine.

Leptorrhine noses are tall & narrow, have a downward and inferior direction of the nares, maximum mucosal surface to volume, they facilitate heat and moisture exchange in cold, dry environments, airflow must negotiate 90º bend from external nares to horizontal chamber, have well developed nasal valve, greater projection of the nose, high nasal sill and projecting turbinates that enhance turbulent airflow.

Platyrhine noses are short and broad.

They have a lower surface area to volume ratio, less efficient heat recapture, nares more anteriorly directed, poor or no development

• Nose breather – the nares flare (see Figure 5B to left) B. Figure 5: A. Nares constrict. B. Nares flare. Source for Fig. 5A: Hurbis, Charles Gerard. Arch Facial Plast Surg. 2008; 10(2):142-143.

A.

Figure 6: Types of airflow

36 DSP | Fall 2018

B.

Figure 7: Two distinct types of noses. A. Leptorrhine.

B. Platyrrhine.

MEDICALinsight of nasal valve, poorly developed or no nasal sill, little or small projection of turbinates, eco-geographically warm weather settler.

Mouth Breathing

Nasal obstruction can cause the central nervous system to initiate oral breathing. The following functional adaptations must occur for nasal breathers to breathe through the mouth: the soft palate is raised to make a nasal seal with posterior pharyngeal wall, the mandible drops to facilitate oral breathing, the tongue is lowered from contact with the palate, anterior tongue shape flattens, greater inter-arch freeway space is created, swallowing occurs with the teeth apart (dysphagia), scalloped border of tongue develops, dentoalveolar intrusion of lower posterior teeth (step plane of occlusion), higher narrower palate results, as well as maxilary posterior crossbite, lowered tongue position (reduced cross-sectional area of pharyngeal airway), narrow palate results in narrow nasal passage and increased nasal airway resistance, dysphagia from anterior tongue thrust and the constantly open mouth results in extrusion of posterior teeth (anterior open bite).13 A characteristic of chronic mouth-breathers is forward head posture. The hyoid musculature contracts to pull the mandible distal and inferior for maintenance of the open mouth, the suboccipitals and SCMs extend the head, the mid and lower trapezius and rhomboid muscles are protracted (flexion) and internal rotation of the shoulders. The resultant clinical findings in mouth-breathers are long face, anterior open bite, high palatal vault, steep mandibular plane angle, malocclusion, inflamed anterior gingiva, in-

A.

B.

competent lip closure, open mouth gaping expression, forward head posture, no diaphragmatic breathing, neck and shoulder breathing instead and rapid breath rate.14

Thumb or Digit, Sucking vs Propping

Infants and small children are often seen with a finger in their mouth. This is correctly referred to as “digit habit”. There are two distinct kinds of digit habit that must be differentiated – sucking and propping. There are children who truly suck their thumb or other finger. In these kids the digit is a nipple substitute. The lips completely surround the digit, the tongue engages the anterior segment of the digit, the soft palate is in contact with the back of the tongue, the child is nose breathing and there is negative pressure in the mouth. Try and remove the digit and you will experience the suction.15

Clinicians trained in oral appliance therapy should be capable of identifying nasal resistance.

With digit proppers the lips are not closed, the digit is between the lower front teeth and the hard palate, the tongue is in the floor of the mouth and the child is mouth breathing.

The digit is propping the mouth open so the child can oral breathe because their nose is obstructed. Propping exerts repetitive, deleterious forces on the child’s developing dentition and face.

The question, “Can mouth breathing cause OSA?” has generated many studies.

Deegan16 and McLean17 point out that a vari-

C.

D.

Figure 8: A. Thumb propper. B. Thumb sucker. C. When you see this and think of the thumb... D. You begin to understand this.

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MEDICALinsight

A.

B.

C.

E.

D.

ety of defective respiratory and control methods are found in OSA including impaired respiratory drive, defective inspiratory load responses and local upper airway protective reflexes appear to be important. Sforza18 emphasizes that the lower position of the hyoid bone and abnormal pharyngeal soft tissue in mouth-breathers contribute to the upper airway patency. Horner19 also showed that the lower position of the hyoid bone and abnormal pharyngeal soft tissue in mouth-breathers contributes to significant collapsibility to the upper airway and that sleep reduces the activity of pharyngeal dilators and reduces the ability of the pharynx to defend itself from collapse. The summary of these papers is that because OSA is not exclusive to mouth breathers, it could possibly cause OSA or be a risk factor but that it is not the proximal cause.

Conclusion

F.

G.

Figure 9: A. If left untreated, grows up into image B. B. Difficult case for oral appliance if patient has OSA. C. If left untreated, grows up into images D. and E. Source: Dr. John Mew. F.-G. Examples of adults who were not treated for digit habits as children. Source for Fig. 9F: Gage Skidmore

There are daytime breathing problems that can exacerbate or possibly cause OSA during sleep. The complex functional and morphologic relationship of the nose and mouth was presented. A dysfunctional relationship between nose and mouth breathing can have serious health consequences.

Dentistry is a health specialty well-qualified to prevent and treat the etiologies as well as the symptoms. It is important to not only treat both the causes and effects, but understand the respiratory physiologic effects. That is the subject of Part II in this series.

1.

Sher AE, Obstructive sleep apnea syndrome: a complex disorder of the upper airway. Otolaryg Cl of N Amer, Aug 90 23(4):593-608

2.

Moses AJ, Kalliath E, Pacini G, Evolution of the oral airway and apnea. Dental Sleep Practice, Winter 2017, 24-31

3.

Fitzpatrick MF, McLean H, Urton AM, et al, Effect of Nasal or oral breathing route on upper airway resistance during sleep. Euro Respir J. 2003 22:827-832

4.

Swift, Campbell, McKown, Oronasal obstruction, lung volumes and arterial oxygenation. Lancet 1,1988, 73-75

5.

Naftali S, Rosenfeld M,et.al. The air-conditioning capacity of the human nose. Annals of Biomedical Engineering, April 2005, 4:545-553

6.

Elad D, Wolf M, et.al. Air-conditioning in the human nasal cavity. J Respir Physiol, Neurob, 2008, 163, 121-127

7.

Witticombe J, The physiology of the nose. Clin Chest Med 1986;7 159-170

8.

Baraniuk JN, Neural regulation of mucosal function. Pulm Pharmacol Ther, 2008; 21(3) 442-448

9.

Nishimura T, Suzuki K, Anatomy of oral respiration: morphology of the oral cavity and pharynx. Acta Otolaaryng Suppl. Jan 2003 (550): 25-28

10.

Watelet JB, VanCauwenberg, P, Applied anatomy and physiology of the nose and paranasal sinuses. Allergy 54, 1998, 14-25

11.

Tikanto J, Effects of Cottle’s maneuver on the nasal valve as assessed by acoustic rhinometry. Am J Rhino 2007, July-Aug; 21(4) 456-459

12.

Bruintjes TD, Van Olphen AF, Hillen B, et al, A functional anatomic study of the relationship of the nasal cartilages and muscles to the nasal valve area. Laryngoscope 2009, 7 108, 1025-1032

13.

Lee SH, Choi JH, et,al, How does open-mouth breathing influence upper airway anatomy? Laryngoscope 2007, 117: 1102-1106

14.

McNamara JA, Influence of respiratory pattern on craniofacial growth. Angle Ortho 1981, 51 (4) 269-300

15.

Moses AJ, Thumb sucking or thumb propping Chicago Dental Society Review, vol 80,1987, pp40-42

16.

Deegan PC, McNicholas WT, Pathophysiology of obstructive sleep apnea. Eur Respir J 1995 8:1161-1178

17.

McLean HA, Urton AM, et.al. Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea. Eur Respir J, 2005, 25:521-527

18.

Sforza E, Bacon W, et.al. Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit C Med. 2000, 161(2) 347-352

19.

Horner RL, Pathophysiology of obstructive sleep apnea. J Cardiopulm Rehab and Prevent, 2008, 5:28, 289-298

38 DSP | Fall 2018

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LASERfocus

The Importance of Orofacial Myofunctional Therapy Before and After CO2 Laser Frenectomy in Achieveing Optimal Orofacial Function

by Karen M. Wuertz, DDS, ABCDSM, ABLS, FOM, and Brooke Pettus, RDH, BSDH, COMS Frenectomy Methods

Frenotomies performed with a scalpel or scissors can be accompanied by significant bleeding, obscuring the surgical field making it difficult to ensure if the restriction has been completely removed. Because of the increased risk of early primary closure of the site, postoperative active wound care is essential to reduce the risk of potential scarring. To properly restore and maintain optimum function, active wound care should be implemented as soon as possible.

However, if sutures are placed, the active wound care may be delayed so as not to cause early tearing of tissue. Due to the contact nature of conventional procedure, there is a certain potential for infection; in addition, higher levels of postoperative pain and discomfort have been reported.1,2 Electrocautery and a hot glass tip of dental diodes may leave a fairly substantial zone of thermal tissue change3 and may result in delayed healing. Erbium lasers produce excellent incisions, but are not efficient for coagulation.3 Therefore, the clinician utilizing an erbium wavelength for frenectomy may need to control intra-operative bleeding. The 10,600-nm CO2 laser has been shown to accurately incise soft tissue, with simultaneous efficient coagulation. The photo-thermal coagulation depth of this wavelength closely matches the diameters of small oral soft tissue blood and lymphatic vasculature.1,3 This helps maintain a clear surgical site and reduces the risk of postoperative edema.

speaking, and breathing patterns may be caused by incorrect oral posture and oral restrictions. Therefore, in the authors’ opinion, the removal of oral restrictions is necessary to attain optimal orofacial function, and must be combined with regular pre- and post-frenectomy orofacial myofunctional therapy (OMT).1,4 OMT helps re-educate the tongue and orofacial muscles during movement and at rest to create new neuromuscular patterns for proper oral function, including chewing, swallowing, speaking, and breathing.5,6 Camacho et al.7 demonstrated the reduction of apnea-hypopnea index in children and adults following myofunctional therapy. In the absence of such re-education therapy, deviant oral and breathing habits may continue to exist, eventually leading to

Frenectomy and role of OFMT

Improperly formed orofacial structures and deviant swallowing, chewing,

A.

C.

B.

D.

A. Figure 1: A.-B. Pre-frenectomy: note jaw deviation, facial asymmetry, bulbous tongue tip, and inability to lateralize without downward pull from lingual restriction; C.-D. 3 weeks post-frenectomy/OMT: note improved facial symmetry, unrestricted and controlled tongue lateralization, and less jaw deviation.

40 DSP | Fall 2018

A.

B.

Figure 2: A. Pre-frenectomy/OMT: Long, narrow face and low facial muscle tone, a short upper lip (philtrum length: 14mm), open mouth resting posture with 7 mm interlabial gap; B. 3 weeks post-frenectomy/OMT: Improvement in overall facial tone, philtrum length: 18 mm, relaxed closed mouth resting posture with 0mm interlabial gap.

B.

Figure 3: A. Posture pre-frenectomy/OMT: forward head/neck, forward rolled shoulders; patient reported tension in neck and shoulders B. Posture 3 weeks post-frenectomy w/ OMT: forward head/neck, forward rolled shoulders is considerably reduced; patient reports neck and shoulder tension has decreased significantly, and she is able to maintain better posture for a longer time.

LASERfocus the return of airway and sleep issues that preceded frenectomy.1,5

Case Example

A 29 year old Caucasian female (an orofacial myologist) presented to a dental sleep office for labial and lingual laser frenectomy.

The patient was unable to efficiently progress through myofunctional therapy due to tethered oral tissues. She had always struggled to maintain a proper lip seal due to a restricted labial frenum and demonstrated a short upper lip from mouth breathing. While treating her own clients, she was unable to demonstrate certain myofunctional therapy exercises that were required elevation of the middle and posterior portions of the tongue.

The patient hoped the frenectomy procedures would aide in her ability to create a lip seal, correct her tongue rest posture, and establish a proper swallowing pattern.

Childhood history of symptoms: The patient was bottle fed during infancy. A history of thumb-sucking and pacifier use until the age of four were reported. At the age of seven, the patient underwent adenoidectomy and tonsillectomy. She had a deviated septum after breaking her nose at the age of nine (this has not been corrected), and reported frequent mouth breathing. The patient had orthodontic treatment from age twelve to fourteen that included rapid palatal expansion and retractive headgear. Due to orthodontic relapse, she also had orthodontic treatment at age twenty and again at age twenty five.

Clinical exam and symptoms: The following TMD symptoms were observed: jaw deviation to the right along with clicking/popping/crepitus on the right side (Figures 1A and 1B). The patient reported neck pain and frequent headaches.

A.

B.

Figure 4: A. Pre-Frenectomy: 28 mm ROM with tongue tip to incisive papilla; functional ROM 60.8% B. 10.5 months Post-Frenectomy: 47mm ROM with tongue tip to incisive papilla; functional ROM: 94%.

The patient had a long, narrow face, low facial muscle tone, a short upper lip (philtrum was 14 mm long), and open mouth resting posture with the 7 mm interlabial gap (Figure 2A). The patient reported mouth breathing all night, regular night time drooling, restless sleep, and frequent waking.

She complained of daytime fatigue and never waking well rested. Her left nostril “whistled” during nasal breathing, and she was frequently congested.

Moreover, the patient had a forward head/neck and forward rolled shoulder posture; she reported significant tension in the neck and shoulders and was concerned about Dowager’s hump formation (Figures 2A and 3A). She had a bilateral tongue thrust during swallowing and low tongue resting posture (tongue tip resting against lower incisors). The patient reported dry, chapped lips and the habits of lip licking, cheek biting and clenching.

Intraoral examination revealed a narrow, high palatal vault with pronounced rugae, and narrow soft palate. The tight upper labial frenum and attached gingiva blanched when extending the upper lip. The tongue appeared short and wide with a tight, restrictive lingual frenum. The functional range of motion (ROM) was 60.8%: the full ROM was 46 mm, and the ROM with tongue tip to incisive papilla was 28 mm (Figure 4A). The patient’s Mallampati score was IV (Figure 5A).

Medical history: At the time of the visit, no medications were taken; no known drug allergies, recent illnesses, or hospitalizations were reported.

Laser surgery: After local anesthetic (Articaine hydrochloride 4% with 1:100,000 epinephrine) was administered by infiltration, the LightScalpel laser frenectomy was performed to release both the maxillary labial and lingual restrictions. LightScalpel® CO2 laser (LightScalpel, LLC, Bothell, WA) with 0.25 mm focal spot size laser handpiece was utilized, delivering 2 watts SuperPulse laser beam gated at 70% duty cycle at 20 Hz (average power to the tissue was 1.4 watts). For efficient incision, gentle traction tension was applied to the

Karen Wuertz, DDS, has been recently awarded the first ever Fellowship of Orofacial Myology by the International Association of Orofacial Myology; is a Diplomate, American Board of Craniofacial Dental Sleep Medicine; a Fellow, American Academy of Craniofacial Pain; and a Diplomate, American Board of Laser Surgery. She is an Assistant Adjunct Professor, UNC Dental School, Chapel Hill, and maintains membership in the Texas Dental Society, American Dental Association, American Academy of Dental Sleep Medicine, American Academy of Craniofacial Pain, and serves as the credentialing Chair for the American Board of Craniofacial Dental Sleep Medicine.

Brooke Pettus, RDH, BSDH, COMS, is the owner of Myofunction Junction in Richmond, VA, where she works full time helping children overcome oral habits and myofunctional needs.

She has trained through the Academy of Orofacial Myofunctional Therapy, the International Association of Orofacial Myology, MyoMentor, and is a certified orofacial myology specialist through the Graduate School of Behavioral Health Sciences. Brooke has spent hundreds of hours studying with, learning from, and partnering alongside pediatric and airway-focused dentists and orthodontists, speech language pathologists, ENTs, occupational therapists, and lactation consultants. She strongly believes a team approach is necessary for optimal oromyofunctional outcomes.

Brooke graduated from Virginia Commonwealth University in 2009. She has spoken nationally and internationally on a variety of oral health topics.

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LASERfocus tongue and the lip during lingual and labial procedures, respectively. The laser nozzle was held 1-3 mm away from the target tissue and moved in zigzagging fashion until the tension was released. As frenectomy progressed, the dentist stopped several times to evaluate the extent of release and the function of the lip and the tongue. Minor bleeding was encountered during the labial procedure, but was quickly resolved by switching to the non-SuperPulse mode and increasing the distance between the nozzle and target tissue (i.e., defocusing the laser beam).

After the tension was released, the patient was asked to lift, extend, and lateralize the tongue, with the chin stabilized. This allows the dentist to see if lingual mandibular differentiation can be observed. The upper lip was retracted and a finger dissection of

A.

B.

Figure 5: A. Mallampati score IV with tongue scalloping and limited opening due to TMD symptoms pre-frenectomy; B. Mallampati score I three weeks post-frenectomy w/ OMT.

A.

B.

C.

the remaining frenal fibers completed the procedure. After the surgery, the patient gained 19 mm in the ROM with tongue tip to incisive papilla – from 28 mm to 47 mm (Figure 4B).

Postoperative care and healing: Almost immediately after the CO2 laser frenectomies, the patient reported less neck and shoulder tension, felt she could stand up straighter, and that her “airway feels more open” when breathing. She was able to close her mouth comfortably and without strain on her upper lip. She was able to elevate the middle and posterior portions of the tongue to the palate, and complete previously difficult myofunctional exercises with ease. 800 mg Ibuprofen was taken twice the day of and once the day after the procedure for minor postoperative soreness, and a soft, bland diet was maintained for 48 hours.

As an orofacial myologist, the patient was diligent with her active wound management and strictly followed her customized, progressive OMT regimen in order to achieve optimal healing of frenectomy sites, maximum ROM, and optimal oral function. Healing progressed with no complications (Figure 6 demonstrates lingual healing). At 10.5 months post frenectomy, the patient’s functional range of motion (ROM) was 94%: the full ROM was 50 mm, and the ROM with tongue tip to incisive papilla was 47 mm.

OMT helped the patient retrain and re-pattern neuromuscular movements that had been foreign to her and helped her integrate them into her everyday life. The establishment of proper oral rest posture (tongue to palate, instead of in the floor of the mouth), lip competence (no open mouth posture at rest – Figure 2B), nasal breathing (this got increasingly easier aided with Buteyko breathing techniques, even with a deviated septum), and correct chewing and swallowing patterns has made a profound difference in her life. She has better posture, more energy, eats less, feels rested in the morning, and sleeps through the night. Her bilateral tongue thrust has been eliminated and night time drooling has been resolved. The patient reports a decrease in clenching and biting the sides of her tongue at night. As a long term goal, the patient intends to continue working on oral habituation and improving/maintaining better posture. The patient was informed that if symptoms of sleep disordered breathing returned, she would be referred to a sleep medicine physician for further evaluation.

Summary

Optimal orofacial function in adult patients can be achieved through the extensive functional release1 of restrictive oral tissues. The functional release is accomplished through a) the SuperPulse CO2 laser frenectomy performed with the tongue and lip mobility assessment; and b) regular pre- and post-frenectomy OFMT. The authors find that the reduced postoperative wound contraction, minimal thermal tissue change, less traumatic surgery, predictable incision depth and ability to achieve hemostasis, make the SuperPulse 10,600 nm CO2 laser an effective surgical alternative to scalpel, electrocautery, diodes and erbium lasers.

1.

2.

3.

4.

D.

E.

F.

Figure 6: A. Pre-frenectomy; B. Immediately after laser frenectomy; C. 24 hours post-frenectomy w/ OMT; D. 48 hours post-frenectomy w/ OMT; E. 2 weeks post-frenectomy w/OMT; F. 10.5 months post-frenectomy w/ OMT.

42 DSP | Fall 2018

5.

6.

7.

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.

Wuertz K, Vitruk P. Superpulse 10,600 nm CO2 laser revision of lingual frenum previously released with a diode hot glass tip. Dent Sleep Pract. 2017 fall;34-6.

Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med. 2013 Jun;14(6):518-25. doi: 10.1016/j.sleep.2013.01.013.

Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009 May 15;179(10):962-6. doi: 10.1164/rccm.200806-981OC. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA. Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep. 2015 May 1;38(5):669-75. doi: 10.5665/sleep.4652.

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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.

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PRACTICEmanagement

CARVE your Path to Social Media Success Be Consistent, Accurate, Responsible, Varied and Effective

by Sasha Thompson-Bachtold, MEd

I

n a social media evaluation of ten dental sleep practices, only 20 percent of practices that appear to practice dental sleep medicine had successfully met all five criteria for optimal social media results.

The CARVE formula is the perfect guide for creating your own path to success. Add the five CARVE questions to your weekly meetings, and you should be well on your way!

To make your social media efforts land with the biggest impact, ask yourself the following: • Is your social media posting Consistent? Are you posting to social media on a regular schedule or sporadically?

• Is your social media connectivity Accurate? Are your website settings and technology set up to reach potential patients the way you want to reach them?

• Are you socially Responsible online?

Are you unintentionally revealing personal health or identifying information about your patients through social media?

• Is your social media content Varied?

Do your posts represent the sort of variety that gets patients to pay attention, or are they repetitive content that makes viewers tune out?

• Is your social media messaging Effective? Are your posts reflective of the unique qualities of your practice that will inspire viewers to engage?

Is your social media posting CONSISTENT? Of the ten practices audited, 70 percent posted consistently.

44 DSP | Fall 2018

Realistically, a dental sleep practice should post on Facebook, Instagram and Twitter once a week. Facebook’s free Facebook Business Manager tool makes it easy to schedule posts for delivery in the future as well as easily manage Facebook ads. Many other social media applications allow practices to schedule future posts in one place.

The most common social media scheduler is Hootsuite. The free version of Hootsuite offers future scheduling for up to three social media accounts, which can include Facebook, Twitter and Instagram. Wonder when to post? A guide to optimal posting times that coincide with practice hours is included on the next page.

Is your social media connectivity ACCURATE? Of the ten practices audited, 50 percent were connected accurately to social media properties.

Inaccuracy online is a large factor in poor search engine optimization and website ranking. Online properties such as websites, online directories, and social media are at great risk for error and duplication. Commonly, links to social media on websites are designed to open in the same window. This takes website visitors away from the practice site. Check your website settings to make sure that your social media links open in a new tab so you don’t lose visitors to your practice site. Also look for duplicate Google+ listings and Facebook Pages. Delete or merge the duplicates so that your visitors are coming to the one right place and your practice is managing the right page. This saves everyone time, money, and frustration!

PRACTICEmanagement Now is a good time to review your website. Look over every page for errors, inconsistencies, and out-of-date information.

Make all necessary edits and corrections so that visitors get the most current and accurate impression of your practice. Be sure to have a website page dedicated to each patient research topic and that your social media posts have website links, so visitors can easily find their way back to your practice site.

Are you socially RESPONSIBLE online?

Fortunately, of the ten practices audited, 100 percent were socially RESPONSIBLE online. This is definitely a trend you want to follow.

Review responses on social media are one major concern for keeping protected health information private. When responding to a negative review, take care to not indicate that the reviewer is a patient. Simply state “The office is sorry to hear of the experience. Please call at the earliest convenience.” For a positive statement, a simple “Thank you. That is appreciated.” is the most conservative approach.

Open the review tab in Facebook and make sure no statements are violating this standard. If you find responses to reviews that seem risky, consider removing the Review Tab in the Facebook settings. (It is currently not possible to remove individual responses to Facebook reviews.) Read any responses on Google+ and Yelp as well. Ensure all responses are generic and positive.

If the practice delivers an email newsletter, ensure the office has recorded permission of recipients who have opted in to receive it. One convenient way to do this is a newsletter sign-up button on the website. Simply provide a form that acknowledges that the patient will receive email notification

It’s always time to review your website.

Now is good.

With a background in business, marketing, and education, Sasha Thompson-Bachtold, MEd, launched her career in the dental space at Sonicare in 2008. She has lectured on digital marketing and dentistry since 2009. As a marketing consultant, she considers all aspects of marketing to create optimal results in our digital and physical environment.

She uses her unique skill set to help dentists make the most of their marketing through consultation, speaking engagements, and publications at national and international conferences.

Sasha’s 8 years of experience at two Pacific Northwest dental technology companies deepened her knowledge of the dental business and broadened her awareness of the dynamic changes in both dental technology and marketing.

Recognizing a growing need for personalized dental marketing with a wider scope of service options drove Sasha to launch Marketing Front in mid-2017.

Before entering the dental space, Sasha was an AP French teacher at Issaquah High School in Issaquah. She has formally studied French, Business, Marketing, and Education. She holds a Master’s degree and lives with her family in the Pacific Northwest/Western Washington.

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PRACTICEmanagement and automate an email to their inbox. Many patient connection systems already have a newsletter system in place. If so, simply review the software settings for patient permissions and start creating custom personalized quarterly newsletters. For email reminders and newsletters, always have a simple unsubscribe process in place. When taking photos for social media, ensure that there is no patient-sensitive information in the background. If HIPAA compliance is a concern, consider hiring a professional HIPAA compliance agency or auditor.

Is your social media content VARIED? Of the ten practices audited, 60 percent had VARIED content on their social media pages to drive visitor interest.

For dental sleep medicine, consider the following types of content: • User-generated content: Share testimonials of patients who have solved their problems with oral sleep appliances.

• Influencer endorsements: Repurpose public service announcements by high impact initiatives such as World Sleep Day. • Use memes for humor.

46 DSP | Fall 2018

• • • • •

Use hashtags for finding followers.

Use quotes that fit with your message.

Share recipes.

Celebrate holidays and events.

Keep current with hashtag trends by using services such as Unmetric, a social media artificial intelligence company.

• Use mobile apps such as IMGplay for creating short, edited videos.

• Use positive psychology in your posts.

When creating a visual for sleep apnea, focus on the positive outcome, such as performing well at work, driving safely, or sleeping with a bed partner again.

Is your social media content EFFECTIVE? Of the ten practices audited, 50 percent had EFFECTIVE content.

20 percent of audited practice Facebook Pages utilized canned, repurposed content from a low-cost social media agency. None of these posts had any engagement from followers. All generic posts were only liked by the practice itself. The most successful posts featured content that was original. Consider the following types of effective content: • Personal Videos º Doctor and Patient Discussing Treatment

º Office Events º Testimonials • Team Photos • Health News and Information • Practice Team News • Humor • Pet and Family-Related Content • Local Sports • Community Service It’s hard to deny the impact of social media on successful dental-practice marketing in our connected world. Having a formula in place and knowing the tools that can make your social media strategy run more smoothly will take the hassle out of this important element of your marketing plan.

Making time each week for your staff to CARVE out a successful social media system for your practice will reduce stress and build results.

PRACTICEgrowth

Marketing in the Era of #MeToo by Chris Bez

M

arketing your practice should be simple, right? In a great marketing environment, you tell your story, people are convinced you’re great, they love you, they flock to your door, they get an appliance and you’re off to vacation with the family, sipping margaritas at the shore.

Then you wake up. As you jolt into awareness, that perfect marketing dream, like a purple unicorn, is catapulted into the ozone and is exposed as total fiction.

Our marketing environment is no longer simple. Instead, awash with news of unethical, immoral, disrespectful, and any number of other categories of behaviors, we are forced to tell our stories against a laundry list of standards. A list against which we must measure up before people will believe in our greatness and flock to our doors. Accountability. Transparency.

Responsibility. Ethics. Morality. The list lengthens as the pendulum swings to wherever the offsetting extreme is that will get us to the mean. Often, the extreme feels like a moving target that is getting farther away.

Understand that we never market in a vacuum. We always market against the bigger backdrop of current values, economies, political agendas, weather, times of year and yes, even sporting events. What we can fail to recognize is that the dental sleep medicine practice is further challenged because it has a relatively unique position in our current marketing environment. The typical patient that walks through the door of the dental sleep medicine practice, unlike the general dentistry patient, has been sleep deprived for anywhere from months to decades. Their behaviors range from mildly irritable and tired to what seems depressed, angry and hungering for the adrenaline rush a good argument will provide them. Added to that lack of sleep is the added pressure of coping with the news of the day. News that for even the non-sleep deprived person, feels crammed to the brim with political parrying, egalitarian dialogues, and media vying for the most dynamically charged story they can conjure. The result? A setup for Murphy’s Law on an apocalyptic scale.

How to navigate the areas where emotion and marketing converge is a source of debate in every industry. In an area where the patient must, by the very nature of the practice, invite the practitioner, office staff and clinical

Chris Bez, from a start as a Sales Manager for a national manufacturing company, has 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.

assistants into their boudoir and that very vulnerable place where they embarrassingly admit to snoring, the stakes are high. Applying the wrong inflection to a question that was until a year ago considered benign can derail an interview. An out-of-fashion term makes a joke no longer PC. Misinterpreted proximity during treatment or simple statements misunderstood as inuendo can immediately be sent viral via social media. The wise practitioner will avoid one-on-one private conversations by including team members during office visits.

Setting an intention to treat patients with the highest degree of ethics and morality – and discussing what that “looks like” among staff and doctors is a great place to start. Being completely accountable and responsible for the care you are providing is absolutely required. Recognizing that taking the time to review what was once thought of as acceptable behavior, considering the lessons we are all learning about the new normal, is essential. But before spinning out of control, might we consider that in the long run, it’s not the basics that have changed – the need for ethics, morality, accountability and responsibility was there before poor behavior called our attention to that need. What’s changed is how we are now called to deal with these topics. While setting and staying aware of standards for yourself and your staff, communicating, asking for and providing feedback, and staying present as each patient and each marketing piece is addressed, may sound like a tall order, it’s really not. Most likely you’ve been doing it all along – or all those people wouldn’t have been flocking to your door to begin with.

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TEAMfocus

Adjunctive Therapy Can Increase the Value of Your Services

by Glennine Varga, AAS, RDA, CTA

T

he good news is sleep disordered breathing is starting to become more of a focus in our profession. The bad news is…well, there is no bad news. The increase in awareness may create a competitive environment with patients and your referral sources, but competition is good. Dental teams have expressed frustration that patients want to see in-network providers or only do what the insurance allows. How do we work with these types of patients and what’s the best thing to say? Now is the time to ask: Is there anything else we can do to increase the value of our services in an up and coming competitive market?

Dental Sleep Medicine can be a wide range of various services including combination therapy with Positive Airway Pressure (PAP) or surgical intervention. No matter the options offered to patients, it’s important that everyone delivers the same message. In the spirit of team – call a team meeting and determine what information will be provided and if there are any other therapies/remedies that may help your patients’ therapy succeed.

Make sure to get properly trained and determine what communication will be said about each offering. Remember, if your patients are successful with their therapy, you will be part of that success and that is something invaluable. Establish a way to communicate with patients, preferably in an interactive style. Invite them to share complaints and concerns and offer ways to address them. Be clear with expectations regarding finances and insurance. Here are the most common adjunctive therapies and communication pointers for patients.

Sleep hygiene awareness is one of the most important added value services you can provide. Communication should start with your first introduction to the patient online or over the phone. Before patients pick up the phone to call you regarding your dental sleep therapy services they must first know you provide them. Educate patients on your website about signs and symptoms; give them interactive questionnaires and videos

48 DSP | Fall 2018

to watch. Once you have them on the phone, make sure you know how to schedule a sleep specific patient or introduce sleep within your general dental new patient comprehensive exam. Learn how to help them connect the dots between medical, family and social history and sleep related breathing disorders.

Guide them to discover proper sleep breathing is essential to overall health and wellness. If possible give your patients resources like apps, articles, videos or give them a list of your favorite sleep books. Patients will remember you when you take the time to educate them on their own sleep and give them pointers that can make a huge difference.

Nasal guidance is my favorite adjunctive therapy! Help your patients breathe through their noses. We have two ways to breathe.

Our oral appliances are designed to reposition the mandible to hold the tongue and soft tissue out of the way. However, nasal airway is paramount and your upper airway resistance syndrome (UARS) patients will love you for guiding them toward optimal nasal support. My favorite regime is Max Air Nose Cones and a humidifier or an essential oil diffuser. Some patients may need a little more help like lip tape or chip straps. When communicating with patients, promote how comforting the air will be flowing through the nose and how relaxing it is to just let go and fall asleep knowing the airway will be supported. Learn how to use the products

TEAMfocus you are promoting and if possible try out the products yourself. The best way to explain something is to experience it firsthand. Everyone on the team should know your referral preferences, providers and products, and have your referral information readily available. Patients will pay closest attention to the person they’ve connected with the best in the office; any referrals should come from the ‘most trusted’ person in the office.

Pediatric guided growth of the maxilla and mandible is way to intervene with a non-optimal airway. Communication surrounding this type of therapy should be focused on developing better sleep and breathing patterns. Children with growth deficiencies may need extra guidance to achieve symmetry and balance, which will also provide more room for all the teeth and more sagittal space which is very favorable for the airway. In all communication it’s important never to promise any outcomes. We can be supportive and positive with our comments as we help our patients reach maximum medical improvement (MMI). It’s fun to celebrate your patient’s progress with enthusiasm and genuine interest.

Ancillary sleep products to improve the quality of your patients’ sleep can be a great way to add value to your services.

White noise machines, blue screen blockers, sleep masks, cooling mattress pads and fans are items you can carry in your practice for patients to purchase or you can provide an item list they can purchase online. You can educate your patients about sleep hygiene let them know research shows blocking the blue light from electronics and sleeping cool improves sleep. Having products patients can try that same night is exciting. Don’t forget positional therapy products like pillows, apps or items to use to keep your patients off their backs.

Supplements and sleep aids may be a focus in your practice. Create fun ways for your patients to participate with compliance.

You can give them printed materials, charts or calendars and remember: the more natural the supplement, the better. Melatonin is a natural hormone that helps to relegate the sleep and wake cycle. Magnesium is one of the most common minerals on earth and can aid patients with insomnia. It is essential for human health and can help the body and brain relax. By quieting the nervous sys-

tem, magnesium can help prepare the body and mind for sleep. Calcium for relaxation as it helps the cells in the brain to use tryptophan to create melatonin. Research shows it works best to take both calcium and magnesium together. Theanine is an amino acid that is found in tea leaves, preferably black tea, a lower-caffeine alternative to coffee. It can also be taken in supplement form and helps with relaxation, focus and sleep. Essential herbs or oils such as bergamot, lavender, sandalwood, frankincense and mandarin are all great and when combined can be very useful sleep – inducing blend. Passion flower tablets or liquid extract have proven benefits improving sleep quality and effective treatment for insomnia. The Encyclopedia of Natural Healing for Children and Infants is considered by many an authoritative reference on natural pediatric medicine. Invite a local nutritionist or natural medicine practitioner to a team meeting to learn more.

Think outside your walls reach out to local mattress companies, chiropractors, naturopathic and holistic communities see if you can co-sponsor each other by offering patients extra cost savings on new mattresses, services or products. Maybe you can offer a fun sleep awareness event to showcase products and services. Dental sleep medicine is patient specific – let your patients tell their stories and look for ways to help them resolve complaints. The more remedies you know about the better your chances of success.

Patients will pay closest attention to the person they’ve connected with the best in the office – their ‘most trusted’ person.

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

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

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PRODUCTprofile

Choosing the Right Appliance May Reduce Side Effects

by Mark T. Murphy, DDS, FAGD

A

lthough not technically part of the Hippocratic Oath1, “first do no harm”, is a standard component of good medical and dental care. Side effects are a necessary evil that are secondary to the intended effect; the term is predominantly employed to describe adverse outcomes. Numerous studies show that physicians and patients care about Oral Appliance side effects and that they may impact referral decisions. The American Academy of Dental Sleep Medicine published a position paper, “Management of Side Effects of Oral Appliance Therapy for Sleep-Disordered Breathing”2, to provide guidelines. Prosomnus® Sleep Technologies is making an effort through product development and scientific studies to enable dentists to mitigate these risks while still achieving successful treatment outcomes.

Good medicine would prescribe avoiding, minimizing or at least managing unwanted side effects without compromising the quality of primary care. Common examples of mild adverse effects related to drugs include: constipation, skin rash, diarrhea, dizziness, drowsiness, dry mouth or headache. The therapeutic benefit may far outweigh these inconveniences. If we could prevent or avoid side effects while still achieving the desired result, that would be preferable.

For CPAP therapy, patients may experience nasal problems (e.g., rhinorrhea, epistaxis, URI); mask problems (e.g., dermal abrasion due to poor fit, conjunctivitis due to air leaks); flow problems (e.g., difficulty exhaling); and other types of difficulties that interfere with effective therapy3. Claustrophobia, headaches, belly bloating, difficulty with nocturnal bathroom visits and machine noise are also mentioned as challenges.

However, despite advancements in size, portability, titration, noise, and mask fit, studies report that CPAP compliance rates remain well below the recommended threshold of >4 hours on at least 70% of nights4.

Historically, OAT patients have had a list of unwanted side effects to therapy. Not only can these sequelae interfere with compliance and treatment, physicians often sight them as reasons to prescribe CPAP. Today, not only are we aware of CPAP’s own side effects, but the next generation of oral appliances from ProSomnus are designed to prevent and minimize untoward outcomes from OAT. The AADSM and AASM list of OAT side effects includes: joint discomfort, noise, tender muscles, soft tissue irritation, excessive salivation, dry mouth, occlusal changes, tooth movement, metal allergies, hygiene issues, gagging, and restoration and appliance breakage. On the next page is a list of next generation oral appliance improvements from ProSomnus that were not available just a few years ago.

Joint Discomfort

ProSomnus Sleep Device

50 DSP | Fall 2018

CPAP Machine

Two of the causes of joint pain and discomfort in OAT are excessive/rapid advancement and asymmetrical titration. The engineered, precision design ensures that the mandible is advanced in a true A/P direction regardless of the arch shape or angulation.

Several clinicians report less advancement because of the lower material volume and greater tongue space.

PRODUCTprofile Oral Appliance Side Effects

ProSomnus Sleep Apnea Devices

Handmade Lab Sleep Apnea Devices

Joint/muscle discomfort

Precision engineered bilateral symmetrical advancement

Asymmetrical advancement is common

Tooth movement

Retainer like, precision fit

Ball clasps retention replaced ‘fit’ or flexible materials

Soft tissue irritation

Smoother, smaller devices

Posts, rods, straps and size are larger

Occlusal changes

Chairside re-aligner use and precision digital Morning Occlusal Guide [MOG]

Infrequent [MOG] use

Dry mouth

Patient centric designs, smaller devices with less bulk

Bulkier devices, less customization

Metal allergies

Metal-free options, less monomer leaching

Nickel, monomer and other material sensitivity

Hygiene issues

Denser material, less bio-gunk and stain

Difficult to keep clean, more porous

Appliance breakage

Milled solution from stronger control-cured PMMA

Weaker PMMA material options

Restoration damage

Retainer like, precision fit

Ball clasps and imprecise fit

Gagging

Stronger smaller, lingualess design allowing more tongue space

Larger devices, less tongue space

Tooth Movement A recent study and poster presented at the AADSM Annual Meeting (with models and measurements made independently in the Orthodontic department at the University of the Pacific) demonstrated no significant tooth movement over a 2.3-year period using the Littles Index. Addtionally, no statistically significant change was reported in overjet or overbite when the models were placed in MIP (Maximum Intercuspation)5. It is noteworthy that the ProSomnus Sleep Device was used without ball clasps or a soft liner and confirms the goal of a retainer-like fit.

Soft Tissue Irritation Smoother, more comfortable oral appliances with less obtrusive advancement mechanisms provide less cause for soft tissue irritation. The ProSomnus [IA], an Iterative Advancement Device, has no screws, mechanisms, or elastics required other than the contoured posts. The ProSomnus [CA], a Continuous Advancement Device, has been designed with patient comfort in mind.

Occlusal Changes ProSomnus uses digital technology to design and manufacture a precision Morning Occlusal Guide or [MOG]. Not only does it help reposition the condyles in the morning, but the precise tooth position is stored so that if the need should arise, a new MOG could be milled easily from those records.

ProSomnus Sleep Device Symmetrical Titration

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

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PRODUCTprofile

ProSomnus

Lab Acrylic (a)

Lab Acrylic (b)

Metal Allergies The ProSomnus [IA] has no metal components. The dense milled control-cured medical grade PMMA leaches less monomer than any of the handmade predicate devices.

Dry Mouth

A UoP study demonstrated no significant tooth movement over a 2.3-year period.

Less overall volume, patient centric designs and standard Dual 90º Posts allow ProSomnus Devices to create less lip competency problems and ergo, dry mouth. Milled elastic hooks are a feature that can be a requested if desired.

Appliance Breakage The stronger control-cured medical grade PMMA performs better than predicate devices in strength and breakage testing.

Hygiene Issues All ProSomnus Devices are milled from a dense control-cured medical grade PMMA puck. Besides being stronger and smaller, the material density provides less of a substrate for bacterial growth and stain.

Restoration Damage The precision fit of the ProSomnus Sleep Devices is unlike other retention solutions presented to date. Ball clasps mean the fit of the device is not good enough for retention

52 DSP | Fall 2018

Printed Nylon

and ergo, the metal balls provide that. Biting on or into acrylic versus a metal ball clasp is potentially far less damaging to restorative materials.

Gagging Smaller devices allowing more tongue space will always be less of an irritant than larger, bulkier solutions.

So, what does this really mean? With fewer side effects and better therapeutic outcomes, there is a better choice to treat OSA. Patients should understand, be presented all options, and be involved in making health care decisions about treatments, their side effects and the risks and rewards of each. The design and engineering of ProSomnus Sleep Devices provide a next generation solution that is intended to be better for patients and engage more physicians. ProSomnus is far from done. Continuous Advancement is more than the name of our newly launched Sleep Device. It is a way of approaching and solving the Sleep Apnea crisis in the world today. With an estimated 1 billion sufferers worldwide6, we need better coordinated patient centric solutions that are examples of precision medicine. ProSomnus’ charge is treating more patients with greater efficiency, efficacy and effectiveness while reducing side effects to provide better outcomes.

1.

Hippocratic Oath, NIH National Library of Medicine Medical History Section. https://www.nlm.nih.gov/hmd/greek/greek_oath.html/.

2.

Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. Journal of Dental Sleep Medicine 2015;2(3):71– 125.

3.

Side Effects of CPAP Therapy, NIH, National Heart, Blood and Lung Institute; https://www.nhlbi.nih.gov/node/4248/.

4.

Rotenberg et al. Trends in CPAP adherence over twenty years of data collection; A flattened curve, Journal of Otolaryngology - Head and Neck Surgery (2016) 45:43 DOI 10.1186/s40463-016-0156-0.

5.

Vranjes et al, Tooth Movement and Bite Changes for a Hard-Acrylic Sleep Appliance; 2 Year Results; Poster Session at the AADSM Annual Meeting, Baltimore, MD 2018.

6.

Benjafield et al. Global Prevalence of OSA in Adults; Estimation Using Currently Available Data. Thematic Poster Session American Thoracic Society Annual Meeting, San Diego, CA 2018.

EXPERT view

Myofunctional Therapy

by Kristie Gatto, MA, CCC-SLP, Certified Orofacial Myologist

I

deal health and function of the body is directly dependent upon optimal breathing patterns. Just as breathing impacts cellular regeneration; blood oxygenation; overall brain function; hormonal levels; and the strength and stamina of the muscular system, poor breathing patterns can also impact the development and function of orofacial complex. Orofacial myofunctional disorders can be found in both children and adults and often develop across the course of a lifespan. Orofacial myofunctional disorders (OMDs) are atypical patterns that emerge when normalized patterns are interrupted or impeded in some way. These maladaptive patterns often emerge during early growth and development, following a trauma or surgical procedure; and poor diet or not being able to breathe appropriately.

Jaw musculature Images courtesy of Kristie Gatto

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EXPERT view

Ankyloglossia

To date, Hanson (1982) still provides the most thorough definition of Orofacial Myofunctional Disorders: “Orofacial myofunctional disorder refers to abnormal resting labial-lingual posture of the orofacial musculature, atypical chewing and swallowing patterns, dental malocclusion, blocked nasal

airways, and speech problems. These are patterns involving the orofacial musculature that interfere with normal growth, development, or function of the orofacial structures, or calls attention to itself.”

OMDs commonly seen in children, include an atypical swallowing pattern that requires dentalized tongue movement (anterior or interdental) and has historically been referred to as “tongue thrust.” OMDs encompass nonnutritive sucking behaviors such as thumb and/or digit sucking, cheek or tongue sucking, prolonged pacifier usage, clenching or bruxing, and so forth past 12 months in age. These patterns can lead to the development of other abnormal lip, tongue and jaw movement and posture patterns, affecting the eruption of dentition, and creating other changes to the oral cavity.

OMDs in the adult and geriatric populations occur secondary to various neurological impairments, oral hygiene problems, dental restorations, altered function of muscles due to aging, systemic diseases, or trauma to the oropharyngeal complex.

Oromyofunctional disorders are multifactorial in nature and are often the consequence of a sequence of events or lack of intervention at critical developing periods.

This results in further oral dysfunction that can cause malocclusion, as well as changes in cranio and dentofacial development.

The presence of systemic disordered breathing contributes to structural and functional symptoms of OMDs. For example, the impact of enlarged tonsils and/or adenoids

Kristie Gatto, MA, CCC-SLP, COM, received her bachelor’s and master’s degrees from the University of Houston in Houston, Texas. She has worked as a speech-language pathologist in the public and private school systems, skilled nursing, rehabilitation and children’s hospitals, and in private practice. In 2004, Ms. Gatto became the co-owner of a private practice in Northwest Houston and began her journey in treating children with pediatric feeding disorders. After years of searching for answers in traditional feeding approaches, she underwent training in the field of Orofacial Myology and became the first certified orofacial myologist in the city of Houston in 2011. Ms. Gatto is currently the owner of The Speech and Language Connection, which has two offices in the greater Houston area and employs 24 speech-language pathologists with various specialties.

For the past ten years, she has focused her clinical skills on treating patients with issues in feeding, dysphagia, deglutition, oral sensory aversion, orofacial myology, and swallowing-related disorders, as well as articulation, phonological processing, apraxia, and early childhood intervention. Ms. Gatto is the author of three books: Understanding the Orofacial Complex: The Evolution of Dysfunction (Outskirts Press, 2016), Understanding the Orofacial Complex – Muscle Manual (Outskirts Press, 2014), and Sam the Super Chewer, Eats (Mindstir Media, 2016). She is the President of the International Association of Orofacial Myology, a Board of Directors member for the American Academy of Private Practitioners in Speech Pathology and Audiology, and a member of the American Speech-Language-Hearing Association.

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EXPERT view

Orofacial myofunctional disorders are a cascade of dysfunction that emerges from a variety of etiologies.

and accompanying development of chronic upper airway obstruction. Growth and development can be negatively impacted by mouth breathing as a result of the hypertrophied tonsils and adenoids and their direct causal relationship with the anterio-posterior position of the maxilla. The reduced airflow through the nasal cavity forces the tongue downward in the mandible further impacting the vertical growth patterns when the lips part to breathe. The palate is then impacted when the absence of the tongue to palate fails to provide needed stability for maxilla development. This, in turn creates further soft tissues changes further altering muscle function. OMD’s are a cascade of dysfunction that emerges from a variety of etiologies.

Causes of OMDs include: • Functional airway obstruction to include enlarged tonsils and adenoids, enlarged nasal turbinates, deviated septum, sinus infections, allergies (environmental or seasonal), chronic upper airway infections, asthma, sleep disordered breathing, including obstructive sleep apnea, and low oropharyngeal muscle tone resulting in airway collapse • Oral resting postures, including mouth breathing • Craniofacial disorder, craniofacial dysmorphology, malocclusion • Sensorimotor dysfunction or disorder, functional limitations, low orofacial and oropharyngeal muscle tone • Dysphagia • Restricted oral frenula (early nursing difficulty with labial, lingual, and buccal movements for latching, sucking,

lingual retraction, cupping, and elevation) • Nonnutritive sucking & chewing habits – in utero or learned later that continue beyond the 12 months in age • Chewing and eating behaviors, prolonged pureed feeds, or atypical soft food diets • Idiosyncratic or aberrant movement behaviors These changes require a multidisiciplinary approach including a certified orofacial myologist (COM™). An IAOM professional trained in orofacial myofunctional disorders specializes in the restoration of normalized function within the orofacial complex. Participation in their 48-year old Certification program is currently only open to professionals that have orofacial myofunctional disorders within the scope of practice for which they are currently licensed to practice. Those professionals include: dentists, dental hygienists, and speech-language pathologists.

Proper assessment and intervention can vary from person to person and is dependent upon the underlying etiology or cause of the dysfunction. An effective treatment program consists: a comprehensive assessment, development of an individualized treatment plan, implementation of techniques to facilitate the dissociation of orofacial movements, followed by the coordinating the sequential orofacial movements for chewing, swallow and rest posture. A good program includes a period of maintenance where a program of habituation is developed and a period of follow-up checks to ensure that habituation outside the therapy setting.

Jaw musculature

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CASEreport

OSA and Cerebral Palsy

by Ronald S. Prehn, ThM, DDS

P

atient: Matthew is a 17-yr. old male with OSA and CPAP intolerant due to Cerebral Palsy (CP).

He is a special kid who is full of happiness and brings joy to others.

Diagnosis: OSA. AHI 14; RDI 15; PSO2 89%; 6 central apneas Previous Treatment: CPAP was attempted, but with his CP he was not able to keep his head from moving and keep the mask on his face. Also, his mouth is wide open most of the night. Was referred by Texas Children’s Hospital for consideration of Oral Appliance Therapy.

History: Matt had a history of facial pain, TMJ and jaw pain, morning HA, tooth pain from severe clenching, bruxing, insomnia, moderate snoring and fatigue. His mother and father said that since he was a child, he has woken up every 2 hours during the night, and so were they. They switch nights watching over him. Epworth Sleepiness Scale was 15. CPAP was attempted, but after trying multiple masks, he was unable to keep them on his head.

Exam: He had previous orthodontics 3 years ago, and his bite was class 1 at the time (per parents). Today he presented as a new patient with a 5mm anterior open and a 10mm over jet, due to severe tongue thrust.

Oral exam was difficult due to his movement, but he had all his permanent teeth with good periodontal health. We were able to obtain a cone beam x-ray that showed he had no significant tonsils, and average size airway and a severe high vaulted palate. TM joints were

56 DSP | Fall 2018

Matthew splint in mouth

Matthew holding splint

well formed and free of arthritis. Images also confirmed his anterior open bite and over jet that started at the canines.

Treatment Considerations: The parents main concern about an oral appliance (OA) for sleep, was that with Matt being a quadriplegic, he would not be able to remove it himself. I had two concerns in trying to advance his mandible with any Mandibular Advancement Splint (MAS). First was that his mouth would be too open most of the time.

The second was his severe clenching during certain periods at night. I did not think any MAS could control his mouth and stay retained on the teeth, or if a side winged MAS was used, he would over open to disengage the wings or break them off.

Treatment: With my background in Orofacial pain, I remembered the anterior repositioning splints that were used in the 1980s to treat TMJ. With our new understanding that bruxing is possibly a compensatory mechanism to protect the airway, I thought that this anterior repositioner worked at the time, because every time the patient clenched to protect the airway, the splint would advance the mandible and the clenching would stop because the airway opened. So, I took that idea and decided to fabricate a single arch upper anterior repositioning splint to advance his mandible 5mm when he clenched.

If that mechanism of action were accurate, then this splint should resolve his OSA. Result: At the one week follow-up, the mother (who was skeptical) came in with Matt crying. She said for the first time in 18 years, he slept through the night. She kept waking up checking on him to see if he was breathing! HST demonstrated resolution as

CASEreport his ODI was 4 events an hour and his PSO2 was 90%. All symptoms resolved.

Discussion: Using our assertion that clenching is a protective mechanism for a collapsing airway, we were able to use an anterior repositioning TMJ splint that advances his mandible only when he clenched. While not ideal, it was enough airway support to maintain his airway and reduced the arousals to the point that he had resolution of symp-

If that mechanism of action were accurate, then this splint should resolve his OSA.

toms. This treatment should be considered when faced with the challenges that Matt brought to this sleep clinic. Words cannot express the feeling of relief on the parents face when they returned for follow up. Matt had a friend recently pass due to his OSA. And now their son will be better able to face the challenges of CP in his day to day life, without the fatigue, the facial pain and without the fear of dying.

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

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TMDscreening

SDB and TMJ It’s not One or the Other

by Robert M. Grill, DDS

D

id I really want to treat “TMJ” patients? No! Who in their right mind would? It was 25 years ago, and I had been in practice for several years. Bob Isaacs, a brilliant local orthodontist, talked to me about a shared patient who had what was thought to be occlusal-muscular pain. Bob wanted me to equilibrate this patient’s bite. I recounted that I didn’t want to do anything irreversible. He argued that the patient needed the treatment and if I wouldn’t do it then who would? His statement got me thinking and changed my professional life from that point on. Twenty five years later, with continual C.E., that’s all I do – treat orofacial pain and Temporomandibular Joint (TMJ) damaged patients. Thanks Bob! For the past five years, I have been treating dental sleep medicine patients, most of whom came to me for orofacial pain and TMJ damage issues first.

Have you heard that “TMJ” patients and mandibular advancement devices (MAD) don’t mix? The concern of treating Obstructive Sleep Apnea (OSA) with a MAD is a valid one. In my practice, the patients that are treated for OSA with a MAD are one of two groups: those that present initially with orofacial pain and/or TMJ instability and those that don’t. With a non TMJ/orofacial pain patient that presents for a MAD for the management of their documented OSA, a head and neck muscle and soft tissue and TMJ palpation evaluation is accomplished along with

58 DSP | Fall 2018

a thorough history and dental evaluation.

Those patients that present for diagnosis and management of TMJ/orofacial pain issues, the exam and data gathering process is extensive.

Invariably I use MRI and/or Cone Beam CT (CBCT) scans to aid in the diagnosis process.

It is accepted that a CBCT can typically provide informative views and volume studies of the upper airway however, I primarily use MRI to diagnose TMJ damage. My MRI protocol requests sagittal, transverse and coronal views of the nasopharynx and oropharynx.

Based on scan presentation and clinical data (sleep quality, snoring, nocturia, somnolence (Epworth/STOP BANG), I make a referral for a sleep medicine consultation if I have suspicion that Sleep Disordered Breathing (SDB) may be present. It is explained to patients that in addition to treating the TMJ damage aspect of their facial pain that the sleep medicine consultation is necessary to know if there is an airway component to their pain presentation. It is explained that their orofacial pain issue typically won’t shorten their life expectancy but OSA statistically will. If OSA is present, then my efforts to manage their pain may produce a less than desirable result.

Obstructive sleep apnea and nocturnal parafunction appear related. One study states “obstructive sleep apnea was the highest risk factor for tooth grinding during sleep”. In this same study, treating the OSA with CPAP eliminated the tooth grinding.

TMDscreening

Normal TMJ MRI – closed & open

Sleep disordered breathing can adversely affect REM sleep. The reduction of REM sleep can increase a patient’s pain level including pain from within the TMJs and orofacial pain.

The decision to manage OSA in the TMJ damaged patient with a MAD is really a factor of the TMJ diagnosis and the achievement of joint stability. An unstable TMJ damaged patient presents with TMJ/facial pain and/or changing jaw position (active bite changes).

It is not advisable to use a MAD in an unstable TMJ patient. MAD therapy positions the condyle down and forward on the eminence.

If there is effusion and/or active osseous change in the TMJ, placing potentially more stress on these structures could lead to increased instability. Some studies suggest that the presence of Temporomandibular Dysfuction (TMD) is a contraindication for MAD therapy and excluded these patients. Interim CPAP therapy would be advisable until stability can be achieved and verified along with appropriate management of the TMJ damage.

It is explained to patients that it isn’t so much a matter of the TMJs being damaged – it is a matter of stability. In non-surgical TMJ damaged patients, I typically would recommend a MAD at some point in their airway management once stability is achieved. In fact,

MRI – TMJ closed-anterior displaced disc

MRI – same TMJ with MAD

in the case of the anterior displaced disc that reduces with opening (clicks), by advancing the mandible forward the condyle can be placed back on the disc while the MAD is in place. (See MRI example above.)

It is essential that a patient use a morning positioner appropriately, upon removing the MAD after each and every time they use the MAD. If a morning positioner is not used, the risk of forming a posterior open bite (POB) increases. A POB is created with a change in jaw position, therefore a change in condyle position. This could potentially lead to instability in the TMJ. Much has changed in the last 25 years for me. I now treat TMJ damaged/disease patients along with other orofacial pain patients, and I cannot manage my patients without considering airway.

1.

2.

3.

4.

Orofacial pain issues typically won’t shorten their life expectancy but OSA statistically will.

Oksenberg A, Aarons E, Reduction of sleep bruxism using a mandibular advancement device: an experimental controlled study. Sleep Med. Nov. 2002;3(6):513-515.

Roehrs T, Hyde M, Blaisdell M, Greenwald M, Roth T. Sleep loss and REM sleep loss are hyperalgesic. SLEEP 2006;29(2).

Sanders AE, Essick GK, Fillingim R, Knott C, Ohrbach R, Greenspan JD, Diatchenko L, Maixner W, Dubner R, Bair E, Miller VE, Slade GD. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res. Jul.2013;92(7 Suppl):70S-7S. doi: 10.1177/0022034513488140. Epub May 20, 2013.

Giannasi LC, Almeida FR, Magini M, Costa MS, de Oliveira CS, de Oliveira JC, Kalil Bussadori S, de Oliveira LV (2009) Systematic assessment of the impact of oral appliance therapy on the temporomandibular joint during treatment of obstructive sleep apnea: long-term evaluation. Sleep Breath 13(4):375-381.

Dr. Robert Grill has been in practice in the Baltimore metropolitan area since 1983. Dr. Grill opened the TMJ/ Facial Pain Center at it’s present location, across the street from St. Joseph’s Hospital, in Towson, Md. in 2008.

Dr. Grill limits his practice to the diagnosis of Orofacial pain and Temporomandibular joint (TMJ) damage/disease, dental sleep medicine and complex restorative dentistry. Dr. Grill takes a comprehensive, evidence based approach to the diagnosis and management of his patients, providing individualized and compassionate care.

Since 2014, Dr. Grill has been Adjunct Faculty Johns Hopkins School of Medicine, Department of Otolaryngology, Department of Dentistry teaching orofacial pain diagnosis and management in the dental residency program.

Dr. Grill is a graduate of the University of Maryland School of Dentistry and received advanced training at the Mahan Facial Pain Center at the University of Florida, LSU Orofacial Pain, the Pankey Institute, The Piper Clinic, and the Dawson Center. Dr. Grill is a member of the American Dental Association, the American Equilibration Society, the American Association of Orofacial Pain, and the American Association of Dental Sleep Medicine. Dr. Grill was recognized as one of “America’s Top Dentists 2009” from Consumer’s Research Council of America and one of the “top local dentists” in Baltimore Magazine 2011.

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LEGALledger

HSAT USAGE: Are We There Yet?

by Ken Berley, DDS, JD, DABDSM

T

he turf war continues and sadly, nothing has been decided. Almost daily I’m asked by a dental client why a dentist cannot diagnose OSA or Snoring. Many of my clients want to be able treat their patients who complain of chronic snoring without referring that patient to a sleep physician. Many dentists believe that an in-lab sleep study is unnecessarily costly and may result in some patients being placed on CPAP who could easily be treated by Oral Appliance Therapy.

In response to this growing demand for sleep testing, a cottage industry has emerged. Home Sleep Apnea Testing (HSAT) companies are now selling testing equipment and encouraging dentists to test their screened patients for Sleep Related Breathing Disorders (SRBD). Dentists determine the need for a sleep test, then prescribe an HSAT to determine the existence and severity of the patient’s SRDB. Frequently, but not always, dentists will have a Board-Certified Sleep Physician review the test and provide a diagnosis.

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In direct response to the actions of some dentists who are circumventing Sleep Physician examinations and supervision, the AASM has enlisted the American Medical Association to define what actions constitute the practice of medicine.

AMA resolution and AASM advocacy defend the sleep profession

The American Academy of Sleep Medicine (AASM) has begun a new nationwide initiative to defend the scope of practice of physicians and advanced care providers who manage patients with obstructive sleep apnea from encroachment by dentists and other practitioners who are not trained or qualified to diagnose a medical disease.

The AASM distributed to every state medical board a copy of the American Medical Association (AMA) resolution, Appropriate Use of Objective Tests for Obstructive Sleep Apnea (H-35.963).

The resolution was introduced in November 2017 at the Interim Meeting of the American Medical Association, where it was adopted by the AMA House of Delegates. The adoption of the resolution followed the publication in October of the AASM position statement on the clinical use of a home sleep apnea test.

“Obstructive sleep apnea is a potentially lethal disease, so it is critical to ensure that patients receive the highest quality of care from medical providers who are licensed to practice medicine,” said AASM President Dr. Ilene Rosen.

“Sleep apnea commonly occurs along with complex comorbidities such as hypertension, coronary artery disease, and pulmonary disease, all of which require accurate identification, effective treatment and long-term management from a licensed medical health care provider.”

AMA resolution H-35.963 states: “It is the policy of our AMA that: 1. Ordering and interpreting objective tests aiming to establish the diagnosis of obstructive sleep apnea (OSA) or pri-

LEGALledger mary snoring constitutes the practice of medicine; 2. The need for, and appropriateness of, objective tests for purposes of diagnosing OSA or primary snoring or evaluating treatment efficacy must be based on the patient’s medical history and examination by a licensed physician; and 3. Objective tests for diagnosing OSA and primary snoring are medical assessments that must be ordered and interpreted by a licensed physician.”

The AASM has historically taken the position that only a Sleep Physician who is Board Certified has the knowledge and training to order a sleep study and diagnose SRBD. Now the AMA has joined the AASM in condemning the actions of dentists in providing sleep testing and SRBD diagnosis. This restriction on sleep testing with type 3 and type 4 devices has brought into question actions by some dentists who order HSATs. Readers should be aware that the legality of dentists ordering a sleep study for diagnostic purposes has not been determined.

If you are screening your patients and ordering a HSAT to diagnose whether your patient has SRBD, you are at risk of being charged with practicing outside your Scope of Practice and Practicing Medicine without a license.

Pennsylvania Case: After the AASM/AMA Policy statements on HSAT usage was published, complaints were filed with the Pennsylvania Dental Board and the Pennsylvania Medical Board accusing Dr. X a Pennsylvania general dentist, of practicing outside the scope of his dental license and practicing medicine without a license. Dr. X routinely screened his patients for SRBDs and dispensed an Ares HSAT to test his patients. Each sleep study was scored and diagnosed by Dr. Chandra-Ali, a board-certified sleep physician who worked for the testing company. Dr. Chandra-Ali had a Pennsylvania medical license. Dr. X relayed the diagnosis of Mild OSA to his patient who then felt compelled to initiate the respective complaints with the Pennsylvania Medical and Dental Boards. The Boards had been placed on notice by the AASM/AMA statement on SRBD, therefore Dr. X was subjected to a full investigation of this matter. The biggest area of concern for Dr. X was the fact that practicing medicine is a criminal act in Pennsylvania and subject to all associated remedies.

As the investigation unfolded, Dr. X was allowed to submit a legal brief about the current

state of affairs regarding HSAT testing. Both Pennsylvania boards were made aware of the turf battle that currently rages between DSM providers and Sleep Physicians. Based on the facts submitted, the respective boards dropped the matter. This issue caused Dr. X to suffer physically, emotionally and financially due to his decision to provide HSAT testing. This matter was completed and recorded on June 7, 2018, therefore, this information is timely.

I understand many sleep testing companies are encouraging dentists to provide the identical care that was provided by Dr. X It is essential to in the above case. I know that numerous establish protocols CE providers have endorsed this protocol to jump start a DSM practice. I understand with your referring your frustration with sleep physicians who physicians and don’t respect you as sleep professionals and will not refer, however, you must be resolve any issues aware that there is still risk. that they might What I expect to happen is that some poor dentist will be charged with prac- have regarding ticing medicine without a license and his HSAT usage. state board will try to make an example out of him. Ultimately, the case may terminate at the State Supreme Court. That case will serve as a precedent and give us some direction for the future. However, you don’t want to be the unfortunate dentist who is charged and pays to set that precedent.

Can a dentist utilize HSAT or Pulse oximetry to titrate mandibular advancement appliances?

Here the question is easier to answer.

While the American Academy of Dental Sleep Medicine has consistently denounced the use of any type of testing or oximetry, the ADA has now published a policy statement which specifically authorizes the use of Type 3 and Type 4 testing for MAD titration purposes.

Dr. Ken Berley has practiced dentistry in Arkansas for over 35 years and practiced law for over 22 years and is licensed in Arkansas and Texas. He is Diplomate of the American Board of Dental Sleep Medicine and a Fellow of the American College of Legal Medicine. For the past 10 years, he has focused on the practice of sleep disordered breathing and has developed many of the forms and consents routinely used in sleep medicine. Dr. Berley and his wife Patty, own Berley Consulting, providing mentoring, training and forms for those practitioners wishing to take their DSM practice to the next level.

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LEGALledger The ADA Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders states: 7. Dentists who provide OAT to patients should monitor and adjust the Oral Appliance (OA) for treatment efficacy as needed, or at least annually. As titration of OAs has been shown to affect the final treatment outcome and overall OA success, the use of unattended cardiorespiratory (Type 3) or (Type 4) portable monitors may be used by the dentist to help define the optimal target position of the mandible. A dentist trained in the use of these portable monitoring devices may assess the objective interim results for the purposes of OA titration.

In a court of law, the ADA policy statement would be introduced as a learned treatise and I feel comfortable that HSAT/Pulse Ox usage would be found to be within the scope of practice of a dentist trained in the usage of such devices.

Can a dentist utilize HSAT or Pulse Oximetry to screen dental patients of SRBD?

This is a much harder question to answer.

This issue has not been adjudicated. Two states (Georgia and North Carolina) have placed dentists on notice that this act may exceed the scope for general dentists. Both the AASM and AADSM have published policy statements condemning this practice.

In response to the position of the AASM, screening products have been developed such as the high-resolution pulse oximetry (HRPO), which are specifically designed to utilize bruxism along with the patient’s Oxygen Desaturation Index (ODI) to screen patients for SRDB. Here the argument is that oximetry is not diagnostic of OSA, therefore these screening tests do not rise to the level of a “Sleep Test” for the purpose of diagnosing OSA. The legality of this screening has NOT been tested yet. However, if you live in North Carolina, Georgia or New Jersey, I would not utilize HRPO, HSAT, or similar devices for screening patients for SRBD or MAD titration.

Talk to Your Sleep Physicians!

You should be aware that most sleep physicians do not know about this controversy. They are too busy treating patients to worry about how we titrate our patients and screen for

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SRBDs. However, in my home state of Arkansas, the State Dental Board has not addressed HSAT usage at any board meeting. However, since anyone can file a board complaint, in an effort to minimize the risk of an adverse board ruling, I contacted my referring sleep physicians and took them to dinner to discuss these recently published policy statements. At dinner I presented the AMA/AASM Position Paper and the ADA Policy statement and explained how these policy statements were in direct conflict.

For clarity you need to understand that I am the number one referral source for all these sleep physicians. Additionally, they are all well aware of how I utilize HSAT and HRPO in my office and the results that we achieve with MAD therapy. After discussing these issues, we worked out the protocol that we would follow in Northwest Arkansas.

In my opinion, it is essential to establish protocols with your referring physicians and resolve any issues that they might have regarding HSAT usage. My sleep physicians expressed a desire for me to rely on the ADA Policy Statement and continue to use testing to titrate our patients. If the Arkansas state board were to question my use of testing, I can rely on the support of my sleep physicians and the protocols that we have agreed to implement in Northwest Arkansas.

In conclusion, given the fact that nothing has been settled regarding HSAT usage in the treatment of SRBDs, any dentist who chooses to utilize HSAT or Pulse Oximetry should proceed with caution. Make sure that your state has not recorded a board opinion or statute restricting HSAT usage. Have a discussion with your referring physicians regarding your screening and titration protocols. If they have any objection to the usage of testing, follow their recommendations.

Finally, regardless of what you have been told by salesmen who want you to provide testing and diagnosis for your patients, you are the one with a license to practice dentistry.

You will be the one who will suffer if your state board wishes to make an example out of you.

Personally, I do not use an HSAT to diagnose my patients. I refer all patients to a local sleep physician, and we work together to provide the best care possible for our patients. Reciprocal referrals will allow me to sustain a long-term sleep practice. Therefore, my advice is to develop a good relationship with your local sleep physicians and don’t provide in-house SRBD diagnosis. This will keep you out of trouble because, “We are NOT there yet!”

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