Dental Sleep Practice Fall 2019 by MedMark, LLC

SHAQ puts the

SLAM-DUNK on Obstructive Sleep Apnea with the Help of Dr. Jonathan Greenburg and Sleep Certified

FALL 2019 | dentalsleeppractice.com

Growing a Dental Sleep Practice:

Marketing Assets by Marc Fowler

PLUS

CE/Special Feature:

ADA Policy Statement The Role of the Dentist

Supporting Dentists Through PRACTICAL Sleep Apnea Education

by ADA President Jeffrey Cole, DDS, et al.

PATIENT SCREENING l BITE REGISTRATION l ORAL APPLIANCE SELECTION / FABRICATION

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INTRODUCTION

Not Sudden, But Relentless

ometimes things change in a big hurry – in my restorative practice, the day I took my first digital interproximal image was the last day I ever wanted to look at a film. When I put the files and gutta percha in the drawer and covered them up with referral pads for the endodontist across the street. The time when a patient looked at me and thanked me for explaining her sleep test and giving her hope that she could sleep well, quietly, and safely with my help. Sometimes things change slowly. I used one type of mandibular advancement device for years, because that’s what my mentor taught me, and I was very comfortable with it. As an educator, I was limited – as a medical provider, I realized some patients did not really match that device perfectly. I added another, then another, and now I’m trying new ones all the time. I still prescribe that first device (albeit with an updated design) because my view has expanded, reaching beyond what I first learned, but not abandoning the basics and wisdom that comes with experience. How easy is it to learn something well, become successful, and take what appears to be the easier path by avoiding new information that challenges that comfort level! We can continue in that mode, as long as we keep our head down, blinders on, and focus on the repetition of ‘what works.’ Around us, however, nearly nothing in medicine is sticking with ‘what works’ and not striving for a bigger impact on community health. Dental Sleep Medicine / Airway Therapy / SRBD Treatment is a perfect example of that. Our ADA Policy statement deserves much of the credit – in this issue you will read about how it impacts your practice in our Legal and Team columns, as well as a special section. In this first of two parts (look for Part 2 in the Winter edition of DSP), Dr. Jeffrey Cole, ADA President, fills us in on the ‘how and why’ of the statement, and leading dentists from our field give us their thoughts about the first six of the policy statement provisions.

Our ADA is boldly embracing airway therapy as a regular part of everyday dental practice. Soon, there will be a House of Delegates consideration on creating a valid screener to identify chil- Steve Carstensen, DDS dren at risk of SRBD – a direct outcome Diplomate, American Board of from the first Children’s Airway Initiative Dental Sleep Medicine hosted at ADA headquarters in August of 2018. This effort continues, with the third CE event scheduled for June 12-13, 2020. I can’t let mention of the Inititative go by without a tribute to the first sleep physician to enthusiastically endorse the project and, with his powerful imprimatur, draw other sleep leaders to participate. Dr. Christian Guilleminault was a champion to nearly everyone in the sleep field and especially so to those concerned with children’s airway. He passed in July this year but lives on in the work of uncountable dentists, physicians, myofunctional therapists, and other medical professionals. Dr. Guilleminault and others have worked for decades to bring us to the point where dentists have tools, education, a policy, and a willingness to step in and be the major change for airway health. It’s a wave that cannot be avoided – relentless.

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing questions about the special ADA Policy statement section which starts on page 22. The CE quiz can be submitted online at www.dentalsleeppractice.com or via mail. Sponsored by MedMark, LLC, and Seattle Sleep Education.

DentalSleepPractice.com

CONTENTS

Cover Story

Shaq Puts the Slam-Dunk on Obstructive Sleep Apnea with the Help of Dr. Jonathan Greenburg and Sleep Certified MedMark Media Founder and DSP Publisher Lisa Moler sits down with Basketball Hall of Famer Shaquille O’Neal Achieving your goals starts with a good night’s sleep.

From left: Basketball Hall of Famer Shaquille O’Neal, MedMark Media Publisher Lisa Moler and Dr. Jonathan Greenburg

2 CE CREDITS

Technology

16 22

The Simple Sleep Solution

by Erin Elliott, DDS Embracing new technology enhances patient care.

Continuing Education/Special Feature Read what the ADA and industry leaders say about sleep-related breathing disorders impact on your practice, Part One.

SRBD: The Role of the Dentist by Jeffrey Cole, DDS, President, American Dental Association

Marketing

Growing a Dental Sleep Practice: Step 2 – Marketing Assets by Marc Fowler Make it easy for patients to find you by covering all the bases.

2 DSP | Fall 2019

Screening Patients to Find Who is at Risk of SRBD by Steven Lamberg, DDS

Organized Dentistry Takes on Children’s Airway by Barry D. Raphael, DMD, MS, and Mark A. Cruz, DDS

A New Hope by Todd Morgan, DMD Evaluating Patients for Success – It’s More Than What You Can See by Gy Yatros, DMD Informed Consent in Dental Sleep Medicine by Ken Berley, DDS, JD, DABDSM

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CONTENTS

Publisher’s Perspective

Turn your dreams into reality by Lisa Moler, Founder/CEO, MedMark Media

Product Spotlight

Screen Snorers with Vivid Visuals from Detailed Data People learn best with visuals to enhance the words.

Product Focus

Help Physicians Help Us by Mark T. Murphy, DDS Improve MD confidence with precision devices.

Team Focus

Roadmap to Enhancing Your Sleep Culture by Glennine Varga, AAS, RDA, CTA Systems make it simple.

Fall 2019

Product Spotlight

Give Your Patients a HealthyStart

Every breath, every night, as early in life as possible.

Product Focus

Clenching and Grinding Affects More Than Teeth: A New Treatment Option by Joe Pelerin, DDS Help your patients protect themselves tonight!

Product Spotlight

Restorative Dentistry in Airway Health by Samuel E. Cress, DDS Read about the “Silent Disease”.

Practice Management

Medical Insurance Reimbursement for Pediatric Airway Treatment by Rose Nierman, CEO, Nierman Practice Management How to get paid for treating kids.

Laser Focus

A Team Approach to Functional Laser Frenuloplasty and Optimal Orofacial Function by Melissa Mugno, OMT, RDH, and Tara Erson, DMD The best outcome takes more than one provider.

4 DSP | Fall 2019

Technology

Don’t Lose Sleep Over an Unprotected Network by Gary Salman Knowing your system is safe promotes happy slumber.

Legal Ledger

ADA Policy Statement and the Role of Dentistry in the Treatment of Sleep Related Breathing Disorders by Jayme R. Matchinski, Esq. Is treating OSA required of every dentist?

Seek and Sleep

DSP Sudoku

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

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 2019. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

PUBLISHER’Sperspective

Turn Your Dreams into Reality

ecently, I had the exciting experience of interviewing Shaquille O’Neal for our publications. Shaq’s sleep (and health) have been impacted over the years by his sleep apnea, and our discussion primarily focused on his journey to finding a solution. Fortunately, we also had time to delve into his philosophy of life, his path to fulfillment, and future goals. Two of his basic tenets of life resonated with me, so much so that I wanted to share them with you in this issue’s message.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Fall 2019

First, Shaq noted that one of his favorite quotes is from Dwight D. Eisenhower, a former U.S. president and fivestar general: “The greatest leaders are the ones smart enough to hire people smarter than them.” How true. While you bring the clinical knowledge to the practice, surrounding yourself with the best and the brightest opens up your world to ideas, insights, and talents beyond your own in other important areas. Thankfully, we have done that with the team at MedMark Media and recommend that our readers should also take advantage of all of the experienced people who can expand your practice’s management, clerical, social media, and even clinical options in this very competitive arena. Shaq developed his life’s mission from another concept that he learned from his mother. He had given her some material gifts, to which she responded, “‘I don’t want these, Baby; I love you very much. What have you done to brighten up someone else’s day?” This reinforced what we try to practice every day. We know that taking care of business is our daily focus, but we also need to focus on taking care of others — and what better way than changing lives through our life’s calling! For me, it is improving dentists’ and patients’ health through bringing to light the important concepts and breakthroughs of our profession through our authors and advisors. You can expand patient care possibilities through CEs, our articles, webinars, DocTalk Dental videos, or any of the many educational options available in this quickly changing dental industry. While you’re at

it, let your patients know how your practice is capable of changing or improving their lives! Use your social media, smartphones, and websites to spread the word. We’d like to spread the word about a few articles in our fall issue of Dental Sleep Practice. Our cover story reflects the amazing conversation that I had with Shaq regarding his personal experience and journey to a solution for his sleep apnea. His mission to educate others on this life-threatening condition and how he found a resolution for his own symptoms was truly an inspiration. In this interview, Dr. Jonathan Greenburg also discusses Sleep Certified, an online educational platform that trains dentists and their staff on how to treat sleep apnea with nine possible levels of certification, in an inexpensive and accessible platform. Our special feature section spotlights the dentists’ role in sleep-related breathing disorders. This section delves into the ADA’s perspective on the care of patients with certain SRBDs, on possible policy for screening patients for risks of SRBD, a look at a comprehensive approach to dealing with children’s airway issues, and even early prevention of OSA. The section also features articles on evaluating patients for dental sleep therapy and informed consent regarding dental sleep medicine. In our marketing column, Marc Fowler offers his ideas on how to attract sleep patients through digital marketing. While my interview with Shaq mainly focused on his nighttime sleep, we ended up discussing how to make every day count — a topic which always is our goal for all of you and your teams. To your best success!

COVERstory

Dr. Jonathan Greenburg with Basketball Hall of Famer Shaquille Oâ&#x20AC;&#x2122;Neal

8 DSP | Fall 2019

COVERstory

SHAQ puts the

SLAM-DUNK on Obstructive Sleep Apnea

edMark Media Founder and DSP Publisher Lisa Moler sits down with Basketball Hall of Famer Shaquille O’Neal to discuss his struggle with OSA and how he is fulfilling his dream of spreading awareness of this life-threatening condition.

Shaquille O’Neal’s powerful athleticism and personality have made him one of the world’s most recognized celebrities. He undoubtedly is an MVP, and now has added MVS (Most Valuable Sleeper) to his long list of accomplishments. He met with MedMark Media Publisher Lisa Moler to speak candidly about his personal issues with sleep and how he sought the help he needed for his sleep apnea.

Lisa: I know that you derive inspiration from quotes. Which ones have been “life changing,” and why? Shaq: One of my favorite quotes is from General Dwight Eisenhower. “The greatest leaders are the ones smart enough to hire peo-

ple smarter than them.” After I read that quote, that’s how I started handling my business affairs. I don’t know it all, but I do like to know people who know it all.

Lisa: Tell us about your sleep journey.

Shaq: Some years ago, I was part of a Harvard sleep apnea study. Dr. Charles A. Czeisler, who did a lot of research with sleep apnea, let me know the warning signs, and that I had severe sleep apnea. At the time, I thought, ‘I’m Shaq; it’s not going to happen to me. I am one of the world’s greatest athletes to ever play the game.’ Sleep apnea is very serious. I know for a fact that I stop breathing 72 times per hour. I

Watch the complete DocTalk Dental video interview at https://www.dentalsleeppractice.com/doctalk/shaquille-oneal/

DentalSleepPractice.com

COVERstory love sleeping on my back, and my tongue falls back and blocks my airway. Every now and then I’d wake up panting. I’m 47, have six children, and I’m starting to come on the other side of the hill. The ‘D-word’ always scares me, so to prevent it, I’m trying to do better. I had all the toys like the CPAP machine, but I didn’t use it all the time.

wag your tail! Because of the sound of the air from the CPAP, even when I was tired, it would take me another hour to get to sleep. And then when I talked, I sounded like Darth Vader! I didn’t like it.

Lisa: Your son, Shareef, snore-shamed you on social media! How did you feel about that?

Lisa: Tell us how you finally came to be treated for sleep apnea, and why is it so important for you to spread the word on sleep apnea awareness?

Shaq: He caught me sleeping, and I am a heavy snorer, everyone knows I snore. Doctors say if you have an 18-inch neck or bigger, you probably will be a snorer and have sleep apnea. My neck is 21 inches, and therefore, I have struggled with this issue for a long time.

Lisa: Big, small, young, or old, sleep apnea doesn’t discriminate. It is an epidemic and a deadly disease. Bringing awareness through DSP has been my focus since I was diagnosed with sleep apnea 5 years ago. I completely fell out of bed one morning at 2 a.m. because I had stopped breathing. I had every symptom of a heart attack, and my That’s my mission brain didn’t wake me up until I fell. It was very scary. You said you tried after I retire — make a CPAP; what was your experience people smile and let with that?

“

them know I care about them.

“

Shaq: It is just too loud. After working all day, when I sleep, I want complete darkness and silence. I have puppies and they know that when Daddy goes to sleep, don’t even

Basketball Hall of Famer Shaquille O’Neal, MedMark Media Publisher Lisa Moler and Dr. Jonathan Greenburg

10 DSP | Fall 2019

Shaq: One day after retiring from basketball, I gave my mother a lot of gifts – my way of thanking her. She said, ‘I don’t want these, Baby; I love you very much. What have you done to brighten up someone else’s day?’ And it hit me; that’s my mission after I retire – make people smile and let them know I care about them. So this is my way to help. A lot of times, you need that ‘higher voice’ to tell you. I didn’t pay attention, even when I was in the Harvard study, and then, I heard ‘the higher voice.’ One day, I was on Instagram, and someone sent me this really brash message –

‘Do you want to die?’ I thought the guy was threatening me. It was Dr. Jonathan Greenburg, who said, ‘You have sleep apnea.’ We started talking, and I went to his office. We discussed that when we stop breathing in the night, the heart has to work extra hard and, over the course of time, one day your heart is going to say, ‘I can’t handle this anymore.’ He had a device called the ZYPPAH®. Basically, it is an oral appliance that stops your tongue from falling back and blocking your airway. With this device, I get nice uninterrupted REM sleep. So, now, if I can be the higher voice to help people be aware, then, that’s what it’s

COVERstory

“

With this device, I get nice uninterrupted REM sleep. So, now, if I can be the higher voice to help people be aware, then, that’s what it’s all about.

Lisa: Thanks for joining us, Dr. Greenburg, what made you contact Shaq and offer him your help? Dr. Greenburg: Many people think, as Shaq did, ‘It is not going to happen to me.’ The impact of sleep apnea – strokes, heart attacks, the correlation with Alzheimer’s, and the fact that these people have a 4 times increased risk of cancer (as some studies are now showing), this is no joke, and yet so many people are not being treated. If we don’t get a good night’s sleep, we wake up grouchy; we snap at people; we’re not very nice or friendly, but if we get a good night’s rest, our nature is different – we’re patient, understanding, giving and, on top of that, we are also adding quality and years to people’s lives. I couldn’t think of a better person than Shaquille to help change the planet for the better.

Lisa: Dr. Greenburg, tell us about how your company, Sleep Certified, is working to change the trajectory of OSA in our country? We are educating the public, creating that demand for treatment, and then, training the

“

all about. People ask me what I want to be remembered for, and the answer is simple; I just want people to say Shaq was a nice guy. No one cares about what I invested in. People will remember that when they met Mr. O’Neal, he was nice to their kids – end of story.

dentists to treat those patients properly and at the highest level. To achieve those goals, we created Sleep Certified® (sleepcertified.com), an online educational platform that trains dentists and their staff on how to treat sleep apnea at a high level. Sleep Certified creates nine levels of certification so that we can be very transparent with the consumer on the dentists’ expertise level, not only on their training, but also on their five-star reviews. The patients can go online to our Sleep Certified map, see what level that dentist has achieved, and then, choose the best dentist for them. That’s the whole goal – to be able to provide an inexpensive and accessible platform and to bring those dentists training so that they can actually handle the influx of patients they will be seeing. We are incredibly excited. This is about changing people’s lives.

Lisa: Shaq, there are not a lot of celebrities who say, ‘I have this issue,’ and bring it to people’s attention like you did. Shaq: I’m not a celebrity – just a young kid that listened to his parents.

Lisa: Just a regular guy! I am so excited to be on this journey with you, and hope we can get together again and have another chat. It is truly ALL of our missions to help educate our dental audience on the importance of properly diagnosing OSA, what to look for in breathing-airway issues, delivering proper treatment, and just how critical your everyday role is in helping to save lives. Join the team, become the MVP of your practice, and put some serious Shaq-style slam dunk on this epidemic! And, as always, for all information on dental sleep, please visit DentalSleepPractice.com. And for more information on Dr Greenburg and Sleep Certified, please go to www.sleepcertified.com. Keep making our world smile! This interview was edited for brevity and clarity.

DentalSleepPractice.com

PRODUCTspotlight

Screen Snorers with Vivid Visuals from Detailed Data

million Americans are tired and snore. The ADA now recommends that dentists screen for sleep apnea. Questionnaires alone are ineffective at getting patients to diagnosis or therapy. Nocturnal oximetry is a cost-effective way to convert patients to therapy.

Patient Safety helps you choose the best care path for your patients.

Patient Safety, Inc. is committed to providing reliable, consistent and effective high-resolution pulse oximeters and software that allow practitioners to accurately screen patients for sleep-disordered breathing. Using the most precise oximetry data on the market, Patient Safety helps you choose the best care path for your patients by determining risk of subtle and complex sleep-related breathing disorders not easily identified with other pulse oximetry products. Our SatScreen Report has a green to red dashboard that is designed to eliminate patient questionnaire fatigue by providing visualized, objective data that is more likely to result in patient engagement. The SleepSat 3-D Hi-Res oximeter uses a high sampling rate, precise signal resolution and superior averaging times to accurately track small changes and short-cycle fluc-

SatScreen Report with green to red dashboard

12 DSP | Fall 2019

SleepSat 3-D Hi-Res oximeter

tuations. Our SatScreen software applies advanced analytics and pattern detection to the SleepSatâ&#x20AC;&#x2122;s best-in-class data to index ventilatory instability and baseline drifts in oxygen, which can help detect UARS, Nocturnal Hypoventilation, and Cheyne-Stokes. SleepSat is not an HSAT, so dentists can use it to test patients at any point without fear of diagnosing OSA. SleepSat data is analyzed within minutes, and uploaded reports are accessible 24/7 through our cloud-based viewer. Stop missing patients with inadequate data: convert them to therapy and capture more revenue. For more information, visit www.patientsafetyinc.com, call 888.666.0635 or e-mail sales@patientsafetyinc.com.

PRODUCTfocus

Help Physicians Help Us by Mark T. Murphy, DDS

leep physicians have a reluctance to prescribe Oral Appliance Therapy (OAT). A recent survey1 indicated three of their top concerns were: Efficacy, Comfort and Side Effects. OAT device selection should address these concerns. In fact, some next generation OAT devices, such as ProSomnus® Sleep Technologies devices, have been specifically engineered to address them. Gone are the days when we had to settle for lower efficacy, universal discomfort, and unavoidable side effects. Let’s review these innovations.

Efficacy

According to a review of 42 papers included in the AADSM guidelines and numerous scientific studies published since, OAT efficacy has been improving since 1995 from under 50% to nearly 70% recently. Why? The function of an OAT device is to “protrude and help stabilize the mandible.”2 Clinical practice, in vitro tests, and scientific studies demonstrate that next generation, precision, OAT devices are better at performing this function.

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

14 DSP | Fall 2019

Comfort and Compliance

The material advantages of next generation precision OAT devices do more than provide a smaller lower profile platform that patients prefer, it also is much easier to clean and does not ‘gunk’ up. The dense control cured PMMA allows more tongue space which can mean less advancement and a considerable reduction in volume. Studies using sensors demonstrate comparable to better Mean Disease Alleviation and overall adherence than CPAP.

Side Effects

Again, technology and innovation advances solutions. The precision fit is designed to mitigate tooth movement as was demonstrated in a recent JDSM3 article utilizing the ProSomnus platform. Preventing a posterior open bite and occlusal changes can be enhanced through the use of the propriety CAD/CAM Morning Occlusal Guide available as well. Innovative engineering, materials, precision manufacturing and a company dedicated to helping you, your patients and referring physicians thrive in Sleep Medicine…“Better OSA Therapy; By Design”. 1. 2.

”Oral Appliance Therapy Awareness and Perceptions Survey” By Sree Roy. Sleep Review. January 2016. Scherr SC, Dort LC, Almeida FR, Bennett KM, Blumenstock NT, Demko BG, Essick GK, Katz SG, McLornan PM, Phillips KS, Prehn RS, Rogers RR, Schell TG, Sheats RD, Sreshta FP. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. Journal of Dental Sleep Medicine 2014;1(1):39–50. “Assessment of Potential Tooth Movement and Bite Changes with a Hard-Acrylic Sleep Appliance: A 2-Year Clinical Study” Journal of Dental Sleep Medicine: Vol. 6, No.2 2019.

The Endo, Perio, Hard & Soft Tissue, Sleep & Snore Laser Er:YAG & Nd:YAG Combo

Airway Enhancement NightLase Treatment is a fast, non-invasive and friendly way of increasing the quality of a patient’s sleep. NightLase can decrease the amplitude of snoring through the use of gentle, Fotona proprietary Er:YAG laser light. No anesthesia is used in this treatment.

As seen on ABC, NBC, FOX, & CBS News! • Non-invasive • Increases sleep quality • Lessen the effects of snoring • Safe and patient-friendly treatment

To learn more about what the Lightwalker™ can do for your practice contact Fotona at (972) 598-9000 or marketing@fotona.com today.

www.fotona.com/us FotonaLasersUS

TECHNOLOGY

The Simple

SLEEP Solution by Erin Elliott, DDS

am a 70-year-old lady. Really, I’m 42 but when it comes to technology my friends tease me that I act like a 70-year-old. Don’t worry… I can handle the teasing. But what they mean is that I am not a tech geek. I used the technology when I needed to, but I did not care to beyond that or master it. This is my approach with any technology in my life. I didn’t even want my free upgrade for my iPhone 7. Let me tell you about the end of 2016 when my partner and I were discussing adding technology to our general dental practice. Why would we invest in technology when what we were doing was working “just fine”? Granted, we took the plunge into being a paperless office with digital x-rays in 2004, before many other offices were, and I had reservations then. But could you imagine still having to develop film? Think about it! Paper charts and film worked ‘just fine’ but digital made our office better. Now we

16 DSP | Fall 2019

were at a crossroads. Our next step in our technology journey was scanning, chairside milling and cone beam. Once again, I was hesitant, and I had all the excuses NOT to move forward – what we were doing with analog dentistry was working ‘just fine.’ But thanks to the integration of Dentsply Sirona technology, we have elevated our dentistry and differentiated our sleep apnea services. Dental Sleep Medicine has also seen advancements in technology, but sometimes we as dentists can be hesitant to adopt new technologies. Does this sound familiar in our world? Our practice was against cone beam for sleep. I know that an image from an upright and awake patient doesn’t translate to how an airway behaves when the patient is horizontal and asleep, but with our Dentsply Sirona SL cone beam, we can capture reliable images and I am happy I can use the volume coloring as a tool for patients to visualize their airway and understand why we as dentists even care about how they sleep. Patients used to look at me like I had two heads when I asked how they slept, but now with high-quality images of patients’ airways, they can better understand, and furthermore, I can evaluate the jaws for abscesses, cysts, bone loss, and other abnormalities. However, my favorite part of having the larger field of view is visualizing nasal obstructions. By evaluating the turbinates and sinuses I can set patient expectations and have a road map to nasal breathing, an important goal in sleep. I am happy to report the most recent addition to our technology family: the MATRx plus, an at-home Sleep Theragnostic device developed by Zephyr Sleep Technologies. Traditionally when a patient was referred to me, we would assess the patient and tell them that, based on research, an appliance should work for them. Are they mild, moder-

TECHNOLOGY

This technology, known as The Simple Sleep Solution, not only makes our treatment and screening better, it makes things better for our patients, too.

ate, or severe with C-PAP intolerance? What is their BMI? Age? Neck size? Skeletal class? We would look at all these things plus some other parameters to decide who we think would be a good candidate for an efficacious sleep appliance. We would make the appliance at a protrusive position that is a good guesstimate, have the patient advance their appliance based on their symptoms, give them time, re-test with the appliance in place, and then the most important part… cross our fingers and hold our breath until we get the therapeutic outcome results back. Now, all in the comfort of their own home with Zephyr’s MATRx plus, we know in advance whether a sleep appliance will effectively treat a patient and the target protrusion. Not only that, there is research to support it. The MATRx plus device has been validated in two clinical trials; the article published in the Journal of Clinical Sleep Medicine1 can be found here: www.zephyrsleep.com/ resources/research. But it boils down to the fact that the device has a positive predictive value of 97% and a target protrusion accuracy 86% of the time. The patients who did not

Dr. Erin Elliott grew up in Southern California but went away to a small NAIA school in Western New York where she played collegiate soccer and graduated summa cum laude from Houghton College. After graduating Creighton Dental School in 2003, she settled in North Idaho to begin her general dentistry career. She has a special interest in Dental Sleep Medicine. She has lectured extensively on this topic and loves to help general dentists extend this life-saving service to their patients. She is an active member of her local American Dental Association, the American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and is the past president and a diplomate of the American Sleep and Breathing Academy. She’s teaching sleep apnea with 3D-Dentists and Dr. Tarun Agarwal as well as privately coaching practices about sleep.

18 DSP | Fall 2019

show an ODI less than 10 at the predicted target protrusion only needed minor adjustments to their sleep appliance for full resolution of their SRBD. Zephyr’s MATRx plus also simplifies my workflow because the patient is confident to move forward, we know exactly where to set the bite, and, with fewer follow up appointments, I need less chairtime. A win for everyone. My assistant makes the temporary trays and instructs the patient how to use the at-home MATRx plus device for the Sleep Theragnostic test. The how-to videos are easy to follow. At less than 3 oz., the motor that moves the jaw is not a problem. Once we receive the results stating that the patient will be a responder to mandibular advancement with a sleep appliance, we use our CBCT to build the appliance to that target protrusion by taking a low-resolution scan with the MATRx trays in the mouth. Software links the Dicom CT image and the STL chairside scans. With a click of a button we can order the appliance without impression material ever touching the patient, and there is no mailing or shipping. Sorry, US Postal Service! This technology, known as The Simple Sleep Solution, not only makes our treatment and screening better, it makes things better for our patients, too. Physicians and Dentists have similar goals: scientifically validated tests, to be confident in the treatments they prescribe, predictability and accuracy, and their patients’ happiness. You may think that old appliances and old workflows work “just fine.” Today, however, “just fine” isn’t good enough anymore. At least, not for this 42-year-old! 1.

Remmers JE, Topor Z, Grosse J, Vranjes N, Mosca EV, Brant R, Bruehlmann S, Charkhandeh S, Jahromi SA. A feedback-controlled mandibular positioner identifies individuals with sleep apnea who will respond to oral appliance therapy. J Clin Sleep Med. 2017;13(7):871–880

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PRACTICEmanagement

Medical Insurance Reimbursement for Pediatric Airway Treatment by Rose Nierman, CEO, Nierman Practice Management

here are exciting developments on the horizon! Medical insurers are beginning to consider oral appliances or functional orthopedic appliances medically necessary for pediatric patients with airway issues. Medical insurers are aware of the enormous costs of untreated Obstructive Sleep Apnea (OSA) in adults and children and are increasingly “getting their ducks in a row” by setting coverage criteria for pediatric airway issues.

Coverage Criteria and Required Documentation

What documentation supports the medical necessity for reimbursement? The answer is listed in the individual insurers’ coverage policy. When the policy does offer coverage, the dental practice’s documentation in the “medical model” format is essential for successful reimbursement.

Medical Policy Statements

Positive coverage statements for treatment of services such as adenoidectomy, tonsillectomy, and CPAP for pediatric airway are nothing new. However, an emerging trend shows policies considering payment for oral appliances in children as evidenced by the sample policy statement below.

Dedicated pediatric forms

It’s widely known that the physical presentation of sleep breathing disorders

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

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(SBD) in pediatric patients differs from that of adults. With this in mind, Nierman Practice Management (NPM) has built dedicated pediatric questionnaire and exam forms to gather the documentation essential for pediatric reimbursement.

SOAP notes

The dental practice’s clinical documentation (SOAP notes) are vital to the insurance process. The subjective documentation includes chief complaints and other related history (e.g., snoring, mouth breathing, behavioral problems). The objective documentation consists of specific exam findings such as major anomalies of jaw size or anomalies of jaw-cranial base relationship (e.g., maxillary asymmetry, maxillary and mandibular hypoplasia or microgenia). The assessment section states both the pediatric patient’s diagnosis of OSA with applicable ICD-10 diagnosis codes for conditions such as major anomalies of jaw size or anomalies of the jaw to cranial base relationship. In the plan, describe the type of oral appliance and whether it is a custom or a prefabricated device.

Be an airway hero

Uncovering craniofacial anomalies and providing solutions for pediatric patients to improve airway function is extremely rewarding and has been proven to increase significantly the pediatric patient’s (and likely the parent’s as well!) quality of life through proper growth and development. With medical insurance reimbursement for these services now possible as well, we invite practices to become airway heroes for these patients and their parents.

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Sleep-Related Breathing Disorders: The Role of the Dentist by Jeffrey Cole, DDS President, American Dental Association

An ADA Perspective In 2017, the American Dental Association (ADA) took a major step toward helping patients who suffer from sleep-related breathing disorders (SRBDs). That year, the ADA House of Delegates adopted a policy urging dentists to play a role in the care of patients with certain SRBDs. The ADA believes that dentists are uniquely positioned to collaborate with physicians in the care of patients with SRBDs in part, because of their knowledge and expertise in the oral cavity and in oral appliance therapy. Evidence shows that custom-made, titratable

ADA

Educational purpose:

The ADA’s Policy Statement on the Role of Dentists on treating Sleep Related Breathing disorders arguably triggers more changes in dentist behavior as it relates to the health of their patient than any other policy statement published by the ADA. Dentists who understand the implications found within the statement will impact community health beyond any expectations they might have made during professional training or practice. The purpose of these essays are to bring together the opinions of the nation’s leading experts so every practicing dentist can recognize areas where mastery exists and where further study is necessary. At the end of this reading, the participant will be able to 1. Discuss with their team and peers the implications of the policy statement for their practice 2. Lead their teams to develop communication skills so the changes can be introduced to patient communications 3. Have confidence their practice is working towards the highest ideals of collaborative medical/dental services.

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oral appliances (OA) can help alleviate the effects of SRBD in adults. While OAs have been generally considered inferior to positive air pressure devices such as continuous positive airway pressure (CPAP), their superior acceptance by patients has shown them to often provide equivalent medical benefit.

Developing the ADA Policy

The ADA started researching the issue in 2015. ADA’s House of Delegates directed that a policy on the dentist’s role in SRBD be developed by the appropriate ADA agencies. Together, the Councils on Scientific Affairs (CSA) and Dental Practice began investigating the scientific literature for systematic reviews, meta-analyses, and selected randomized trials for the use of oral appliances in the management of sleep-related breathing disorders, primarily obstructive sleep apnea (OSA). In addition, they reviewed and graded clinical practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine on the treatment of obstructive sleep apnea and snoring with oral appliances1 as well as a consensus guideline co-authored and published in 2015 from dental sleep medicine societies in Italy.2 The goal was to develop an overview of the “state of the science” behind the use of oral appliances in the management of SRBDs. This document was reviewed by a CSAassembled workgroup of subject-matter ex-

SPECIALfeature perts, as well as members of the ADA Council on Dental Practice. This phase of the process resulted in an evidence brief, Oral Appliances for Sleep-Related Breathing Disorders. The first policy draft was posted on ADA. org for external comments and feedback and the response was astounding. More than 87 comments poured in from a wide range of readers, including members of the public, dentists, physicians and other healthcare providers, researchers and professional organizations, including some from outside the United States. To ensure that all the feedback was considered, comments were categorized according by clinical topics, including early intervention/growth and pediatrics, orthodontics, diagnostic, surgical treatment and portable home monitoring, and non-clinical topics including policy language, general comments, and supportive comments. The Council on Dental Practice then reviewed those comments and determined appropriate changes. A second draft was posted for another round of comments. After considering the 47 additional comments and again amending the policy statement, the Council submitted the policy for consideration by the 2017 ADA House of Delegates in Atlanta, where it was adopted.

What Does the Policy Say?

What Role Should Dentists Play?

Where Do We Go from Here?

The extent to which dentists can implement this policy is determined by state dental boards. The ADA encourages dentists to investigate the scope of practice in this area in their state, educate themselves about SRBDs and, where appropriate, begin to provide care to their patients for SRBDs through screening, professional collaboration and treatment. The ADA has resources available to help you and your patients learn more about SRBDs. Several CE courses are available on ADA.org, and the topic will be featured in a two-day workshop at the 2019 ADA/FDI World Dental Congress in San Francisco. To help educate your patients, the ADA has developed a brochure on sleep apnea and provides more information on MouthHealthy.org. The ADA is committed to promote dentistry’s involvement in helping achieve optimal health for all. 1. 2.

The topic will be featured in a two-day workshop at the 2019 ADA/FDI World Dental Congress in San Francisco.

Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015;11(7):773-827. Levrini L, Sacchi F, Milano F, et al. Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS). Ann Stomatol (Roma) 2015;6(3-4):81-6.

Jeffrey M. Cole, DDS, MBA, a general dentist from Wilmington, Delaware, is president of the American Dental Association. Dr. Cole served as the ADA Fourth District Trustee. He served as the chair of both the Budget and Finance Committee and the Strategic Planning Committee. Dr. Cole was a member of the ADA Council on Dental Practice before being elected a trustee. Dr. Cole is involved in several additional dental organizations including the Academy of General Dentistry, where he served as president in 2012–13. He is a Fellow of the International College of Dentists, the American College of Dentists and the Academy of Dentistry International. He was president of the Delaware State Dental Society in 2008–09 and received the Distinguished Service Award from that society in 2015. Dr. Cole received a bachelor’s degree from Villanova University in Villanova, Pennsylvania. He received his doctoral degree from Georgetown University School of Dentistry in Washington, D.C. He later earned a master’s in business administration degree from The Fox School of Business at Temple University in Philadelphia.

The policy encourages dentists to play a DentalSleepPractice.com

ADA

The policy states that dentists can and should play an essential role in the multidisciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients at increased risk of SRBD. SRBDs can be caused by several multifactorial medical issues and are, therefore, best treated through a team approach with collaboration between the patient’s dentist and physician. Properly trained dentists are uniquely positioned with the knowledge and expertise necessary to provide such therapy. In children, the dentist’s recognition of suboptimal early craniofacial growth and development or other risk factors may lead to medical referral or orthodontic/orthopedic intervention to treat and/or prevent SRBD. Oral appliance therapy is a dentist-provided choice to treat SRBD; surgical modalities and positive airway pressure devices are employed by physicians. Various surgical modalities exist to treat SRBD when CPAP or OA therapy is inadequate or not tolerated.

role in patient screening, and when necessary, to consult with the patient’s physician. Dentists should assess patients for suitability of OA upon the referral of a physician, and if appropriate, fabricate and titrate the oral appliances and/or refer the patient to other health care professionals as needed for further treatment.

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Screening Patients to Find Who is at Risk of SRBD by Steven Lamberg, DDS

he ADA’s position paper on “The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders” establishes that dentists play an “essential role” in identifying and caring for these patients. The document states dentists “should be encouraged” to screen for these disorders as part of a medical and dental history. This call to action is not exactly a mandate. Rather than arguing about the absolute level of responsibility dentists have to screen patients, I will lay out what screening is and let the tides of time calibrate the level of our actual responsibilities.

ADA

Screening is more than handing the patient a questionnaire and reviewing their responses, but it is also not a definitive test for a disease. Screening is intended to identify risk, to indicate who should be sent for ‘the next test.’ Questionnaires such as the STOP-BANG and the Epworth Sleepiness Scale have been “validated”, which means that they have been shown to be statistically meaningful in assessing risk of having SRBDs. Although valuable, a screening questionnaire needs to be combined with a thorough

Table 1 and 2: The LQ-PAS questionnaire and the ARF. Visit www.dentalsleep practice.com or www.lambergseminars to view the complete forms.

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clinical examination to best illuminate the complete health status of the patient. It is important to assert that questionnaires can do much more than assess risk. They can serve to educate patients about the correlation between many medical conditions and airway problems. This knowledge gives patients the opportunity to “treat the cause” rather than the symptom. We also have the opportunity to become airway advocates through political action, to influence public school systems to mandate the use of questionnaires to test for airway problems along with currently mandated evaluations for hearing and vision deficiencies. The first step is making these questionnaires available to all new patients as well as making it part of your health history update at hygiene visits. Although the amount of health information that can potentially be unlocked by reviewing a patient’s answers is invaluable, not everyone shares this view. In fact, the question of “who do you give the questionnaire to” has been probed by many. Should every patient be asked to complete one? In 2017, the United States Preventative Services Task Force “USPSTF” concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults.1 The problem with their conclusion is that we don’t have a clear definition of “symptomatic” because of a general lack of appreciation of the correlation between medical conditions and airway problems. As the patient’s basic health history will lay out medical conditions that confer an increased risk of having SRBDs, it becomes incumbent upon us to know the increased odds ratios of having SRBDs associated with all medical conditions. We need to think about the correlation between airway/sleep issues and problems with all of the body’s systems. Oxidative stress and sympathetic activation associated with problematic breathing create an inflammatory load

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Table 3: The Lamberg questionnaire. Visit www.dentalsleeppractice.com or www. lambergseminars to view the complete form.

providing us with a higher level of screening accuracy in the future, at this time we must rely on our clinical examinations and questionnaires to best find the individuals whose health is at risk and recommend more detailed testing for accurate diagnosis. 1.

US Preventive Services Task Force. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(4):407–414. doi: 10.1001/jama.2016.20325.

Steven Lamberg, DDS, practices all phases of dentistry in Northport, New York. He is a graduate of the Kois Center and serves as a scientific advisor for airway there. He writes and lectures nationally on topics related to airway health.

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that impacts all of the systems in our bodies. Adding the patient’s medical condition status to the typical clinical signs and symptoms being evaluated will bring us a step closer to discovering all the patients who require further objective testing to confirm the need for treatment. The Lamberg Questionnaire (LQ) is built on revealing the correlation between airway and overall level of health. I composed the LQ by mining increased odds ratios of having SRBDs from over 300 articles, and it has been refined by experts in the different fields and updated continually. I have no financial interest in the LQ or the LQ-Pediatric Airway and Sleep (LQ-PAS) and believe that every practice will benefit from making it part of their new patient protocol. (Free download available at www.LambergSeminars.com) Every person will benefit from a more comprehensive approach in your practice that includes understanding risk factors, identifying clinical manifestations, using screening questionnaires, and employing other observations that indicate the need for further testing. Children should be viewed in a more urgent manner due to the impact SRBDs can have on growth and development. Risk factors for children include: a family history of SRBDs, various syndromes, behavioral problems, and craniofacial abnormalities such as high narrow hard palate, overlapping incisors, and crossbites. Signs and symptoms can be checked off on a simple questionnaire like the LQ-PAS. See table 1 LQ-PAS (Note that this 2 page questionnaire needs to be evaluated along with the medical history and a thorough clinical exam.) Adults have less concern for ongoing growth and development problems but a careful evaluation of medical history and a clinical examination are crucial. All of the body’s systems must be reviewed to see if there are conditions associated with an increased risk of SRBDs. See table 3. (This questionnaire should be evaluated along with the medical history as well as a thorough clinical exam) With a better understanding of which conditions are correlated with SRBDs, screening the higher risk patients will be accomplished much more efficiently. Although it is worth mentioning that the relationship between SRBDs and combinations of blood biomarkers show promise in

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Organized Dentistry Takes on Children’s Airway by Barry D. Raphael, DMD, MS, and Mark A. Cruz, DDS

he 2017 ADA Policy Statement includes a broad statement regarding the treatment of children with sleep or breathing disorders: “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.”

ADA

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The last portion of the statement charges us with a more comprehensive approach to dealing with children. There is wisdom in the phrase “optimal physiologic airway and breathing pattern” that goes well beyond having dentists play a supportive role to physicians. Dentists and orthodontists are far better prepared to influence the growth and development of a child’s airway than are physicians.1-6 We can influence optimal wellness to lower risk factors for SRBD. Therefore, it is critical for every dentist to understand the underpinnings of this part of the policy. Essentially, having an optimal physiologic airway and breathing pattern means that the upper airway – from the tip of the nose to the larynx – is easy to breathe through AND that the child knows how to breathe through it easily. The basic premise of having an airway that’s “easy to breathe through” is that air should be able to pass unimpeded in any way. Air swirls inside the nose to clean and humidify the air, but once it reaches the softer parts of the airway, we want “laminar flow,” with no turbulence or swirling as the air passes through.7-9 Turbulence creates negative pressure that pulls on the flexible walls of the airway, making it narrower and impeding flow. This is the origin of snoring, Upper

Airway Resistance Syndrome, and obstructive sleep apnea. Since breathing is such a critical part of our physiology, our bodies will successfully compensate for anything that impedes it. Like an overresponsive immune system, the struggle to breathe easily has negative consequences, leading to a downward spiral of poor facial growth, poor oral function, poor sleep, and overall poor health.11 Getting a child out of that negative spiral is the essence of the ADA’s policy.

The Consequences of Poor Breathing in Children

It is imporant to know that a child can have flow limitation and fragmented sleep and NOT have sleep apnea or desaturations. Daytime problems, like mouth breathing, nasal congestion, and over breathing can be the risk factors that lead to nighttime flow limitation. In other words, the problem is breathing, not just sleep. Children with poor breathing patterns can have problems with brain and neurocognitive development, fragmented sleep, behaviors of hyperactivity or sleepiness, chronic activation of the sympathetic nervous system, disregulation of digestive and metabolic hormones, and more.11-13

Clinical Implications: Screening and Outcomes

Our first obligation is to screen every patient for risk factors of turbulent air flow. The ADA has sanctioned development of a screening tool that can be easily implemented in the dental practice, using a questionnaire and clinical data. Simple questions about snoring, restless sleep, bruxism, open mouth posture, and be-

SPECIALfeature havioral issues are included in the initial and periodic exams. The clinical exam will look for some of the phenotypic risk factors such as a narrow dental arch, malocclusion, a tethered tongue, a long soft palate, and vertical development of the lower third of the face. Together, they will direct the clinican to either refer the patient directly to a sleep physician or do a more thorough second level screening, which will also be defined in the ADA’s recommendations. A second task force is looking to define the favorable outcomes that will be the goal of effective treatment and the metrics used to measure them. Examples of favorable outcomes are: 1) Nasal breathing as the dominant mode, 2) Good lip competence (instead of mouth breathing), 3) The tongue positioned on the palate to support good bony growth, 4) A competent swallow using only lingual, not facial, muscles, 5) Good body posture, 6) A peaceful, rejuvenating night’s sleep, 7) Efficient intake and delivery of oxygen to all body tissues, and 8) Improved health and wellbeing. Many of these outcomes have direct or surrogate metrics that can be used to characterize them.

Clinical Implications: Interventions

1. 2. 3.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Eichenberger M, Baumgartner S. The impact of rapid palatal expansion on children’s general health: a literature review. Eur J Paediatr Dent. 2014;15(1):67-71. Mew JR, Meredith GW. Middle ear effusion: an orthodontic perspective. J Laryngol Otol. 1992;106(1):7-13. Iwasaki T, Saitoh I, Takemoto Y, et al. Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: a cone-beam computed tomography study. Am J Orthod Dentofacial Orthop. 2013;143(2):235-245. Sayinsu K, Isik F, Arun T. Sagittal airway dimensions following maxillary protraction: a pilot study. Eur J Orthod. 2006;28(2):184-189. Villa MP, Rizzoli A, Miano S, Malagola C. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath. 2011;15(2):179-84. Katyal V, Pamula Y, Martin AJ, et al. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2013;143(1):20-30. Catalano P, Walker J. Understanding nasal breathing: the key to evaluating and treating sleep disordered breathing in adults and children. Curr Trends Otolaryngol Rhinol. 2018;CTOR-121. Rappai M, Collop N, Kemp S, deShazo R. The nose and sleep-disordered breathing: what we know and what we do not know. Chest. 2003;124(6):2309-2323. Guilleminault C, Sullivan SS. Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. Enliven: Pediatr Neonatol Biol. 2014;1(1):001. Molfese DL, Ivanenko A, Key AF, et al. A one-hour sleep restriction impacts brain processing in young children across tasks: evidence from event-related potentials. Dev Neuropsychol. 2013;38(5):317-336. Horne RSC, Roy B, Walter LM, et al. Regional Brain Tissue Changes and Associations with Disease Severity in Children with Sleep Disordered Breathing. SleepJ. 2018;1-10. Bonuck K, Rao T, Xu L. Pediatric sleep disorders and special educational need at 8 years: a population-based cohort study. Pediatrics. 2012;130(4):634-642. Gozal D, Kheirandish-Gozal L. Neurocognitive and behavioral morbidity in children with sleep disorders. Curr Opin Pulm Med. 2007;13(6):505-509.

Barry D. Raphael, DMD, received dental degree from the University of Pennsylvania School of Dental Medicine and his Certificate in Orthodontics from the Fairleigh-Dickinson University School of Dentistry, Department of Orthodontics. He is a lecturer and staff member at Mt. Sinai School of Medicine, Pediatric Dental Residency; Clinical Instructor at Institute for Family Health. He is a life member of the American Dental Association, a member of the American Association of Orthodontists, and Fellow of the American College of Dentists. Dr. Raphael is in private practice of orthodontics at The Raphael Center for Integrative Orthodontics Clifton, New Jersey and is owner/director of The Raphael Center for Integrative Education. Mark A Cruz, DDS, graduated from the UCLA School of Dentistry in 1986 and started a dental practice in Monarch Beach, California upon graduation. He has lectured nationally and internationally and is a member of various dental organizations including the American Academy of Gnathologic Orthopedics (AAGO), North American Association of Facial Orthotropics (NAAFO), Pacific Coast Society for Prosthodontics, and the American Academy of Restorative Dentistry. He was a part-time lecturer at UCLA and member of the faculty group practice and was past assistant director of the UCLA Center for Esthetic Dentistry. He has served on the National institute of Health/ National Institute of Dental & Craniofacial Research (NIH/NIDCR) Grant Review Committee in Washington D.C., and on the Data Safety Management Board (DSMB) for the National Practice-Based Research Network (NPBRN) overseen by the NIDCR, as well as on the editorial board for the Journal of Evidence Based Dental Practice (Elsevier).

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Procedures that help develop an optimal physiologic airway will focus on maximizing tongue space in the anterior of the face using the natural growth of the jaws, guided, if necessary, by appropriate professional intervention. Optimizing a breathing pattern requires both physical therapies and behavioral modification. First, a clean and clear nose is fundamental. Then, any physical restrictions to good posture or movement of the diaphragm have to be addressed. This may require an interdisciplinary team working with the dentist. Because habitual compensations are responsible for much of the damage we see to the facial skeleton and airway, it is crucial that these habits be re-trained as soon as they are discovered. No longer is the age for treatment defined by dental staging. Success is not limited to straight teeth. This is a very exciting time to be in dentistry. The ability to help a child breathe better, sleep better and perform better will give them an head start to a life of good health. Join us as we take dentistry and our children

into the bright 21st Century. And join us for the Third ADA Conference on Children’s Airway Health in June 2020.

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A New Hope by Todd Morgan, DMD

ADA

ope, this not about Star Wars or a galaxy far, far away, but it is about the now, and organized dentistry coming to terms with policy regarding the dentist’s role in treating airway disorders during sleep, for adults and children. This is our ADA responding to the great scourge of OSA, and it is truly, A New Hope.

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The essence of the ADA policy statement issued in 2017 reflects the important role of the dentist in detecting potential sleep apnea among our patients. I consider us as “first responders” to many of our patients’ medical needs, including screening for high blood pressure, auto-immune disorders, and now OSA. The old adage that says: “the oral cavity is the window to overall health” holds true. Most of the signs of sleep apnea are easy to see in the mouth, and with the help of quick questionnaire(s), screening for potential OSA is easy AND appropriate. Many of us in leadership have lobbied to for a long time to simplify the screening for OSA and have the ADA come forward with a policy statement on the responsibilities of dentists to screen for this deadly epidemic.

Now that we have this bold move in place, I am pleased that a new task force is working on the prevention of OSA by forming reasonable protocols for screening by pediatric dentists. A growing number of our orthodontic colleagues are well-steeped in airway awareness – be sure to ask those in your community about it. Promoting the proper growth and development of the airway as well as protecting and healing those adults with Obstructive Sleep Apnea are some of the best things that have happened to dentistry in a long time. We dentists have an incredible set of tools to improve the lives of our patients – both young and old – like never before. We will need to learn to operate with a team approach and with our medical colleagues to make this happen. A new twist for many of us! Very exciting, but there are some rules. We stand with a policy in hand that may quickly fall out of date as studies continue. I cannot imagine a wider frontier ahead! Good scientific evidence has proven the veracity of oral appliance therapy for mild and moderate OSA. We are on very solid ground here, bolstered by the publication

SPECIALfeature of standards of care by the AADSM and the AASM, such as: Dental Sleep Medicine Standards for Screening, Treating and Managing Adults with Sleep-Related Breathing Disorders and Clinical Practice Guideline for Oral Appliance Therapy. So our stage is set for mild and moderate, but OAT is also viewed as a viable alternative for severe OSA when CPAP fails. All of you that have done this work for a while know that we hit home runs often for patients with every level of diagnosis, but we also have our failures; this is exactly why we should always work as a team with our physician colleagues. Research is the key to successfully relating to our physicians, who have been trained to rely on validated evidence to make all of their decisions about patient care. I remember the first meta-analysis paper I read on oral appliance therapy was published in the Journal Chest (Pancer, Hoffstein, December 1999). They concluded from an analysis of roughly 3000 patients in past studies that “adjustable mandibular positioning appliance is an effective treatment alternative for some patients with snoring and sleep apnea.” Since then we have proved in many more studies that these results are repeatable and reliable. A very recent meta-analysis publication: “Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: A systematic review and meta-analysis’” (A. Hoekema, et al.) continues to show the benefits of the work we do in DSM. We are armed with the evidence we need to continue our conversations with MDs. Now we must begin to challenge the status-quo that calls for CPAP at every turn and bring oral appliances to the forefront of treatment for OSA. Good communication with colleagues

Our treatment is not inferior to CPAP, and I say it is irresponsible to not fully embrace our duty together, as healers. is at the cornerstone of any successful Dental Sleep Medicine practice. Dentistry is poised to become the front line of uncovering sleep apnea. OSA patients are everywhere and they need the medical referral we can provide. But dentistry may not have the full confidence we deserve from our MDs – largely because we created that! For example, most physicians I know cringe at the term “TMJ” and retract in fear. Fortunately, dentistry as a profession has become less isolationistic over time, promoting a new expectation of evidence-based data and proof of “best practice” in fields like periodontics, implantology, oral surgery, and now DSM. Notably, DSM has become a unique exercise in promoting collegiate interaction between dentists and physicians. I actually think this is the coolest part of DSM, where we can explore this field together with our knowledgeable friends and share in the glory of our achievements! This is a time to move toward our medical colleagues instead of away from them. This is the time to create mutually beneficial relationships that promote the best care our patients can receive. Embrace the New Hope and start a conversation with your MDs on the established validity of OAT and show them the evidence. Our treatment is not inferior to CPAP, and I say it is irresponsible to not fully embrace our duty together, as healers.

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Dr. Todd Morgan is a graduate of Washington University in St. Louis, and became a Diplomate of the American Board of Dental Sleep Medicine in 1999. He is recognized as an expert in the field of Dental Sleep Medicine and lectures nationally and internationally on oral appliance therapy. His team has completed several NIH funded clinical trials, and he has authored several peer-reviewed articles and books on the treatment of sleep apnea and snoring with dental appliances. He has served 8 years in leadership and educational roles with the AADSM. His current areas of interest include pharyngeal exercise for OSA, and the development of phenotyping models for successful Oral Appliance Therapy. He has extensive clinical experience in DSM and is now exploring airway CBCT analysis. Most recently, Dr. Morgan’s team are the recipients of three research awards from the American Academy of Dental Sleep Medicine in 2019.

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Evaluating Patients for Success – It’s More Than What You Can See by Gy Yatros, DMD

ADA

valuating patients for Dental Sleep Therapy (DST) is an essential part of successful treatment in Dental Sleep Medicine (DSM). Treating patients with DST requires our collaboration with the medical community. Although this may seem like an obstacle to dentists new to DST it is an incredible opportunity to broaden our reach as healthcare providers in our community. Through our interactions, physicians can help us better understand our patients’ medical condition as we have an opportunity to enlighten them on our medical dental concerns such as systemic oral health issues in addition to OSA. Our collaboration requires that our patients have a medical diagnosis from a sleep physician, copies of their clinical notes, a prescription for DST and a Letter of Medical Necessity (LOMN). In addition, we should regularly communicate with our DSM team on our patients’ progress. Not until our patients have a medical diagnosis and we have fully communicated with our patients’ other health care providers should we begin to treat our OSA patients in the dental office.

30 DSP | Fall 2019

Once our patients have a diagnosis of OSA, we can begin our evaluation for DST. Candidacy evaluation is a multifactor process that requires a step-wise approach by a trained DSM dentist. At a high level the goals of the DSM evaluation are to determine if the patient’s craniofacial anatomy and treatment goals are conducive to a positive treatment outcome. That may sound straightforward but in reality, it often isn’t. Complex dental histories, TMJ issues, missing dentition, nasal airway problems and patient compliance can complicate the former while unstandardized, debated and ill-defined treatment goals can muddy the latter. A successful DSM exam begins with the realization that we are heading into grey areas of medicine which often conflict with the dentist’s analytical and precise nature. But don’t give up hope – with education and experience, dentists can help patients navigate this complex process to achieve life altering and lifesaving outcomes. Let’s begin in the dentist’s comfort zone with a physical evaluation for DST candida-

SPECIALfeature of the dentition to help us determine the stability of the teeth. We should look for short roots, periodontal bone loss, abscesses and other conditions that could affect our treatment outcomes. We recommend a CBCT for our patients, which also allows evaluation of the sinuses, TMJ’s, nasal and oral airways. Unless you are an expert in radiology, it is advisable to have a radiologist interpret these large fields of view to ensure proper evaluation and documentation. This may sound like a lot of information, but when proper systems are utilized, the DST evaluation can be completed in a minimal amount of time. Ultimately, the evaluation will determine if the anatomy is stable enough for DST, which device is best suited for the individual patient, and the three-dimensional position where the device will be constructed. The ADA guidelines call on us to determine if fabricating an oral appliance is ‘appropriate.’ Patient autonomy and proper medical practice means that we must take into account their preference, history, and our judgement of likelihood this therapy will be successful. The dentist and patient should discuss the likelihood of achieving the agreed upon goals, the risks associated with DST, and other treatment options. By discussing the information in a knowledgeable, caring, and sincere manner, most qualified patients will readily choose DST to treat their airway problems. In 30 years of practicing dentistry, nothing even comes close to the satisfaction I have experienced in providing this valuable service. With experience and conviction, the dental team will soon realize the benefits of bringing Dental Sleep Medicine into their practices while helping their patients live better and live longer.

Dentists can help patients navigate this complex process to achieve life altering and lifesaving outcomes.

Dr. Gy Yatros has practiced dental sleep medicine for over fifteen years and is a key opinion leading international lecturer in the area of sleep-disordered breathing and dental sleep medicine. He has offices in Bradenton, Sarasota, and Tampa, Florida devoted exclusively to the treatment of sleep disordered breathing. He is Co-Founder and CEO of Dental Sleep Solutions and the DS3 System for Dental Sleep Medicine Implementation. He is a Diplomate of the American Board of Dental Sleep Medicine (ABDSM) and is an Affiliate Assistant Professor of the Department of Internal Medicine with the University of South Florida, College of Medicine.

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cy. Our evaluation should include a review of the patient’s dental history, an oral facial evaluation, and a review of short-term future dental needs. Simply stated, if the patient is to utilize DST, will the teeth, TMJ and other craniofacial anatomy be able to tolerate the forces generated by the device while producing minimal unwanted side effects? Careful examination of the dentition is required. Are there missing teeth, periodontal issues, or teeth with minimal undercuts which could result in retention challenges? Are there any immediate dental needs? This is where the dentist must put on their DSM hat which may often conflict with our focus on optimal oral health. We will routinely need to make challenging decisions while weighing restorative needs against the possibility of postponing DST. The importance of the dental needs must be weighed against the patient’s OSA severity, co-morbidities, age and other available and attempted treatment alternatives. Our job is to help guide our patients in making the best treatment choice based on these many variables. Our DSM evaluation should also include evaluation of the oral cavity, nasal airway, TMJ and the muscles of the head and neck. While evaluating the oral cavity, we look at things like tongue size and position, arch form, and tonsillar and Mallampati classifications. We must carefully document our findings as to how these items affect the airway and we will ultimately use all collected data to steer device selection for the patient. One mantra you will often hear in DSM is “Don’t forget the nasal airway!”. Nose breathing is extremely important for DSM success as well as the patient’s overall health. There are chapters and books dedicated to this one subject but suffice it to say that patients who breathe through their noses while sleeping will have improved success with DST. A careful TMJ and muscular exam is a mandatory part of our examination. We must look for internal joint derangements, muscle tenderness and evaluate the patient’s range of motion. Instruments like the George Gauge or Pro Gauge can help measure the patient’s ability to protrude the mandible. Maximum incisal opening, sore muscles, TMJ issues and history of bruxism will come into play during our evaluation and device selection process. Lastly, our craniofacial examination should at a minimum include radiographs

SPECIALfeature

Informed Consent in Dental Sleep Medicine by Ken Berley, DDS, JD, DABDSM

“D

entists should obtain appropriate patient consent for treatment that reviews the proposed treatment plan, all available options and any potential side effects of using OAT and expected appliance longevity.1”

ADA

Accurate and relevant information must be provided in a form and language that the patient can understand.

32 DSP | Fall 2019

Consent is an act of reason, accompanied with deliberation, the mind weighing as in a balance the good or evil on each side. It means voluntary agreement by a person in the possession and exercise of sufficient mental capacity to make an intelligent choice to do something proposed by another.2 Every patient possesses the legal right to determine the treatments and procedures which will be employed to control any disease or condition that he or she may have. Medical informed consent is the legal embodiment of the concept that all patients of sound mind and legal capacity have the right to make decisions affecting their health. It is generally accepted that patients should be informed of the potential risks and benefits flowing from their medical decisions.3 Dentists must become familiar with any state statutes which regulate the informed consent process for your particular state or jurisdiction. Medical informed consent is ethically, morally, and legally mandated by the fiduciary duty flowing from the doctor-patient relationship. Ethically, dentists are legally bound and morally obligated to identify the best treatments for each patient on the basis of available medical evidence. A discussion must then occur where the patient is informed of the hoped-for benefits and the potential risks associated with the proposed treatment. Dentist are required to disclose the risks associated with the proposed procedure

and the risks of the alternatives to enable patients to make knowledgeable decisions.4 A patient’s understanding of the potential risks of a proposed treatment is critical to medical informed consent.

Elements of Valid Informed Consent

For consent to be valid, it must be voluntary and informed, additionally, the person consenting must have the capacity to make the decision. Disclosure Informed consent must be preceded by disclosure of sufficient information; however, the specific information varies based on the patient and procedure. Accurate and relevant information must be provided in a form (using non-scientific terms) and language that the patient can understand. Informed consent is NOT a patient’s signature on a dotted line obtained routinely by a staff member. Patients should be given the opportunity to ask questions. The information disclosed should include:5 • The condition/disorder/disease that the patient is having/suffering from • Necessity for further testing • Natural course of the condition and possible complications • Consequences of non-treatment • Treatment options available • Potential risks and benefits of treatment options

SPECIALfeature • Duration and approximate cost of treatment • Expected outcome • Follow-up required For DSM, consent must address dental complications associated with oral appliance therapy, as well as, systemic health consequences of non-treatment of SRBD. Properly trained dentists understand the myriad of complications that can arise from OAT – the author specifically warns EVERY patient of all of the possible negative side effects, and that complications related to oral appliance use have been minor. Patients are warned that it is their responsibility to immediately inform our office of any issues and to adhere to recommended management appointments. Other treatment choices for the patient’s specific conditions should be discussed and appropriate resources provided so they can seek the information they need to inform themselves. Expected longevity of an oral appliance varies greatly depending on the appliance chosen and the clinical presentation of each patient. Therefore, it may be difficult to accurately predict. The author cautions against presenting information which might cause the patient to think that it is guaranteed to last a certain period of time. With appropriate disclosure, patients may be treated under conditions which are less than ideal, such as risky periodontal support or a history of TMJ disorders. Practitioners should disclose the information necessary to achieve informed consent based on the particular patient’s clinical presentation. It is possible that consent can result in a refusal to proceed with therapy. Documentation must show the information that was provided and that the patient refused treatment with full knowledge of the seriousness of the decision.

Documentation A well written informed consent document is mandatory to minimize legal risk and be able to present the evidence in court that a consent discussion occurred. A patient is always free to contest the validity of the informed consent, despite a signed consent form.6

Conclusion

Informed consent is a most important document in your medical record to prevent malpractice lawsuits. Most plaintiff’s attorneys are hesitant to pursue a cause of action when the injury that the patient is complaining of is clearly listed on a consent form. Each practitioner should establish protocols that ensure proper consent is obtained from every patient. These simple steps can lead to better patient communications and less overall risk to you and your practice. 1. 2. 3. 4. 5. 6.

ADA Policy Statement: The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders. Adopt ed 2017 Blacks Law Dictionary 6th Edition West Publications Faden, Ruth R.; Beauchamp, Tom L.; King, Nancy M.P. (1986). A history and theory of informed consent. New York: Oxford University Merz JF, Fischhoff B. Informed consent does not mean rational consent: cognitive limitations on decision-making. J Leg Med. 1990;11(3):321-350. Etchells E, Sharpe G, Walsh P, Williams JR, Singer PA. Bioethics for clinicians: 1. Consent. CMAJ. 1996;155: 177–80. Parikh v Cunningham, 493 So 2d 999 11 FL L. Weekly 309 (Fla, 1986).

Dr. Ken Berley is a dentist/attorney with over 35 years of dental experience and over 22 years in the legal profession. For the past 10 years, he has focused his practice on the treatment of Sleep Disordered Breathing and TMD. As the only DDS/JD/Diplomate of the American Board of Dental Sleep Medicine, he stays busy lecturing and consulting in the areas of risk management and the development of a successful dental sleep medicine (DSM) practice. Dr. Berley has written numerous consent forms that are used in general and dental sleep medicine practices. He is the co-author of The Clinicians Handbook for Dental Sleep Medicine (Quintessence). With his unique background he provides consulting services for various insurance companies and actively defends and advises dentists who are facing legal challenges. Dr. Berley is the President of Dental Sleep Apnea Team, a consulting firm offering in-office training on Dental Sleep Medicine, consent forms and other documents to assist the DSM practice.

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ADA

Legal Capacity Patient has adequate capacity if he/she is able understand the information presented, make medical decisions, and communicate the decision to another party. Since severe sleep deprivation has been adjudicated to limit the capacity to provide informed consent, patients should be evaluated on their ability to actively participate in a conversation. When a dentist feels that a patient may be incapacitat-

ed, if no legal guardian has been appointed, a close family member should participate in all discussions and sign as a witness to the informed consent document.

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Special Section: ADA Policy Statement by Jeffrey Cole, DDS, et al 1.

The goal of the ADA in developing the Policy Statement was to ________ . a. Justify oral appliances to insurance companies for payment b. Develop an overview of the ‘state of the science’ for oral appliance therapy c. Check off completion of another inconsequential resolution of the House of Delegates d. Drive a wedge between dentists and sleep physicians to make dentists more important

b. TMJ troubles will prevent OAT from every becoming the first option of therapy c. Physicians will come to rely less on research and more on dentists’ clinical experience d. New policy statements will be needed to make dentists and physicians work together 5.

When using questionnaires for screening adults for risk of SRBD, ________ . a. Only adult patients who demonstrates obvious symptoms should be included b. Handing patients a list of questions and providing a score is sufficient for most practices c. Detailed questions can reveal which patients who require further objective testing d. The best person to discuss the results is always the doctor 6.

In children, the screening process is designed to find children at risk so that appropriate therapy can be initiated to ________ . a. Make sure their front teeth don’t cause social problems during grade school b. Avoid the embarrassment associated with prolonged bed-wetting c. Correct malaligned teeth as early in life as possible d. Use evidence-based treatment to develop an optimal physiologic airway and breathing pattern Good scientific evidence has proven the veracity of OAT for OSA. In the future, a. Dentistry is poised to become the front line of uncovering sleep apnea

34 DSP | Fall 2019

After a patient is identified with OSA, the dentist’s skills are required in order to proceed with OAT. What must be evaluated includes ________ . a. A step-wise approach in order to conclude that the patient is a good candidate (or not) for a specific oral appliance chosen by the trained dentist b. High resolution pulse oximetry to determine if the patient should be on supplemental oxygen c. A CBCT to assess the correct jaw position to keep the airway open at night d. The range of motion of the tongue – from Mallampatti score to an abnormal frenum attachment, no oral appliance can overcome a bad tongue posture. An informed consent document for OAT to treat SRBD protects the dentist by ________ . a. Listing every known hazard with treatment and with a refusal of treatment b. Requiring the patient and their spouse, guardian, or parent to co-sign c. Fending off lawsuits because notarized informed consent papers deter patients from successful conversations with their lawyers d. Providing documentation that a consent discussion took place between the doctor and the patient. Risk factors for children that increase likelihood of them having an SRBD include ________ . a. Diets that include excessive carbohydrates b. Craniofacial abnormalities such as high narrow

hard palate and crossbites c. Rapid growth beyond age norms d. Thumbsucking habits 8.

Any examination to document whether oral appliance therapy is appropriate for the patient must include ________ . a. A determination that the patient is caries-free b. Culture of oral biofilm to ensure the OA will stay clean c. A demonstration that the patient can open at least 40mm and protrude 6mm d. An assessment of the patient’s ability to breathe through their nose

Patients might refuse treatment recommended in good faith by their doctors. Documentation must include ________ . a. Why the patient chose not to proceed b. That the information was provided, and the patient understood the seriousness of their decision c. The costs of the therapy and the likely costs of consequences for refusal d. An assessment of the patient’s capacity to choose wisely

10. One reason it’s important to work as a team with our physician colleagues to address SRBD is ________ . a. Sometimes oral appliances fail as effective therapy and patients must be able to turn to another provider for more options. b. Dentists can bill for oral appliances using the physician’s NPI for greater reimbursement c. Dentists need physicians to sign off on whether oral appliance therapy is the right choice for the patient d. Patients won’t believe in the therapy if only the dentist endorses oral appliances

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LASERfocus

A Team Approach to Functional Laser Frenuloplasty and Optimal Orofacial Function by Melissa Mugno, OMT, RDH, and Tara Erson, DMD Frenum Release Methods

Frenum release may be performed with a scalpel, scissors, electrocautery or lasers. Procedure performed with a scalpel or scissors can result in significant bleeding, obscuring the surgical field and making it difficult to ensure if the restriction has been completely removed. 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 necrosis,3 leading to delayed healing, significant post-operative pain4 and scarring. Erbium lasers produce excellent incisions, but are not sufficient for hemostasis and coagulation.3 The 10,600-nm CO2 laser has been shown to accurately incise soft tissue, with simultaneous efficient hemostasis and 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.

Frenuloplasty and Role of OMT

Improperly formed orofacial structures and aberrant deglutition, mastication, speech, and breathing habits may develop due to deviant oral posture and oral restrictions. The authors, therefore, believe that in order to achieve optimal orofacial function in older children and adults, oral restrictions should be surgically removed (via frenectomy or frenuloplasty), and this must be combined with consistent pre- and post- surgical orofacial myofunctional therapy (OMT).1,5 Lingual frenuloplasty is the division of restrictive frenum, that involves closing the mucosa rather than leaving the surgical wound heal by second intention.6,7 It is hard to overstate the significance of OMT. The goal of OMT is to strengthen the tongue and orofacial musculature and establish proper functioning of the tongue, lips, and mandible. OMT utilizes the association between natureâ&#x20AC;&#x2122;s muscular and behavioral forces and the normalizing bioadaptability of soft and hard orofacial tissues. It helps re-educate the tongue and orofacial muscles, to create new neuromuscular patterns for proper oral function, including mastication, deglutition, speech, and breathing.8,9 Camacho et al.10 showed the reduction

36 DSP | Fall 2019

of apnea-hypopnea index in children and adults following myofunctional therapy. Without such re-education therapy, deviant oral and breathing habits may persist, eventually resulting in the recurrence of airway and sleep issues that existed prior to the release of oral restrictions.1,8

Functional Laser Frenuloplasty

The frenum release in adults is often more extensive than in infants or young children; and along with the mandatory preand post-frenectomy myofunctional therapy, it often involves bodywork and/or speech therapy, etc., if necessary, based on the individual needs of a particular patient. For example, muscular compensations can cause muscle tension and tightness that need to be addressed prior to frenuloplasty, i.e., patient may require pre-release care to help start loosening and aligning the joints affected by oral restrictions. Such collaboration between the frenuloplasty provider and bodyworker may help resolving chronic pain, headaches, airway obstruction, and digestive issues). The authorsâ&#x20AC;&#x2122; technique for the adult Functional Laser Frenuloplasty, involves the following key components: 1. Mandatory regular pre-frenuloplasty OMT exercises to prepare and re-pattern tongue function (in order to facilitate the frenum release as well as the postoperative OMT); 2. CO2 laser frenum release (frenuloplasty) and placing sutures, under local anesthesia, combined with tongue mobility assessment to assure effective removal of restrictions for optimal oral function; 3. Mandatory post-surgical OMT program to attain long-lasting functional results. The Functional Laser Frenuloplasty is illustrated by the case study below. Note both the immediate and the long-term improved mobility and lift of the tongue. The well con-

LASERfocus trolled hemorrhage, sealed lymphatics and significantly reduced zone of thermal impact result in less postoperative edema and discomfort to the patient, than the release performed with an electrosurge or diode. Magnification is encouraged during frenuloplasty due to the close proximity of the surgical site to large blood vessels and lingual nerve. Once the initial frenal restriction is removed, the clinician or the myofunctional therapist should re-access the function. The clinician/myofunctinal therapist must consider the range of motion of the mandible, the flexibility of the mouth floor, along with the patientâ&#x20AC;&#x2122;s ability to elevate, extend, and lateralize the tongue. This will assist in determining that a full released was achieved. Therefore, the clinician should proceed slowly and cautiously in the middle of the site (taking care to avoid large blood vasculature and lingual nerve) and to release tension to attain full movement of the tongue. After laser frenuloplasty, the patient typically returns for post-op evaluation at varying intervals (starting 72 hours post-op, to see the myofunctional therapist, resume OMT and obtain bodywork, if necessary, and 7 days post-op to see the frenectomy provider). This is important for assessing the mobility of the tongue, the tone and function changes of the lingual muscles and healing of the surgical site.

Case Study

A 32-year-old Caucasian female presented with TMJ issues, headaches/migraines, neck and shoulder pain, and restricted tongue (Figure 1A). The patient had a long face with low muscle tone, and showed mid-face and lowface deficiency (Figure 1A). The patient had breathing issues: her tonsils were enlarged; her nighttime breathing habits included mouth breathing in her sleep and snoring; and she experienced fatigue and sleepiness during the day; she reported bruxing at night. Her lips were apart, when at rest. She had developed neck muscle compensations which were apparent when she put the tongue into the â&#x20AC;&#x153;suction-cupâ&#x20AC;? position (Figure 2F). She had slight facial asymmetry. The patient had incorrect swallowing patterns with tongue thrust, and both mentalis and buccinator activity.

Figure 1: Front and side views pre-frenuloplasty: A. at initial visit (no OMT), reported headaches/ migraines, neck/shoulders, TMJ issues; B. 12 weeks of OMT and expansion (note improved facial symmetry and muscle tone and beginning forward facial development). Her neck appeared longer due to improved head posture.

Melissa Mugno is a pioneer within the modern Myofunctional Movement. Since becoming an Orofacial Myofunctional Therapist in 2014, she has improved the lives of hundreds of patients, lectured around the country, and raised the standards of the profession. Her background as a Dental Hygienist and experience in the fields of Orthodontics and Pedodontics contributes to her success. Melissa treats patients of all ages suffering from wide range of conditions stemming from adverse myofunctional habits. She now resides in Las Vegas where she enjoys being with her family, cooking and being involved in her community. Melissa is part of the Smart Mouth team and is also a Breathe Associate at the Breathe Institute in Los Angeles with Dr. Zaghi, MD ENT. Dr. Tara Erson, the owner of Smart Mouth, is a dentist interested in tongue-ties and their impact on breastfeeding, oral, facial, and airway development. She created Smart Mouth to offer her community of Las Vegas (where she was born and raised) a much needed and missing service. Dr. Erson takes great pride in bringing up-to-date knowledge to her patients for the best possible outcomes.

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After several weeks of myofunctional therapy, the patient could not progress further with her exercises due to restrictive lingual frenum.

She had a slightly forward head posture, as can be seen in Figure 1A. In the past, she had a tongue piercing which exacerbated improper (low) resting tongue posture (tongue resting on the teeth), which does not allow for normal resting relationship between teeth and jaws.11 Intraoral examination revealed narrow, flattened dental arches and posterior overjet (Figure 2A-D). Teeth crowding was present in both jaws, along with a midline discrepancy (Figure 2A-D). The tongue appeared wide, with scalloped edges (see the right image in Figure 5A). A thick, very tight, restrictive lingual frenal attachment was noted (Figure 2D and 2E). The following measurements were taken: the initial basic range of motion (ROM) was 41 mm, and the ROM with tongue tip to incisive papilla (TROM) was 32 mm. The functional ROM, therefore, was 78%. The premolar to premolar distance was 31 mm.

Planned Treatment

The patient treatment (with pre-frenum release OMT, mandibular and maxillary expansion (maxillary – with a removable 3-way sagittal appliance and mandibular – with a removable biobloc), CO2 laser frenectomy, and post-frenum release OMT) was estimated at 12-14 months and the patient is currently in month 7. By the day of frenum release, the patient had already undergone 12 weeks of OMT (both in-office and at home) and expansion

(Figure 1B). Expansion was intended to create the necessary additional space for the tongue, as well as to gain some forwarded facial growth and better occlusion to help with the patient’s ability to chew. 6 weeks prior to frenum release, the myofunctional therapist introduced the patient to Buteyko breathing techniques to strengthen the tongue and improve nasal breathing; most Buteyko exercises were done when the patient’s palatal expander was first delivered. After several weeks of myofunctional therapy, the patient plateaued and could not progress further with her exercises, due to restrictive lingual frenum. At this point, the dentist decided to perform frenum release with a CO2 laser. Prior to the frenum release procedure, in addition to OMT and expansion, the patient worked twice with a licensed massage therapist (LMT) – another member of our multidisciplinary team – to address her neck and shoulder tension and to obtain a myofascial release. The LMT performed another treatment after the frenectomy procedure.

Day of Laser Frenuloplasty

The day of frenuloplasty, the patient’s facial muscle tone was visibly improved (Figure 1B). Her jaw line was more defined and nasolabial folds appeared less pronounced (Figure 1A and 1B). Her neck appeared longer due to improved head posture. Both the dentist and myofunctional therapist examined the patient prior to the laser procedure to confirm the patient was ready for frenuloplasty.

Laser Frenuloplasty

Figure 2: Pre-frenectomy/OMT: A. & B. Note teeth crouding and posterior overjet; C. & D. Narrow, flattened maxillary and mandibular arches; E. a tight, restrictive frenum was present. Note blanching and bulbous tip of the tongue (from a tongue-tie) and limited ROM; F. Note one of the patient’s compensations – neck muscle pull prominent when the tongue is in the “suction-cup” position.

38 DSP | Fall 2019

After a mixture of Lidocaine 2% with 1:100,000 epinephrine was administered by local infiltration, the LightScalpel laser frenuloplasty 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 repeat, non-SuperPulse laser beam gated at 50% duty cycle at 20 Hz (average power to the tissue was 1 watt). For efficient incision, in order to create tension and ensure that the larger vasculature is pushed away from the surgical site, the patient was asked to put her tongue in the “suction-cup” position (Figure 3A). (OMT prior to a functional

LASERfocus frenum release is necessary in order to tone the lingual muscles and ensure the patient’s ability to create and maintain tongue suction.) The dentist applied gentle traction with her fingers, while performing the release (Figure 3B). When performed with scissors, this technique requires the use of a hemostat to clamp smaller blood vessels prior to sharp dissection. With the CO2 laser no hemostat is typically necessary, because smaller vasculature (under 0.5 mm) is efficiently coagulated by the 10,600 nm laser wavelength. The laser nozzle was held 1-2 mm away from the target tissue (Figure 3B) and moved in a steady hand speed for controlled depth of incision motion. The myofunctional therapist was present throughout the entire procedure. In the course of the procedure, the dentist stopped several times, while the therapist assessed the remaining tension and the tongue mobility. First, after the dentist removed the most apparent, superficial fascial restriction, the myofunctional therapist measured the basic range of motion (ROM), palpated the tongue, using gentle experienced touch and trying to locate the presence of tightness or restriction. The patient was asked to lift, extend the tongue, and put it in the “suction-cup” position. The patient was already able to protrude and elevate her tongue better, but there was still tension and the dentist proceeded with a deeper release. At this point, no cutting was done; instead, blunt dissection was used to divide deep fascia – this technique helps the natural release, almost “melting”, of fascia. After that, the patient reported the sensation of the front neck tension alleviation. By the end of the procedure, the myofunctional therapist felt release of the tension in the mid portion of the tongue, where a big knot had been detected during preoperative examination. Finally, the last bit of tension detected by the myofunctional therapist was addressed by extending the incision vertically, upward, with the laser (Figure 3E). The dentist pointed out that if she decided to not suture the surgical site, she would have ablated mucosa laterally (and created more of a diamond shape, as she does in infants and toddlers). For this patient, however, the frenum release was more linear (vertical) (Figures 3D and 3F) and sutures have been placed to facilitate healing without the need to worry about postoperative wound man-

Figure 3: A. Immediately pre-op (after 12 weeks of OMT and expansion); B. CO2 laser incision in progress. Note a close laser tip-to-tissue distance of approx. 1-2 mm; C. Laser frenectomy in progress, after the superficial fascia has been released; D. The dentist used blunt dissection to achieve release of deep fascia – note the narrow, vertical surgical wound and lack of bleeding. If leaving the laser wound to heal by second intention, the dentist would have extended the wound laterally to attain a “diamond” shape. However, since it was decided to suture the wound, narrow incision sufficed for the intended outcome; E. After steps in Figure 3C and 3D, the myofunctional therapist evaluated the tongue and located an area of residual tension. The dentist extended the laser incision upward for optmal fascial release. Note a close laser tip-to-tissue distance of approx. 1-2 mm; F. Post-op and prior to suturing the site – note that genioglossus muscle is visible; G. The myofunctional therapist assessed the tongue for the last time to ensure no restriction remained; H. The wound was sutured.

agement to prevent return of ankyloglossia and begin OMT 72 hours postoperatively (Figure 3H).

Aftercare and OMT Following Laser Frenuloplasty

Our office typically recommends 400800 mg of Ibuprofen every 6-8 hours for adult patients, depending on the patient’s pain level, for 48 hours after the frenum release. During this time, the patient is advised to maintain a soft, bland diet and to abstain from hot, spicy or astringent food or drinks. The dentist saw the patient one week after the laser release. Under supervision of the myofunctional therapist, the patient resumed her OMT exercises, 72 hours after frenectomy. Two bottom sutures snapped during exercise, but this did not affect healing or the patient’s ability to proceed with OMT. The patient was able to elevate the middle and posterior portions of the tongue to the palate, and more easily go through myofunctional exercises that she had previously found challenging. DentalSleepPractice.com

LASERfocus her symptoms, she intends to continue her OMT, working on maintaining proper orofacial habits and further improving and maintaining better posture.

Summary

Figure 4: A. Pre-frenuloplasty/ OMT: attempted tongue to spot pose (TROM was 32 mm). Tongue restriction is obvious; B. Pre- frenuloplasty with 12 weeks of OMT (with the mandible stabilized): improved ROM; C. 3 wks postfrenuloplasty and 15 wks of OMT: noticeably improved muscle tone, ability to isolate the floor of the mouth from the tongue; D. 5 weeks postfrenuloplasty and 17 weeks of OMT: note improved TROM (it has increased from 32 mm to 40 mm, i.e., 25% increase).

Figure 5: Progress – improvement in ROM, lingual muscle control and tongue extension: A. Pre-frenuloplasty/ OMT; B. 3 wks after laser frenuloplasty and 15 weeks of OMT; C. 5 wks after laser frenuloplasty and 17 weeks of OMT.

Three weeks after her frenum release, the patient’s teeth clenching decreased by 75%. Five weeks following frenuloplasty and routine OMT, the patient reported feeling significantly better. Tightness in neck and back were almost completely gone and she noted the decrease in chest tightness. Although the patient’s basic range of motion has remained 41 mm, her tongue-to spot range of motion (TROM) has increased from 32 mm to 40 mm (i.e., 25% increase). In addition to her OMT routine, the patient regularly attends a chiropractor, 2-4 times a month. She will continue with her expansion for another 8-12 weeks, as she relapsed a bit due to being sick and unable to wear the expander at night. Her maxilla has expanded from 31mm to 39 mm (from premolar to premolar). Although the patient has already seen significant improvements in

In adults, optimal orofacial function can be attained through the deep functional release1 of restrictive frenal attachments and re-education of orofacial soft tissues. The functional laser frenuloplasty consists of the following three equally important parts: 1) methodical pre-frenuloplasty OMT; 2) CO2 laser release of tethered oral attachments performed with the frequent assessment of the tongue mobility and the presence of tension (to achieve the maximum ROM and ensure that there are no anatomical obstacles in the way of the patient’s myofunctional therapy); and 3) methodical post–frenuloplasty OMT. The authors strongly feel that the ability to provide extensive OMT, bodywork and deep lingual frenum release within the same practice ensures that the patient receives the most comprehensive treatment in a familiar environment, and without the need to travel to multiple providers. Importantly, all the team members are well familiar with the patient’s treatment plan and closely follow the patient’s progress. The authors find that the minimal thermal tissue change, less traumatic surgery, predictable incision depth, and ability to achieve hemostasis, make the 10,600 nm CO2 laser an excellent surgical alternative to scissors or diode hot tip devices.

Acknowledgments

Authors greatly appreciate the help and contribution from Anna (Anya) Glazkova, PhD, and Peter Vitruk, PhD, in preparing this material for publication.

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. Vitruk P. “Hot Glass Tip Diode Frenectomies ARE NOT Laser Frenectomies. Do dental laser education and proficiency certifications fail patients’ and dentists’ expectations across the globe?” Dent Sleep Pract. 2019 summer;48-50. 5. 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. 6. Baker AR, Carr MM. Surgical treatment of ankyloglossia. Oper. Tech. Otolarhyngol. Head Neck Surg. 2015:28-32. 7. Zaghi S, Valcu-Pinkerton S, Jabara M, Norouz-Knutsen L, Govardhan C; Moeller J, Sinkus V, Thorsen RS, Downing V, Camacho M, Yoon A, Hang WM, Hockel B, Guilleminault C, Liu SYC. Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. The Laryngoscope. 2019. 8. 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. 9. 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. 10. 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. 11. Billings, M, Gatto, K, D’Onofrio, L, Merkel-Walsh, R & Archambault, N. Orofacial Myofunctional Disorders. International Association of Orofacial Myology. 2018. Retrieved from http:// iaom.com/wp-content/uploads/2018/10/OMD-Overview-IAOM.pdf 1. 2. 3. 4.

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TEAMfocus

Roadmap to Enhancing Your Sleep Culture by Glennine Varga, AAS, RDA, CTA

hat does the sleep culture feel like in your practice? Do patients immediately know how your office feels about sleep breathing and how you can help? The American Dental Association (ADA) has started to make progressive steps in the direction of airway supportive therapies and now is the time for our offices to step up and take part. Check out our last team column ADA, Airway and the Team we glanced over the different points of the statement and how we team can integrate these concepts. Now, let’s map out and identify ideas for implementation, and create action plans to help enhance your sleep culture within your practice.

The Path to Diagnosis

When a patient presents for airway screening in your practice and it shows they are at risk for sleep disordered breathing what do you do? Can you or should you test the patient’s sleep breathing? What exactly do we need from a medical doctor? What do we bill to medical insurance? These questions have been presented many times over the years to dental state boards and different organizations. Here are some implementation ideas for the non-diagnosed adult patients and an example action plan. Action Item: Change your existing medical history to include these questions “Have you ever had a sleep test?” or “Have you ever been prescribed Positive Airway Pressure (PAP) therapy? The answer will dictate which protocol to follow. If the patient says NO, ask more questions regarding subjective symptoms. The STOP BANG questionnaire is an excellent choice and can be added to your existing medical history. If the patient says YES, ask about therapy compliance and praise when compliant. When not compliant, it is appropriate to evaluate for oral appliance therapy. Reminder! True compliance is wearing it all night every night.

Follow the Money

“How much does it cost?” and “Will insurance cover it?” These questions seem to be the most commonly asked questions when it comes to patient conversations. It’s simple and easy just to make your patient financially responsible for services, but they may request medical benefits. Since every insurance company has its own policy and rules, it can be difficult to get benefit for every patient. Help the patient understand there will be a fee to obtain a diagnosis from the physician, which will be billed by the physician, and costs at your office for your professional time and judgement, the oral appliance and ongoing management. Benefits, both dental and medical, change frequently. Most successful offices offering SRBD ser-

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DENTAL

SLEEP MEDICINE Mini-Residency 2019-2020

Boston, Massachusetts, USA

Cohort 1: SOLD OUT

Module I: October 17-19, 2019 Module II: January 16-18, 2020 Module III: April 16-18, 2020

! s e

Cohort 2: Registration Open Module I: November 22-24, 2019 Module II: February 7-9, 2020 Module III: April 3-5, 2020

Registration open! Space is limited.

dental.tufts.edu/CE Further questions, please reach out to dentalce@tufts.edu or call us at 617-636-6629

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

e v Sa

e h t

t a d

Our upcoming Dental Sleep Programs starting next fall

Dental Sleep Medicine Mini-Residency 2020-2021 Module I: October 8 -10, 2020 Module II: January 14 -16, 2021 Module III: April 8 -10, 2021

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

TEAMfocus vices have found a way to offer screening for free or a low fee. Action Item: Determine if your practice will be helping patients gain insurance benefit or not. Get a copy of a patient’s medical insurance card and baseline sleep study. Prior to the meeting, verify benefits by contacting the insurance company and researching the medical policy by phone or online. Print and save them for future use. Keep in mind insurance policies can change at any time. Here is Medicare’s Durable Medical Equipment (DME) policy, Local Coverage Determination (LCD): https://bit.ly/2NRxO4w/. You must be enrolled as a DME supplier to file a claim with your Medicare DME jurisdiction.

Identify ways as a team to create Medicare and Medical Billing In January of 2011, Medicare approved awareness within oral appliances; most private insurance folyour community. lowed Medicare’s lead and now offer ben-

efits. In my experience, many commercial insurance companies follow parts or all of Medicare’s policy. So whether you want to bill Medicare or not, you do need to know about it. Even if you don’t want to file a claim, a private financial contract is needed. Also, other medical providers may ask if your office is able to file a claim with Medicare. If the answer is no, the physicians are ready to find another dentist to ask. Many physicians see a high percentage of Medicare patients. Medicare’s LCD states a sleep study must be ordered as a result of a face-to-face physician evaluation. It also states a DME supplier cannot use a Home Sleep Apnea Test (HSAT). Appliances must be Pricing, Data, Analysis and Coding (PDAC) approved. The lab you choose will understand PDAC and advise

Glennine Varga is a dental sleep medicine coach and a co-founder of Dental Sleep Apnea Team. She has been employed in dental education for 20 years. She is a member of the Academy of Dental Management Consultants (ADMC) and a professional member of the National Speakers Association (NSA). She is also a visiting faculty member of The Pankey Institute and Spear Education’s Dental Sleep Medicine courses. Glennine is an expanded duties dental assistant certified in TMD with the American Academy of Craniofacial Pain (AACP). www.dsatsleep.com • 877-217-2127 • g@dsatsleep.com

44 DSP | Fall 2019

you which devices are listed. Also, pay attention to the manufacturer you must use. This list is updated throughout the year. Only appliances with open end dates are approved. Action Item: Select someone to oversee Medicare’s LCD and the rules required to be in compliance. Communicate all changes with all team. The policy can impact diagnosis to delivery.

Team Learning and Maximum Impact

Most dentists invest in airway driven therapy education. However, team may not always participate. If possible, ask your doctors to share the content. Best case scenario: your doc presents the information to you and leads team discussions. If this is not possible, there are many resources online. Check out the ADA’s online courses regarding DSM and children’s airway: https://ebusiness.ada.org/ education/viewcourse.aspx?id=120. Most patients live within a 30 mile radius of your practice. Think local when brainstorming your marketing efforts. Get out of the practice and into the community. Be open minded – sleep and breathing can impact any human at any age. The sky is the limit when it comes to who you can approach to ask for referrals from. If you find other professionals to refer to or accept referrals from nurture the relationship and plan fun events for your office and theirs. Bowling, painting with wine and cooking classes are fun ideas to bring teams together. Action Item: Identify ways as a team to create awareness within your community. Identify what other professionals you can approach with deliverable marketing materials. There is potential within your community, schools, sports, businesses, health clinics, other health care professionals, other functional medicine professionals, holistic providers, law enforcement, insurance companies, DME companies, sleep diagnostic facilities the list goes on and on. Offering services to patients that will help SRBD can be very rewarding. Keep focused on your patient’s success and share their stories on social media, with their permission, of course. As you move through your own action items and team challenges enhancing your sleep culture, align your ideas with the ADA policy statement and refer to it as needed.

PRODUCTspotlight

Give Your Patients a HealthyStart

entists are playing an increasingly active role in helping patients address sleep and breathing disorders. The number of undiagnosed patients with sleep-disordered breathing is far too large of a public health concern for dentists not to be screening every patient. Sleep-Disordered Breathing (SDB) affects every aspect of a childâ&#x20AC;&#x2122;s life and it is imperative to identify and treat the root cause of these issues. If you are a dental professional new to the arena of sleep or working with children, HealthyStart will provide you with all of the necessary education and tools for both the doctor and staff to identify, evaluate and understand the treatment protocols for these patients.

The HealthyStartÂŽ system is a non-invasive, non-pharmaceutical that uses a series of specially designed appliances to promote proper breathing habits. The HealthyStart system addresses mouth breathing, snoring, openbite, cross bite, narrow palate, improper jaw development, speech difficulties, thumb/finger sucking, and improper swallowing. In addition, the HealthyStart system treats orthodontic problems such as crowding, overbite, over jet, gummy smiles, and class III corrections. A recent study of 501 HealthyStart patients, from the ages of 2 to 19, found that 9 out of 10 children display at least one symptom of Sleep Disordered Breathing (Stevens and Bergersen, 2016). This study also found that between 4 and 12 years of age, 92.6% of symptoms did not self correct while 30% worsened with age.

HealthyStart Treatment Series of Appliances

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Early intervention is critical when addressing sleep issues. The optimal age for a HealthyStart patient is as soon as symptoms are identified, as early as 2, but up to 12 years of age. The first step to identifying outward symptoms of SDB is to have a parent complete the HealthyStart Sleep Questionnaire. This requires a parent to identify a series of 27 potential outward symptoms. Each symptom is scored from 1 to 5 indicating its severity, zero being not present and five being severe. The score is used to help families and providers track progress and reinforce good habits. The HealthyStart system is a series of oral appliances that are worn primarily at night, with older children requiring an addition of two hours of daytime wear. The initial HealthyStart appliance, the Habit Corrector, provides built-in myofunctional therapy, acti-

PRODUCTspotlight vated by a swallow, to create correct tongue placement, proper swallow and expansion of the arches. At night, while asleep, a child swallows one time a minute, providing 500 repetitions every night to quickly eliminate improper habits and substitute proper habits. HealthyStart is streamlined to ensure success and is suitable for any dental professional who is just starting their career or looking to expand his or her practice into pediatric sleep. The HealthyStart system is a perfect adjunct for any practice to improve the overall healthcare benefits for their patients. The dental professional and staff can be certified in a 7-week digital self-paced program with a live, interactive forum each Friday. Two free full cases are included that the doctor will treat simultaneously while taking the course. Live courses are also available throughout the US. Additional adjunct educational platforms available to each provider with educational modules, doctor forums, and staff forums to ensure all questions are answered.

Open bite before HealthyStart

After using HealthyStart system

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Continuing education about sleep allows providers and team members to add to their knowledge, treatment proficiency, and confidence. These forums create an environment for HealthyStart doctors to discuss current treatments, procedures, questions, and provide a platform for dentists from all over the world to help other dentists. The HealthyStart system allows collaboration to occur between dental professionals and physicians such as ENT specialists and pediatricians. Through HealthyStart, health care professions can create new avenues of referrals, while providing more comprehensive treatment to ensure better care for the overall health of patients. The HealthyStart team provides consistent and individualized support to aid all providers when transitioning this system into his or her practice. This system allows team members to be the primary therapists, with the doctor involved only about 20% of the time. An additional feature is that our practices find, on average, each patient treated with HealthyStart results in 4 - 10 additional patient referrals with no further marketing expense. Sleep-Disordered Breathing is an epidemic and dental professionals have the power to help children who are suffering everyday. Despite this epidemic, many parents do not have knowledge or education of sleep-disordered breathing. This leads to symptoms being mistaken for other various developmental problems. It is the dental professional’s job to educate these parents and address the root cause of their child’s issues. The importance of identifying and treating these symptoms at an early age, during their growth and development, is imperative and the window of opportunity closes at about age 12. The field of dentistry is constantly changing and evolving. The subject of sleep, breathing and airway issues is critical. Don’t be left behind. Investigate assessing Pediatric Sleep Disordered Breathing and how to incorporate treatment with HealthyStart into your practice. Every child deserves a Healthy Start! For more information about HealthyStart, visit www.thehealthystart.com, e-mail info@thehealthystart.com or call 847-4467600. Visit http://www.healthystartwebinar. com and click on the Parent Education tab. Register for a HealthyStart Medical Webinar at www.healthystartwebinar.com/ medical-webinar-presentations/.

THE VERSATILE APPLIANCE THAT WORKS FOR THE MAJORITY OF PATIENTS

THE MEDLEY SLEEP APPLIANCE

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

Three Different Design Applications

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

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

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

* Herbst is a registered trademark of Dentaurum, Inc.

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

SMLP699Rev072319

Learn more at MedleySleepAppliance.com or call 800.828.7626

PRODUCTfocus

Clenching and Grinding Affects More Than Teeth: A New Treatment Option by Joe Pelerin, DDS

ver 30 years ago I began to experience shoulder pain, neck pain and migraine headaches which were so bad that I had an MRI taken. No cause was evident for this problem. Even as a dentist, I was not aware of clenching or grinding my teeth. Finally, I designed myself a splint, and my shoulder, neck pain and headaches disappeared. How can clenching or grinding cause neck and headache pain? I’ve experienced that phenoma when I injured a muscle in my chest; within hours the pain traveled to my

As many as 1-in-3 patients suffer from some form of bruxism.

Joe Pelerin, DDS, is the inventor of GrindReliefN and the founder of Grind Guard Technologies, LLC. As a patient and former sufferer of bruxism, Dr. Pelerin knew there was a need for a small, reformable, low cost, FDA cleared device to stop teeth grinding and teeth clenching at night.

50 DSP | Fall 2019

back as the muscles had a reflex contraction. I’ve also experienced the reverse, hurting my back and 12 hours later abdominal muscles reacted with contraction. I call this MRC (Musculoskeletal Reflex Contraction). I have personally worn many types of appliances and have treated thousands of patients over the past 30+ years. The first appliance that I designed and used was the traditional “horseshoe”, lab-fabricated appliance. These appliances can be bulky and hard to wear – and can increase muscle activity. As I investigated, the NTI device appeared as the benchmark; it could reduce “bad” muscle activity by 60%, and it was often able to reduce migraine headache in 80+% of a test group. However, its design causes only the front few teeth to be in contact, and this does not suit certain occlusions, especially Class 2/long centric. More than 10 years ago I designed the GrindreliefN (N = Night), and it covers the upper or lower anteriors. With the jaw retruded, some bicuspid occlusion exists, but as the patient moves forward into excursions, pressure is put on a front Central Power Bar. This bar creates pressure on the upper and lower mid-line at the same time. Therefore, my device has twice as many beneficial features as other tension suppression appliances. Now GrindreliefN is available to you, the dentist, in bulk discount, to purchase and deliver to the patient. The clinician can charge the fee of a typical splint, or any fee that is appropriate. There are several CDT insurance codes available, and it has been very profitable for my practice. Patients presenting in the middle of a busy day with muscle pain – within 5 minutes you have them in a splint and getting better. We also sell this device directly to patients, if you prefer to “prescribe” it. I will be glad to answer any inquiries about the product at the same website www. grindreliefn.com.

1 in every 3 patients have some form of bruxism.

Help Your Patients Avoid the Daily Grind Get the Rest & Relief Your Patients Need in One Simple Solution. • Invented & patented by a dentist and bruxism sufferer • FDA Cleared with a 3-Year guarantee • Custom-fit to wear on EITHER upper or lower arch (plus unlimited refitting as needed) • Easily fitted in 5 minutes or less by the dentist OR assistant Power bar creates mid-line pressure; stimulates 60% reduction in muscle activity Similar to NTI® appliance, BUT doubles the action: upper and lower mid-lines are both engaged with the bar

Call 877.401.1224 for a FREE sample For more information, visit grindreliefn.com Grind Guard Technologies, LLC. PO Box 309, Lake Orion, MI 48361

PRODUCTspotlight

Restorative Dentistry in Airway Health by Samuel E. Cress, DDS

atients who have obstructive sleep apnea (OSA) not only suffer from comorbidities such as hypertension and cardiovascular disease but also from occlusal disease. Occlusal disease is sometimes called the “silent” oral disease that many people, including dentists, overlook. Often dismissed as natural aging or wearing of the detention, it is the overworking of a pathological bite to protect the airway. If left uncontrolled, it can cause tooth damage, gum and bone loss, failing restorative work, fatigued muscles of mastication, and damage to the temporomandibular joints.

5mm increase in VDO from 13mm to 18mm

The extra muscle activity in patients with OSA is a result of the brain telling the jaws to protect the airway at any cost, sacrificing the detention. I like to use the analogy that if I were to place a plastic bag over your head, tie it around your neck and push you into a swimming pool, your sympathetic nervous system would kick on and you would use your feet to push off the bottom of the pool, get above the water, and rip off the bag to breathe. OSA patients do the same thing when the airway is compromised and SpO2 drops. Brains kick into high gear to protect the airway, overworking the pathological bite. You may have heard this process called “protective function.” In one way or another we are all nighttime clinchers. Some are greater than others. We all have our teeth together at times during the night, for whatever reason, and we move our jaws back and forth in a “grinding motion,” searching for a position to optimize our airway and unleashing the “silent” oral disease.

Samuel E. Cress, DDS, is the director of The Center for Craniofacial & Dental Sleep Medicine and specializes in dental sleep medicine, TMD, cosmetic, and Full Mouth Rehabilitation. Dr. Cress has successfully treated OSA and TMD patients since 2009. In addition to his practice, Dr. Cress is a clinical instructor where he teaches other dentists the benefits of Airway Conscious Dentistry as well as diagnosis and treatment of patients suffering from TMD.

52 DSP | Fall 2019

Meridian PM Oral Appliance for Sleep Apnea

The most severely affected patients might do that with nearly every breath, overworking the pathological bite and creating a worn detention. Why is educating yourself about OSA so important in restorative dentistry? This comprehensive approach is called “airway conscious dentistry.” Before restorative work begins, especially on patients that need several crowns, implants or bridges, elevate your standard of care and screen for OSA. If you have patients that are constantly breaking dental restorations, look to their airway. If the patient is diagnosed with OSA and is being treated with CPAP or an oral appliance like the Meridian PM, the predictability and success rate of dental restorations has increased tenfold. If you are planning a full mouth rehabilitation, consider whether airway is one of the reasons they need this extensive treatment. Planning treatment to affect the airway by opening the vertical and stabilizing a pathological bite will increase success. Pre- and post-sleep studies will illustrate the airway improvement that takes place when all etiologies are considered before restorative dentistry is begun. This is the ultimate in comprehensive dentistry.

www.dentalsleeppractice.com

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TECHNOLOGY

Don’t Lose Sleep Over an Unprotected Network by Gary Salman

t seems that you can’t turn on the TV or visit your favorite news website without reading about how cyberattacks and ransomware are crippling businesses and healthcare entities across the United States. Unfortunately, dental practices are now becoming the victims of similar attacks. We often hear dentists say, “Why would they want to come after my practice?” Your practice is being targeted because of the vast amount of data you store. In addition, we are now seeing scenarios where dental practices are targeted because their IT company or even their accountant’s office was hacked and the criminals then use this data to attack or target their practices. It is important to understand that the days of simply relying on firewalls and antivirus software to keep hackers out of your network are over. If these devices were so effective at protecting your data, there would be no data breaches. With the continued sophistication of hackers, they can now deliver payloads that completely disable your firewall and allow unauthorized access to your network. Cybercriminals are targeting practices through Phishing or Spear Phishing campaigns. The hackers will send blanket or targeted emails to you and your staff with the intent of getting someone to either click on something or give up the credentials to your network or email system. We have seen many instances where a practice’s email system gets hacked and the hackers then send out emails to the practice’s patients with malware attached to them. The debilitating effects of a cyberattack include loss of produc-

Gary Salman is Chief Executive Officer, Black Talon Security, Katonah, New York (www.blacktalonsecurity.com). He has more than 26 years of dental technology and IT experience.

54 DSP | Fall 2019

tivity and business continuity, lack of trust by your patients and referrals, and negative PR in the community where you worked so hard to build your reputation. Imagine opening an email and clicking on what appears to be an invoice and then getting hit with ransomware or malware. Hackers are also breaking in through vulnerabilities (“unlocked doors and windows” on your network) or, even worse, through your IT vendor. You can no longer rely solely on your IT company to protect your network. IT companies are not Cybersecurity companies. You need the knowledge and expertise of a specialist in Cybersecurity to help ensure the security of your network. Hackers can scan your network for vulnerabilities in a matter of minutes and then identify and exploit these vulnerabilities in order to gain access. This approach in the dental space is much more common than you may imagine. The FBI and Department of Homeland Security posted a bulletin in the Fall of 2018 warning IT vendors that Advanced Persistent Threat Actors (APTs) are targeting IT firms in order to exploit their information to attack their clients. Since your IT vendor typically stores your IP address, user name and password in their database, a breach will give the cybercriminal the “keys to your castle”. Make sure to take defensive measures to help protect your network and critical patient data. It is important to work with a qualified Cybersecurity company who can: (1) perform an audit of your existing policies and procedures, (2) provide you with quarterly vulnerability scans of your network, (3) conduct live employee training to educate your staff on the latest threats and learn how to prevent them and, (4) have penetration testing conducted on your network. You don’t have to be the next victim of a cyberattack if you take action now.

MARKETING

Growing a Dental Sleep Practice: Step 2 – Marketing Assets by Marc Fowler

his is the second in a series of articles that will focus on effectively attracting sleep patients through digital marketing. In the last issue, we discussed the importance of creating a brand identity for sleep that is independent of your dental practice brand. If you missed that article or still aren’t sure if you need a separate sleep brand, watch the video on the home page of DentalSleepMarketing.com. With the core branding elements in place, the next step is to expand your digital footprint and begin developing an online reputation for your sleep practice.

Pro Tip: Complete all the information Google requests. Doing so makes it easier for potential patients to find you and increases your The Changing Digital Landscape When Bullseye Media started working chances of being with dental practices in 2006, all that was included in the Local required for online success was a decent Pack. If you don’t website and some basic SEO. Times have – significantly. Google has comcomplete all fields, changed pletely overhauled the formula they use to someone else could determine online placement as well as the – even a competitor. layout of the search results pages. At the same time, the number of practices competing for a finite amount of online real estate has increased dramatically. Online success today requires a multi-faceted approach. In addition to optimizing your website, you must also create well optimized supporting assets.

Google My Business Listing For searches that Google deems to have local intent, the results page will typically contain a section that is called the Local Pack. After pay per click ads, the Local Pack is the most visible section displayed on a Google search results page. Unlike ads, you aren’t paying Google to appear in the Local Pack. The image to the left is an example of the most commonly shown Local Pack which typically contains the

56 DSP | Fall 2019

three business listings Google considers most relevant to the search term. It is important to note that the Local Pack shows “above the fold” (content displayed onscreen without having to scroll down) on a desktop and is equally prominent on mobile, making it prime real estate. In the Local Pack, Google shows business listings, not websites. To have your sleep practice show up in this section for sleep related searches, it must have a Google My Business (GMB) listing that is separate from your dental practice GMB listing. You cannot create a GMB for sleep using your dental practice information. This is one of the key reasons why creating a separate sleep brand is the first step in this process. Once you’ve created, claimed and verified your GMB listing you’ll need to optimize it for better visibility. This includes adding photos and videos if you have them, writing a compelling description, creating citations via other online directory websites and populating your GMB listing with reviews from sleep patients.

Online Directory Listings Establishing profiles on sites such as Yelp, CitySearch and Foursquare creates citations (references to your practice’s name, address and phone number). Businesses with numerous, accurate and consistent citations are viewed as more credible to Google. How many citations you need largely depends on how strong the competition is in your area. In addition to helping boost your visibility in Google, accurate listings on the right sites will also improve you changes of being found by prospective patients. The patient may search directly on that directory website, or that directory listing may feed data to an app they’re using.

Patient Reviews Online reviews are a big factor in consumers buying decisions. A large, often refer-

MARKETING enced survey by BrightLocal found that 85% of consumers trust online reviews as much as personal recommendations. The most visible and utilized review sites are Google, Facebook and Yelp, in that order. Populating your Google business listing with positive reviews will help your sleep practice stand out. Reviews not only improve listing visibility, positive reviews increase the chances that a prospective patient will call to schedule an appointment. Youâ&#x20AC;&#x2122;ll also want to gather a handful of sleep patient reviews on your sleep branded Facebook page as well as your sleep practice Yelp listing. Beyond generating credibility with prospective patients, having multiple positive reviews from sleep patients will add important keyword terms (sleep apnea, snoring, CPAP alternative, etc.) to your listings which improves your chances of showing up when prospective patients conduct searches that contain those keywords.

The Pay-Off When our sleep clients invest in these critical supporting marketing assets, their marketing tracking dashboards show significant increases in the number of website visitors and phone calls. In many cases, those with well optimized GMB listings are receiving over 50% more patient phone calls than those without.

Marc Fowler is the founder of Bullseye Media, LLC. Since 2006, the team at Bullseye Media has helped hundreds of dental practices across the U.S. and Canada leverage the internet to achieve their practice growth goals. Learn about their turnkey direct-to-patient sleep marketing program at DentalSleepMarketing.com. To discuss the most effective ways to grow your sleep practice, contact Marc at 214-592-9393, Marc@BullseyeDental.com or schedule time on his calendar at BullseyeDental.com/Call.

THE 3 STEP MODEL FOR GROWING A DENTAL SLEEP PRACTICE Discover the direct-to-patient system that is working for successful dental sleep practices nationwide.

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LEGALledger

ADA Policy Statement and the Role of Dentistry in the Treatment of Sleep Related Breathing Disorders by Jayme R. Matchinski, Esq.

n 2017, the ADA House of Delegates passed Resolution 17H-2017 which included language stating that: “Dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy”. The Council on Dental Practice developed the ADA Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders. The Council on Scientific Affairs formed the Oral Appliance Evidence Workgroup and produced an evidence brief, Oral Appliances for Sleep-Related Breathing Disorders, which was used as background to draft this policy. The objective of this brief was to provide a summary of recent literature for the use of oral appliances in the management of SRBDs, specifically, OSA. This brief reviewed clinical practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine, which found that patient adherence with oral appliances was better than that for CPAP, and that oral appliances have fewer adverse effects that result in discontinuation of therapy, compared with CPAP. 58 DSP | Fall 2019

The passage of this ADA policy statement is the result of several years of analysis and discussions regarding the role of dentists in the treatment of sleep related breathing disorders (SRBDs). It was the ADA’s intention to set forth a comprehensive policy to provide guidance to dentists and further define and refine dentistry’s role in the treatment of SRBDs.

Mandate of the ADA Policy Statement

The adopted ADA policy statement outlines the role of dentists in treating SRBDs. Key components include: assessing a patient’s risk for SRBD as part of a comprehensive medical and dental history and referring affected patients to appropriate physicians; evaluating the appropriateness of oral appliance therapy (OAT) as prescribed by a physician; providing OAT for mild and moderate sleep apnea when a patient does not tolerate a continuous positive airway pressure (CPAP) device; recognizing and managing OAT side effects; continually updating dental sleep medicine knowledge and training; and communicating patient’s treatment progress with

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LEGALledger the referring physician and other health care providers. SRBDs comprise multiple diagnoses that involve difficulty breathing during sleep. The disorders, which include obstructive sleep apnea and snoring, can be potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms. Obstructive sleep apnea has been associated with metabolic, cardiovascular, respiratory, dental and other The ADA policy systemic diseases. In children, undiagnosed and/or untreated obstructive statement emphasizes sleep apnea (OSA) can be associated the dentist’s significant with cardiovascular problems and impaired growth, as well as learning and role in screening behavioral problems.

for SRBD.

ADA Policy Statement Recommends that Dentists Conduct Specific Functions

The ADA policy statement emphasizes the dentist’s significant role in screening for SRBDs since dentists are often the first health care provider to identify symptoms and discuss medical and dental history with the patient. The ADA policy statement recognizes the importance of referring at-risk patients to a physician for diagnosis and treatment. It emphasizes that dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy for those individuals with mild or moderate OSA who are intolerant of continuous positive airway pressure (CPAP) therapy. Upon adoption of the ADA policy statement, the Council on Dental Practice began sponsoring continuing education opportunities to educate the dental profession about SRBDs and to inform the council’s medical colleagues of the policy and develop information for the public on dentistry’s role in SRBDs.

Jayme R. Matchinski is a health care attorney and Officer in the Chicago office of the law firm Greensfelder, Hemker & Gale, P.C. Jayme focuses her practice in health and corporate law, including helping health care providers and suppliers handle the complex regulatory and operation issues unique to the industry. She has significant experience in the area of Dental Sleep Medicine. She can be reached at jmatchinski@greensfelder.com.

60 DSP | Fall 2019

According to the ADA policy statement, the dentist’s role in the treatment of SRBDs includes, but is not limited to, the following: • Dentists are encouraged to screen patients for SRBDs as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertention. These patients should be referred, as needed, to the appropriate physicians for proper diagnosis. • For 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 is determined, intervention through medical or dental referral or treatment may be appropriate to help treat the disorder and/or develop an optimal physiologic airway and breathing pattern. • A dentist should be the one to fabricate an oral appliance when oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with OSA. • Dentists should obtain appropriate patient consent for treatment that reviews the proposed treatment plan, any potential side effects, and all available options of using oral appliances. • Dentists treating SRBDs with OAT should be capable of recognizing and managing the potential side effects through treatment or proper referrals. • Dentists who provide oral appliance therapy to patients should monitor and adjust the appliance for treatment efficacy as needed, or at least annually. • Surgical procedures may be considered as a secondary treatment for obstructive sleep apnea when CPAP or oral appliances are inadequate or not tolerated. In selected cases surgical intervention may be considered as a primary treatment. • Dentists treating SRBDs should continually update their knowledge and training of Dental Sleep Medicine with related continuing education. • Dentists should maintain regular communications with the patient’s referring physician and other health care providers regarding the patient’s treatment

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LEGALledger progress and any recommended follow up treatment.

Objective Testing and Usage of HSAT

The ADA policy statement includes the following language in the seventh recommendation for dentist’s role in the treatment of SRBDs: 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. Based upon the ADA policy statement and this objective testing, there has been a lot of discussion regarding whether dentists, who are trained in the use of HSATs, may provide

the patient with an HSAT and then assess the results to determine OA titration. Given that the ADA policy statement provides guidance to dentists who practice Dental Sleep Medicine, and the policy statement is not a regulation, dentists should check their state licensure and third party payor agreements regarding whether they can prescribe HSAT and utilize the objective interim results for purposes of OA titration. While sleep testing companies are encouraging dentists to provide HSATs to their patients for the screening and diagnosis of OSA, this may be outside a dentist’s scope of practice depending upon state licensure. Additionally, certain third party payors, including the Center for Medicare & Medicaid (CMS), require a licensed sleep physician to prescribe an HSAT and interpret the results from the HSAT. Dentists should consider setting up protocols and agreements with referring physician, including sleep physicians, in order to identify each doctor’s responsibilities for the sleep testing, diagnosis and treatment of a patient with OSA. Dentists should be careful not to practice outside their scope of practice and state licensure.

Stay Connected Between Issues Like us on Facebook at facebook.com/dentalsleeppractice Share with us on Instagram at instagram.com/dentalsleeppractice Follow us on Twitter at twitter.com/dentalsleepmag Watch our DocTalk Dental videos at doctalkdental.com Check out our Webinars at dentalsleeppractice.com/category/allwebinars/

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62 DSP | Fall 2019

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