Dental Sleep Practice - Spring 2014 Issue

Spring 2014

Pro NFL Players

Tackle

Driven to

Help the World Sleep

An Interview with W. Keith Thornton, DDS

The Effects of

Enlarged Adenoids

on a Developing Malocclusion

by Derek Mahony, BDS, MScOrth

Sleep Apnea Pro Player Health Alliance members Derek Kennard, Mike Haynes, David Gergen, Roy Green and Mark Walczak team up to raise awareness of sleep apnea

How to

Implement New Initiatives in Your Practice

by Amy Morgan

Legal Ledger

by Ken Berley DDS, JD, FAGD, FICOI

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INTRODUCTION

“What’s Next?”

D

ental sleep medicine course leaders hear this question a lot; attendees are excited to learn about a new service they can provide their patients.

They want to know more about how they can impact the health of their community, how they can grow professionally, give their teams opportunities to expand their skills, and solve clinical riddles that are newly presented in patients they’ve been seeing for years.

Dental Sleep Practice aims to answer the question. Every issue will contain researched, peer-reviewed writing to add to the knowledgebase. This issue, Dr. Derek Mahony discusses the value of evaluating adenoid size in the growing patient. Amy Morgan from Pride Institute talks about introducing new team skills. Dr. Ken Berley, dentist, lawyer, and sleep appliance provider, will weigh in each quarter from his unique perspective.

Have a look at the Editorial Board! I’m grateful for these leaders saying “Yes, I’ll help get the good learning out there.” I’d bet many of you have taken a course from one of these excellent instructors, as I have done, and now their message will reach thousands.

Our Managing Editor, Dr. Lou Shuman, is President of Pride Institute and an orthodontist who has been passionate his entire career about collaborative care, education, and creating opportunities for dentists to grow and thrive. Lou is at nearly every dental meeting and he’s behind major initiatives in dental publishing, industry innovations, sleep apnea treatment, and using social media to enhance our profession.

I have long known that helping my colleagues grasp a concept and learn new skills so they could impact their community health is among my highest professional honors, along with invitations to teach at Pankey Institute, Pride Institute, Spear Education and serving the ADA on the Council for ADA Sessions. I have had wonderful mentors along the way; this magazine gives me a chance to reconnect with some of the wise folks I have met, discover more, and introduce them to you.

Lisa Moler set out to publish the highest quality focused magazines in our profession, and her company, Medmark, LLC, has succeeded with Orthodontic Practice US, Endodontic Practice US, and Implant Practice US. Key opinion leaders are eager to publish with her and our industry partners are happy to support her excellent publications. Dental Sleep Practice is well situated in Medmark’s family of magazines.

Magazines like this don’t Steve Carstensen, DDS exist without the support of our advertisers and sponsors. Just as dentists cannot treat our patients without other health professionals, we need industry professionals dedicated to partnering with us. Our laboratory, instrument, and service support teams are as vital to helping our community as the medical providers are. DSP is not only You will hear perspectives from laboratory and software professionals, many of whom for doctors – started out working in the dental office. every member Leaders find their own ways to contribute. Dr. Keith Thornton has cajoled and of the office mentored hundreds of dentists to add sleep team, so vital to services. David Gergen, another deeply involved industry pro, was unsatisfied with our success, will just running an excellent sleep appliance find interesting lab so has used his lifelong involvement with sports to bring much needed aware- articles to grow ness of the disease to the public and even their skills to the US Congress.

DSP is not only for doctors – every and service member of the office team, so vital to our opportunities. success, will find interesting articles to grow their skills and service opportunities.

All this and there’s so much more. Look for CE Calendars, a Marketplace, and a bit of humor as we move forward. Welcome to Dental Sleep Practice! I hope you’ll enjoy, along with all of us, the journey towards answering, “What’s Next?”

Your thoughts, requests, questions, and insights are enthusiastically invited: SteveC@MedMarkAZ.com

DentalSleepPractice.com

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CONTENTS

18

Corporate Spotlight

Changing Lives with Every Breath Global leader in PAP therapy makes MRD a mainstream sleep apnea therapy option

21

Bigger Picture

The Effects of Enlarged Adenoids on a Developing Malocclusion

46

Inside the Lab

Great Lakes Orthodontics Helping dentists navigate the waters of dental sleep medicine

by Derek Mahony, BDS, MScOrth The growing airway must be included in managing the dental arch shape

6 2 DSP | Spring 2014

Lab Spotlight

CE Focus

Pro NFL Players Tackle Sleep Apnea

Dental Sleep Medicine... What course or seminar should I take?

Pro Player Health Alliance members David Gergen, Derek Kennard, Mike Haynes, Mark Walczak, and Roy Green team up to raise awareness of sleep apnea

33

by Ashley Truitt Hundreds of courses out there: what you should look for

CONTENTS

12

Clinician Spotlight

Driven to Help the World Sleep

An Interview with W. Keith Thornton, DDS

Spring 2014

36

Editor in Chief | Steve Carstensen, DDS Email: steve@medmarkaz.com

Practice Management

How to Implement New Initiatives in Your Practice

by Amy Morgan Learning is not enough – your team must buy in to improve patient health

17 Clinical Spotlight

Airway Development and Prevention of Obstructive Sleep Apnea in Children: A Case Report, part 1

Managing Editor | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com Editorial Advisors Rob Rogers, DMD Ken Berley, DDS JD Amy Morgan John Remmers, MD Dale Miles DDS Steve Bender DDS Bruce Templeton, DDS, MS Ofer Jacobowitz MD Christina LaJoie Brian Allman DDS Sarah Shoaf DDS MSD

by Juan-Carlos Quintero, DMD, MS

28 Product Profile

Publisher | Lisa Moler Email: lmoler@medmarkaz.com

GALILEOS Comfort Plus

National Account Manager | Michelle Manning Email: michelle@medmarkaz.com

The most efficient clinical workflow in dentistry

30 Medical Insights

National Account Manager | Adrienne Good Email: agood@medmarkaz.com

by John E. Remmers, MD Why is it that physicians don’t enthusiastically embrace oral appliances?

Production Assistant/Subscription Coordinator Jacqueline Baker Email: jbaker@medmarkaz.com

What’s the Problem with Oral Appliance Therapy for Obstructive Apnea?

40 Practice Management

Why Dental Sleep Medicine is Important to Rose Dental Hygienist finds a way to improve hundreds of dental offices

43 Legal Ledger “Introductions Please”

by Ken Berley DDS, JD, FAGD, FICOI

48 Sleep Humor 4 DSP | Spring 2014

ctions “Introdu Please”

43

Creative Director/Production Manager Amanda Culver Email: amanda@medmarkaz.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 Web: www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) 3 years (12 issues)

$79 $189

© MedMark, LLC 2014. 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.

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LABspotlight

Pro NFL Players

Tackle

I

n recent years, awareness of the potentially life-threatening effects of obstructive sleep apnea (OSA) has begun to rise, but there’s still widespread confusion about who can be affected by the disorder. Most of those who are aware of the dangers of OSA believe that it affects only overweight and unhealthy people, while many otherwise healthy people go on without ever being diagnosed for OSA. For those it affects, no matter how healthy their lifestyle, the extreme stress poor sleep quality places on their bodies will leave them unrested. Even some of the best athletes in the world suffer the consequences of OSA, especially players 6 DSP | Spring 2014

LABspotlight in the National Football League. In fact, according to a 2009 study by Mayo Clinic, 46% of players in the NFL and 60% of linemen suffer from sleep apnea. The problem is endemic and has even affected draft results. The 2007 #1 NFL draft pick JaMarcus Russell, who played for the Oakland Raiders, didn’t perform on the field nearly to the level that fans expected, all because of sleep apnea.

But David

leSleep Apnea Pro Player Health Alliance members Derek Kennard, Mike Haynes, David Gergen, Roy Green and Mark Walczak team up to raise awareness of sleep apnea

Gergen, the president of the Pro Player Health Alliance, intends to tackle the threat of sleep apnea among players and the general public once and for all.

After noticing countless NFL players seeking treatment for their obstructive sleep apnea, David decided there was an urgent need to spread awareness of the disorder throughout the United States. His response was to form Pro Player Health Alliance (PPHA), which brings current and former professional football players to different communities throughout the U.S. to promote awareness of sleep apnea.

Many of these players have received sleep apnea treatment themselves, including the prominent figurehead for PPHA and former professional wide receiver, Roy Green. Once called the best player in the game by NFL legend John Madden, Roy Green saw enormous success as a two time Pro-Bowler and five time All-Pro player. Green is remembered by many fans for 559 receptions and 66 touchdowns during his career.

However, Roy Green’s health proved not to be as ideal. Later in life, he suffered from two strokes and two heart attacks, in large part due to sleep apnea. Diagnosis showed sleep apnea was causing 36 interruptions in breathing per hour during sleep. Like many other NFL players, Roy Green had to do what was necessary in order to stay on the playing field; and that included taking pain-killers, which have been known to amplify the effects of sleep apnea.

Green wasn’t getting quality rest and his heart was being taxed for that stress. After receiving OSA treatment with a Gergen’s Orthodontic Lab Herbst Appliance, he began to see his overall health improve. In Green’s words, “If I had met David Gergen years ago, I may not have had to experience having a heart attack, let alone two heart attacks and strokes. I am extremely grateful for what he’s done for me and my former teammates and I’m glad to be a part of spreading awareness on sleep apnea so others don’t have to go through what I did.”

Roy Green isn’t alone. Already, over 150 NFL players have been treated for sleep apnea

by Pro Player Health Alliance and many of these players have teamed up with PPHA to spread awareness to the public. Such players include Tony Dorsett and Derek Kennard. Tony DentalSleepPractice.com

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LABspotlight Dorsett, a former Heisman Trophy winner and NFL Hall of Famer, had claimed before being diagnosed with OSA to be “snoring like a freight train.” Then he received his dental sleep device, also a Herbst Appliance custom fit by Gergen’s Orthodontic Lab to treat sleep apnea. Now that he breathes well while he sleeps, he proudly boasts “Superman ain’t got nothing on me.”

Another legendary player, former NFL lineman and Superbowl Champion, Derek Kennard, claimed to be sleeping in two hour increments for years. Sometimes, in the middle of the night Kennard’s breathing would suddenly stop and his wife would have to push him just to make sure he was alive. Then Kennard’s doctor, Dr. Paul Serrano of Phoenix, Arizona, told him Left: Tony Dorsett, a former Heisman Trophy winner and NFL Hall of Famer, holds his dental sleep device with president of the Pro Player Health Alliance David Gergen.

Right: David Gergen with former NFL lineman and Superbowl Champion Derek Kennard.

Below: David Gergen on stage with Roy Green and Larry Fitzgerald Jr.

8 DSP | Spring 2014

that his sleep problems were linked to his severe sleep apnea. Derek knew he needed help. That’s when he found David and immediately began treatment with an oral appliance. After starting treatment for his OSA, Kennard received a phone call from his mother telling him that his brother had passed away in his sleep as a result of sleep apnea. Derek claims, “I’m confident that if I met Mr. Gergen before my brother’s passing, Mr. Gergen could have saved his life.”

Eric Dickerson, another Heisman Trophy winner and NFL Hall of Famer has also suffered from terrible morning headaches and needed extensive dentistry due to sleep apnea. However, Dickerson is sleeping better than ever after receiving treatment for his OSA by Dr. Harry Sugg, in Dallas, Texas.

Other players have joined with Pro Player Health Alliance because of loved ones who have suffered from sleep apnea. Larry Fitzgerald Jr., a current wide receiver for the Arizona Cardinals and an eight time Pro-Bowler, began spreading sleep apnea awareness with PPHA after seeing his father suffer from sleep apnea. His father, Larry Fitzgerald, was a legendary figure in the world of football. For more than thirty years Larry Fitzgerald has been a major sports personality in the Midwest and has presented his unique and socially conscious view of football in print, radio, and television outlets. Yet, despite his larger than life character, Fitzgerald also suffered from severe sleep apnea. But, due to the awareness of sleep apnea which PPHA spread throughout the football community, Fitzgerald received treatment for his disorder. After seeing the transformation in his father, Fitzgerald Jr. immediately wanted to help others inside and outside of the football community to transform themselves, so he teamed up with Pro Player Health Alliance.

Along with Roy Green, Derek Kennard, Eric Dickerson, Mike Haynes, and Larry Fitzgerald Jr., other NFL greats like Warren Moon, Marcus Allen, Dave Krieg, Nesby Glasgow, OJ Anderson, Bart Oats, Carl Eller, Lincoln Kennedy, Ed “Too Tall” Jones,

LABspotlight

“You can’t put a price on a good night’s sleep.”

Derek Kennard

Above: Andre Collins, Director of Former Players with David Gergen.

Below: Warren Moon, David Gergen, and Dave Krieg.

10 DSP | Spring 2014

Isiah Robertson, Chuck Foreman, Nick Lowery and Mark Walczak, have all also received oral appliance sleep apnea treatment and subsequently teamed up with PPHA. Together, these players have visited schools, held meet-the-players events for fans, and even hosted golf-tournaments in order to spread a simple message: get diagnosed for sleep apnea, get treated, and get a good night’s sleep. As Derek Kennard explains, “You can’t put a price on a good night’s sleep.”

So far, these PPHA events have reached thousands of people and have the potential to reach many more, potentially the entire NFL fan base. The beauty of Pro Player Health Alliance’s efforts is that they benefit everyone involved: the public is able to meet their sports heroes while becoming informed of the life-threatening risks of sleep apnea; players are able to receive treatment for this debilitating condition, which means better athletic performance and more exciting games; dental practitioners, especially those who help host PPHA events, are able to attract attention and patients to their sleep practices; and dental sleep appliance labs like Gergen’s are able to conduct more research and find even more impressive oral appliance solutions for obstructive sleep apnea.

With increased patient flow into dentists’ sleep practices, practitioners are able to provide more feedback which allows the lab to produce even higher quality treatment tools. It’s this dedication to research, quality, and advancement, which has made

it one of the highest quality dental sleep labs in America. The quality of their devices has been repeatedly confirmed by patient successes, and all of the NFL players who were treated by the PPHA were impressed by their Gergen’s Orthodontic Lab oral appliances. Derek Kennard, who had an especially severe case of sleep apnea, found CPAP machines to be overly intrusive, too loud, too difficult to operate, and nearly impossible to travel with. The CPAP was too inconvenient for his modern lifestyle. Instead, a Herbst Appliance was used, and it reduced his snoring and severe sleep apnea to normal levels. Most patients tend to agree with Kennard’s complaints about CPAP machines, and a study by the Canadian Respiratory Journal found that 46% of patients are non-compliant with their CPAP treatment. With CPAP therapy failing nearly half of the time, oral appliances succeed nearly universally even for athletes with rigorous demands, it appears that oral appliances produced by high quality labs like Gergen’s Orthodontic Lab are slowly moving to the frontline of sleep apnea treatment.

The Pro Player Health Alliance isn’t the only effort launched by David Gergen to promote sleep apnea awareness and increase the quality of sleep apnea treatment.

The PPHA is only the beginning of an even larger campaign to improve America’s sleep. David also works to promote sleep apnea awareness for former NFL players through the Living Heart Foundation’s HOPE (Heart, Obesity, Prevention, Education) Program for former NFL players. The HOPE Program is a comprehensive obesity, pulmonology, sleep, dentistry and overall health campaign sponsored by the NFL Players’ Association’s Professional Athletes Foundation, that strives to promote healthy lifestyles among former NFL players. David contributes to the HOPE Program through the program’s partnership with the PPHA as well as through his role as Executive Dental and Sleep Apnea Director of the Living Heart Foundation HOPE Program. The HOPE Program conducts evaluations for retired NFL players at leading Hospitals and University Health Centers across the country. Recently, Mayo Clinic in Arizona and George Washington Hospital in Washington DC hosted events, with more to come in Seattle, San Diego, Dallas, Denver and

LABspotlight Chicago. More information on events, locations, and dates can be found on the LHF website at www.livingheartfoundation.org.

David Gergen also contributes to the sleep apnea community through the research conducted by his lab. As a technician, he continually seeks the latest research and design improvements and acknowledges the need for dental sleep practices to work as a community. Therefore, Gergen constantly keeps his eye out for advances in dental sleep technologies and makes endorsements for exceptional devices, as he did in 2013 with his endorsement of the Andra Gauge. Gergen’s Orthodontic Lab is also deeply invested in improving the education of the dental sleep community and has been selected by Henry Schein to participate in their dental sleep apnea programs. These seminars set themselves apart from others with their emphasis on long term education and self-developing practices. Furthermore, Gergen’s Orthodontic Lab’s commitment to helping any and all patients who suffer from sleep apnea was demonstrated in 2012, when they were chosen as one of only two dental labs to make oral appliances available to be billed under Medicare.

In addition to his hard work within his dental sleep appliance lab, the HOPE Program, and the Pro Player Health Alliance, David still continues to serve the dental sleep community as the director of the Dental Division of the American Sleep and Breathing Academy. Because knowledge is essential to a practitioner’s longevity in the field, the Academy seeks to educate professionals in the diagnosis and treatment of sleep disorders. The Academy’s approach is unique due to its vision of creating convenient, affordably priced, and high quality classes involving the entire sleep community. ASBA produces quality learning materials including printed materials, webinars, and the magazine “Sleep and Wellness” which reaches out to dentists, physicians, and technicians in order to promote a complete understanding of sleep treatment across the field. The Dental Division has gone especially far in advancing the quality of sleep disorder treatment by connecting dentists to the nearly 16,000 physicians in the ASBA. In addition, they have been able to provide insurance advantages by

Carl Eller with David Gergen.

working to secure member preferred status with insurance companies. To advance the quality of care dentists provide, the Dental Division provides free webinars on a wide range of sleep topics to its members.

The way forward for Mr. Gergen is to get as many people diagnosed as soon as possible and connect these patients with dentists who can provide oral appliance sleep apnea therapy. David has done so by trying to promote OSA awareness among some of the most at risk groups. In 2013, David appeared before the Department of Transportation in order to request that diagnosis for sleep apnea be required for commercial truck drivers. According to a study by the University of Pennsylvania sponsored by the FMCSA and the American Trucking Association, 28% of truckers have mild to severe cases of sleep apnea. This is an alarming number considering that there are over 3 million truckers on American highways. On October 17th 2013, after David’s appeal, H.R. 3095, which sets standards for the evaluation of truck drivers for sleep apnea, was signed into law. Also in 2013, on behalf of the entire dental sleep community, he testified before Congress to request that dentists be able to order home sleep tests for their patients.

2014 promises to be a productive year for the entire sleep apnea community.

More people are becoming aware of the dangers of OSA than ever before. However, the majority of Americans are still in the dark. With David Gergen and former NFL players’ dedicated efforts, the dental sleep community and the public at large will soon be seeing major changes.

46% of patients are non-compliant with their CPAP treatment

Gergen’s Herbst appliance

DentalSleepPractice.com

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CLINICIANspotlight

Driven to Help the World Sleep An Interview with W. Keith Thornton, DDS

Editor’s Introduction

Dr. W. Keith Thornton is a third generation dentist who now limits his practice to the treatment of sleep disordered breathing, airway management during anesthesia, and temporomandibular disorders.

He has over 75 US and foreign patents for oral appliances, CPAP masks, and combination oral appliance mask interface systems for the treatment of sleep-disordered breathing.

Over the past thirty years, Dr. Thornton has served in many faculty and consultant positions. For 25 years Dr. Thornton has taught appliance therapy for temporomandibular disorders (TMD) at The Pankey Institute and Baylor College of Dentistry. He has also advised the Army, Navy, Air Force, and VA. In addition, he is a member and has held executive responsibilities in nine different dental or sleep societies including the Dallas County Dental Society, Academy of General Dentistry, and the American Academy of Dental Sleep Medicine. He is a Diplomat of the American Board of Dental Sleep Medicine.

In the first issue of Dental Sleep Practice, I thought our readers would appreciate an interview with one of the profession’s greatest leaders in both the development of adjustable mandibular positioning devices and the treatment of sleep apnea by dentists.

Steve Carstensen DDS Editor in Chief, Dental Sleep Practice

12 DSP | Spring 2014

What can you tell us about your background?

I studied science and engineering at Rice University and Southern Methodist University before earning my DDS from Baylor College of Dentistry in 1969. I was commissioned as a lieutenant in the US Navy that same year and spent a year in a general practice residency at the Oaknoll Naval Hospital in Oakland, California. I had a month’s anesthesia rotation during that training. Then, I was stationed in the Philippines for two years at Cubi Point Naval Air Station before returning home to become an associate in my father’s general practice. In 1972, we focused on the treatment of temporomandibular disorders and were among the first dentists to use bite splint therapy.

In 1993 my focus began to change away from TMD treatment and comprehensive restorative dentistry, and over the last 20 years I’ve transitioned to a sole focus on the treatment of sleep-disordered breathing.

CLINICIANspotlight What prompted this change?

In 1993, an ENT specialist in Dallas told me his concern about UPPP surgery, a “roto-rooter” extraction of excess tissues of the throat to clear the airway of any obstruction. It was a primary treatment at the time for patients with severe Obstructive Sleep Apnea (OSA) who did not respond well or comply with Continuous Airway Pressure (CPAP) treatment. The surgical removal can include the uvula, tonsils, adenoids, part of the soft palate and even a part of the inner tongue. With this invasive treatment comes the risk of many complications.

I began studying sleep-disordered breathing therapies and after a year of “inventing” came up with my first TAP® device. Like other oral mandibular repositioning appliances of the time, it alleviated snoring and sleep apnea by holding the mandible forward during sleep to prevent the soft tissues of the throat and the tongue from collapsing into the airway. Unlike other devices at that time, mine could be adjusted vertically, laterally, and protrusively— enabling titration in a sleep lab. I became intrigued with perfecting this device and with helping patients improve their longevity and quality of life.

Back in the 1990s only a few dentists were collaborating with sleep medicine specialists to fit their patients for oral devices.

The potential for helping millions of OSA sufferers drove me to push forward. I was able to create a comfortable oral appliance that greatly increased patient compliance.

That meant a lot to me personally, to my patients, and also my family who joined in the effort to start up the production, marketing, and education required to make my device widely available. This family effort has grown on a large scale, and the contributions of my wife and daughters to this business have enabled me to focus on what I love most: treating patients, teaching colleagues, and inventing.

effect of patients self-titrating their appliances. I worked with everyone who would work with me. This included the patient’s primary physician or referring sleep physician, other dentists interested in airway management, cardiologists, internists, and even influential patients who found CPAP too uncomfortable to use. I developed a reputation nationally for being a serious inventor and passionate student of the subject who could demonstrate results.

What do you recommend to dentists who are interested in developing expertise in this area?

Today, there are several professional societies and many postgraduate learning organizations to turn to for training and advice. Dentists simply need to start thoughtfully and mindfully implementing their learning, continue learning from their experience, and stay up to date through their reading, CE, and conferences.

All along, the patients I have treated have been thrilled with TAP® therapy. Most of my patients either have failed CPAP or want something that they can wear when they can’t wear CPAP or don’t want to take it on a trip. Once they get on the TAP®, they usually stop wearing the CPAP. If the TAP® doesn’t manage their sleep apnea, then we add the TAP® PAP mask combination, which they prefer greatly over the regular mask.

In virtually all compliance and preference studies, oral appliances are signifi-

How did you transition and build a practice focused on treating OSA patients?

Because I was very serious about studying the effects of my appliances, I was assertive in reaching out to sleep laboratories and collaborating with them and used home monitors to objectively measure the DentalSleepPractice.com

13

CLINICIANspotlight

My advice is to make conversation about snoring a part of your general examination. Help the patient discover his or her circumstances and educate them about the health risks of not receiving treatment.

14 DSP | Spring 2014

cantly ahead of CPAP. This is particularly true since the TAP® can treat snoring without the intrusiveness of the sound of the CPAP. We offer a monitor for those who want to measure compliance.

I say all of this, because every general dentist practice has patients who suffer from OSA and want help. Dentists are on the frontline of providing this help. As a dentist specializing in sleep disordered therapy, I can collaborate with the patient’s physician closely in the diagnostic work up and follow up – not just the selection and fitting of the oral appliance. And, I am the one referring many patients to the MD/sleep lab instead of the other way around.

My advice is to make conversation about snoring a part of your general examination. Help the patient discover his or her circumstances and educate them about the health risks of not receiving treatment.

You can send your patients to a sleep lab for diagnosis and oral appliance prescription that you fulfill and continue to evaluate. You can always reach out to lab manufacturers of oral appliances for precise information you need for selecting the most appropriate device.

Dentists and their patients are now benefiting from over 20 years of scientific studies involving oral appliance therapy (OAT).

There was a long period when CPAP was the first recommendation for all severity of OSA. In 2006, when the American Academy of Sleep Medicine (AASM) updated their guidelines, OAT became the first recommendation for mild to moderate OSA. Today’s guidelines indicate follow-up sleep testing is not needed for patients with primary snoring, but it should be performed in patients with OSA after final adjustments of the oral appliance. The latter group should also have a dental follow-up every 6 months for the first year and at least annually thereafter. A repeat sleep study is indicated if signs or symptoms of OSA worsen or reoccur. With new oximetry devices and applications, digital oximetry recordings can be done overnight in the patient’s own home and read remotely by the attending physician and dentist.

The guidelines also recommend that patients with OSA who are treated with OAs have regular follow-up with the dentist to monitor compliance, evaluate device dete-

rioration or maladjustment, and determine oral health and integrity of the occlusion.

Because there are so many US citizens affected by OSA who are yet undiagnosed and treated and because Medicare and insurance companies have opened the way for reimbursement, I personally hope all dentists are participating in OAT on some level, even if it is helping patients understand the benefits and referring their patients to those with OAT expertise. Millions of our patients nationwide can be helped.

What training do you recommend to interested dentists?

All dentists have the basic technical and educational background to be involved in treating sleep disordered breathing.

There is no need to become overwhelmed. I advise dentists to take one course at a time focused on sleep dental medicine, get their feet wet and keep learning in incremental ways. In 2014, I am presenting this type of required course at Texas A&M University Baylor College of Dentistry along with Steven D. Bender, DDS, and hoping to spur interest in seeking more knowledge and helping more patients nationwide.

Dentists should reach out for mentorship, advise each other and collaborate.

The market demand for services is huge and will grow. It’s an enormous opportunity to provide a special service, reputation brand a practice, and do something very meaningful without worrying about the local competition.

Through postgraduate courses focused on dental sleep medicine, they will learn what they need to know about medical insurance and Medicare to ensure that everything required is carefully documented.

I know you are passionate about your inventions and many dentists are interested in how you developed your business. Can you tell us very briefly about this?

When I invented the Thornton Adjustable Positioner (TAP®) in 1994, I immediately founded my first oral appliance company, Oral Appliance Technologies to market and supply TAP® appliances. In 2000, Oral Appliance Technologies was

CLINICIANspotlight succeeded by Airway Management Inc. (AMI), and recently AMI divided into two companies, Airway Management Inc. and Airway Management Laboratories (AML).

As of today we’ve delivered more than 300,000 oral appliances to patients worldwide. The first generation oral appliances were large, minimally adjustable hinged bite plates similar to athletic mouth guards.

The latest generation of OAs are smaller, more comfortable, less visible, and micro-incrementally adjustable.

The TAP® can be vertically adjusted and account for side-to-side movement for patients who grind or clench their teeth. I believe our newest device, the myTAP™ is truly revolutionary. It is an immediate fit, precision appliance that has most if not all of the desirable features of a mandibular advancement device, yet it is inexpensive and can be fit in less than 30 minutes. Ideally, it will be used as both a trial device and as a titration device at both home and in sleep labs.

I attribute a lot of our success to continuing customer education and personalized care, ongoing product research, and highest quality materials provided by partnering suppliers. I am particularly proud of the fact that the Tap was selected by many independent researchers for studies on sleep disordered breathing. There are now over 32 independent studies including one by the Army, which involved approximately 500 soldiers deployed to Iraq and Afghanistan. We have focused on compliance with regulatory requirements and quality standards set forth by the Food and Drug Administration (FDA), ISO Standards, and Texas Health Department.

To get to the level of distribution we see today, early on we partnered with other dental laboratories to construct the Tap appliance. Today we have over 200 laboratories involved.

Just this year (2014), we began working with Pillar Palatal, LLC, a medical device company who is now the exclusive Unit-

A Premier Bite Registration System for Treating Obstructive Sleep Apnea: Identify a target treatment position – Measure a Comfortable mandibular starting position in Both Anterior/Vertical alignment and obtain the pre-measured Bite registration.

SNORE SCREENER

MANDIBULAR POSITIONING SIMULATOR

AIRWAY METRICS LLC Phone: 206-949-8839 www.airwaymetrics.com

BITE FORK AND HANDLE ATTACHMENT

DentalSleepPractice.com

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CLINICIANspotlight

ed States distributor of the myTAP™ oral appliance, for the Otolaryngology (ENT) physician market.

OSA was discovered by researchers in an academic sleep lab, and the first CPAP treatment was developed by a physician.

Sleep-disordered breathing became the purview of, first, psychiatrists and PhD researchers, then neurologists, and now the pulmonologist and dentists. If a dentist or anesthesiologist had been involved initially, I think oral appliances and, therefore, dentists would have played a much more prominent role years ago. Dentists were limited not only by their amount of involvement compared to other disciplines, but also by reimbursement. It took years for insurance companies and the medical profession to accept TAP® appliance therapy.

The TAP® became the device of choice for studies and treatment because it was and is the only appliance that can be infinitely adjusted vertically and protrusively after construction; can be adjusted by the patient while in the mouth; has an attachment for CPAP; and can be titrated in the sleep lab. It is easily portable, providing easy airway management for travelers and deployed military personnel.

Technology is always advancing. I am continuing to develop appliances and looking into the future. One of my most recent developments is the TAP® PAP Nasal Pillow

16 DSP | Spring 2014

Mask that provides patients with all the benefits of other CPAP masks at the same price but with less air leakage and pressure drop, more comfort, and less noise.

Are there any final thoughts you would like to leave with us?

Yes. One thought I’d like to mention is that team-based care that brings the dentist and physician together can make a tremendous difference in the lives of patients. We need partnerships with MDs to treat this sleep disorder, and I am an advocate of developing science based guidance for dentists, practicing physicians who are sleep specialists, and also general physicians who are educated in this sleep disorder. A combined task force approach to develop clinical guidance for dentists, determine research gaps, and promote dentist-physician team-based learning is a goal we should be seeking with our State Dental Boards and other organizations.

I am excited about the launch of the Dental Sleep Practice journal. We need more places where sleep practiitioners can find inspiration and guidance.

I am honored that you chose to pose these questions. It’s especially nice to be able to communicate with so many colleagues in this conversational way. I look forward to another 20 years of making a difference.

CLINICALspotlight

Airway Development and Prevention of Obstructive Sleep Apnea in Children: A Case Report, part 1 by Juan-Carlos Quintero, DMD, MS

O

bstructive sleep apnea (OSA) is a debilitating disease resulting in greater loss of life expectancy (LLE) and diminished quality of life (QOL) affecting anywhere from 3% to 7% of the US population.1 The prevalence of OSA is higher in some subpopulations such as obese adults.2 Comorbidities include cardiovascular disease, renal disease, diabetes, depression, and motor vehicle accidents, among others.1 The number of patients being diagnosed with OSA is increasing at an alarming rate of 15% per year. The estimated annual costs of obstructive sleep apnea and its related comorbidities is to be between $65 billion and $165 billion a year, according to a 2010 report published by the Harvard Medical School.3 Treatment modalities include weight loss, positional therapy, nasal decongestion, oral appliances, CPAP, soft tissue surgery – uvulopalatopharyngoplasty (UPPP), orthognathic surgery in the form of maxillo-mandibular advancement (MMA) or mandibular advancement (MA), and tracheotomy. But perhaps the most effective and least invasive modality is prevention in children through airway development.7, 8, 9,1 0, 11, 12, 13 Part 1 of this article will explore the rationale and potential of preventing OSA in children at risk for OSA through proven methods of airway development and evolving diagnostic aids.

Breathing is a function of craniofacial anatomy and the resultant airflow resistance caused by the collapse of the structures surrounding the upper airway (Figure 1), such as the tongue. The larger the size of the pharyngeal airway, or more specifically, the larger the minimum cross sectional area (MCA) of the airway, the less collapse or obstruction that occurs during sleep when voluntary muscles such as the tongue become flaccid. Recent studies have correlated dentofacial morphology with airway volume, and reduced airway dimensions have logically been correlated with risk factors for OSA.4, 5, 6 Furthermore, recent advances in imaging technology have made ultra-low-dose cone beam computed tomography (CBCT) such as the i-CAT FLX from Imaging Sciences International (Hatfield, Pa.) and everyday imaging of the airways possible with dose exposure less than a panorex and as low as 8 µSv14, 15 (Figures 2 and 3). The applications and implications of this technology in the screening and prevention of OSA in the pediatric population are enormous. It is now possible

to screen children with small airways who either have OSA, are at risk for OSA, or are at risk for developing OSA later in life, and treat accordingly.

Discussion

Orthognathic surgery in the form of maxillomandibular advancement has been shown to be the definitive treatment for patients suffering from obstructive sleep apnea. Several studies have demonstrated a 100% success rate of OSA treatment through MMA, when compared to CPAP or oral appliances, using AHI scores through polysomnograms as the measuring tool.16, 17, 18 This is because Grauer, et al., and others have reported that pharyngeal airspace dimensions are a function of jaw position.4,5,6 It would seem only reasonable to equally expect enlargement of the pharyngeal airspace in children concurrent with the forward growth of the craniofacial complex.

Just as the airway is enlarged in non-growing patients when the face is surgically positioned forward through MMA, so can the airway be enlarged through proper inter-professional collaboration when facial-growth-friendly orthodontics are applied in children.

Part 2 of Dr. Quintero’s article will illustrate treatment of a case of a young patient with a narrow pharyngeal airway.

Follow Dr. Quintero’s blog on airway development on www.airwaydevelopment.com.

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Figure 1

Figure 2

Figure 3

Chiong, T. L. (2009). Sleep medicine essentials. Hoboken, N.J.: Wiley-Blackwell.

Punjabi, N. M. (2008). The Epidemiology Of Adult Obstructive Sleep Apnea. Proceedings of the American Thoracic Society, 5(2), 136-143.

The Price of Fatigue. Sleep Medicine. Harvard Medical School. The Harvard Medical Division of Sleep Medicine. December 2010.

Grauer D, Cevidanes LH, Styner MA, Ackerman JL, Proffit WR. Pharyngeal airway volume and shape from cone-beam computed tomography: relationship to facial morphology. Am J Orthod Dentofacial Orthop. 2009 Dec;136(6):805-14.

Abdelkarim, A. A cone beam CT evaluation of oropharyngeal airway space and its relationship to mandibular position and dentocraniofacial morphology. Journal of the World Federation of Orthodontists. . 16 July 2012.

El H, Palomo JM. Airway volume for different dentofacial skeletal patterns. Am J Orthod Dentofacial Orthop. 2011 Jun;139(6):e511-21.

Pirelli P, Saponara M, Guilleminault C. June 15 2004. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 27;(4):761-6.

Villa MP, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, Ronchetti R. March 2007; Epub 2007 Jan 18. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 8(2):128-34.

Villa MP, Rizzoli A, Miano S, Malagola C. May 2011; Epub 2001 March 25. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath. 15(2):179-84.

Guilleminault C, Quo S, Huynh NT, Li K. July 2008. Orthodontic expansion treatment and adenotonsillectomy in the treatment of obstructive sleep apnea in prepubertal children. Sleep. 31(7):953-7.

Marino A, Ranieri R, Chiarotti F, Villa MP, Malagola C. March 2012. Rapid maxillary expansion in children with Obstructive Sleep Apnoea Syndrome (OSAS). Eur J Paediatr Dent. 13(1):57-63.

Cistulli PA, Palmisano RG, Poole MD. December 15, 1998. Treatment of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep. 21(8):831-5.

Miano S, Rizzoli A, Evangelisti M, Bruni O, Ferri R, Pagani J, Villa MP. April 2009; Epub 2008 August 26. NREM sleep instability changes following rapid maxillary expansion in children with obstructive apnea sleep syndrome. Sleep Med. 10(4):471-8 John B. Ludlow and Cameron Walker Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography Am J Orthod Dentofacial Orthop 2013;144:802-17 Quintero, JC. New Study May Change the Face of Orthodonitcs. Orthodontic Practice US. January/February 2014- Volume 5, N0 1. Page 41-43 Prinsell JR. Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest. 1999 Dec;116(6):1519-29.

Riley RW, Powell NB, Guilleminault C, Stanford University Medical Center, CA. Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac Surg. 1993 Jul;51(7):742-7; discussion 748-9.

White PD, Wooten V, Lachner J, Guyette RF: Maxillomandibular advancement surgery in 23 pts with OSA syndrome. J Oral Maxillofac Surg 47: 1256, 1989

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CORPORATEspotlight

Changing lives with every breath: Global Leader in PAP Therapy Makes MRD A Mainstream Sleep Apnea Therapy Option

T

he 4,000-plus ResMed employees around the world are united by the goal of changing lives by putting a spotlight on the serious health impact of sleep disordered breathing, and engaging the medical and dental communities with innovative, patient-centric products to manage the condition.

Formed in 1989, ResMed is the global leader in developing, manufacturing and selling positive airway pressure – PAP -equipment, but its leadership recognized the need for effective oral appliance therapy as well.

“PAP is the gold standard for the treatment of OSA, but ResMed has always been active in researching other therapy options for patients suffering from sleep apnea,” said Jim Hollingshead, president ResMed Americas. In its quest to better serve all patients, ResMed had to augment its expertise in oral appliance therapy.

In 2002, the development of Narval CC, a custom-made, CAD/CAM-designed

ResMed global headquarters, San Diego, CA

18 DSP | Spring 2014

ResMed scan workstation

ResMed’s Narval CC

mandibular repositioning device (MRD), was started in Lyon, France. The manufacturing platform was unique and scalable and the MRD’s patented design enabled unparalleled patient comfort. Early clinical evidence suggested the Narval CC was achieving excellent results in treating snoring and sleep apnea.

“These attributes led to our 2009 acquisition of the Narval company. We retained their leadership team and transitioned the company into a new dental sleep business unit for ResMed, currently operating across Europe and North America,” said Kristie Burns, general manager, ResMed Dental Sleep.

ResMed’s mission is to increase the awareness of the dangers of undiagnosed and untreated sleep disordered breathing

Narval Design in CAD

CORPORATEspotlight and to improve the quality of life for people with these conditions. “In pursuit of this mission, it makes sense for us to offer multiple, effective therapies. Sleep apnea therapy requires significant patient engagement – even more so than most chronic disease therapies — so we encourage the consideration of what will work for an individual patient’s lifestyle and symptom relief that will still achieve the clinically-measured, positive outcomes.” Kristie added.

ResMed is driving evidenced-based medical research in oral appliance treatment options with its investment in ORCADES. This is a five-year, prospective multicenter study monitoring subjective and objective treatment in patients receiving Narval. Early results have already been shared at the European Respiratory Society in 2013. The rate of treatment success (defined as >50% decrease in AHI) at 3 months follow-up was 84% irrespective of OSA severity or previous use of CPAP in the earliest patient subgroup (n=143). Further publications on efficacy, side-effects and treatment in snoring and mild, moderate and severe obstructive sleep apnea patients are coming soon. This rigorous evidence can have a profound effect on therapy adoption by dentists and sleep physicians.

“Sleep physicians consistently tell us that they are skeptical of oral appliance therapy for a variety of reasons, the top two being uncertain efficacy of treatment and medical reimbursement for the treatment,” said Kristie. “Sleep physicians are used to PAP, where efficacy and reimbursement are very clear. A multicenter study the size of ORCADES can positively address both topics. We have to help payers understand

what results are possible with specific customized oral appliances, evidenced by published results.”

When selecting their one primary concern, 74% of sleep physicians pick treatment efficacy or lack of insurance coverage

41% 74%

Concern about efficacy of treatment Lack of insurance coverage Patient discomfort with oral appliance

33%

Concern about long-term effects to patient’s bite and/or jaw Other

10% 9% 7%

2014 (n=98) Source: MedPanel

ResMed values the opportunity to work with experienced dental sleep professionals as well as sleep physicians to provide untreated patients with access to therapy. Dentists and sleep physicians cannot fully accomplish this working in silos. Kristie shares that this has been a significant challenge.

In an effort to support collaboration between dentists and sleep physicians, ResMed has assembled an experienced team with tools built from its 25 years in sleep apnea treatment. These tools incorporate real-world feedback from physicians.

“It will take professional collaboration to get more untreated patients into therapy, and we’re bringing the insights from the physician community to our dentist partners. Team members are experienced in sleep medicine and specialty dental treat-

Kristie Burns, general manager of ResMed Dental Sleep, joined the company in 2003 and led the strategic marketing team for the Americas from 2005 - 2011. She brought more than 10 years of biotechnology and cardiology expertise to ResMed after business school training at the University of Kansas and graduating the master’s program in Executive Leadership at the University of San Diego.

ResMed’s CAM printing facility

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CORPORATEspotlight ments, the combination of which is critical to supporting our customers. Bridging the two communities can accelerate the use of acceptance of oral appliances among physicians,” said Kristie.

Another critical partner in diagnosis and treatment are referral sources, noted Kristie.

“The general dentists and primary care physicians that identify symptoms and first educate the patients about this chronic condition need our support.” Just as sleep physicians lecture at grand rounds, dental sleep professionals need to educate general dentists at regional study clubs, state dental meetings and regional sleep society meetings.

“Without this sharing, we perpetuate the uninformed practice of placing splints for snoring along with the potential of intensifying the more serious problem of sleep apnea,” she said. Ideally, general dentists would be active in screening for sleep apnea and refer to local dental sleep experts, just like for oral cancer.

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Treating sleep disordered breathing can look like the coordinated care seen in other chronic conditions like diabetes or heart disease; patients and providers working together to match therapy to the individual patient’s unique circumstances. By creating standard protocols that are flexible enough to meet each person’s needs while adhering to proper medical practice, including preand post-testing to verify treatment efficacy, ResMed is breaking down existing barriers and improving overall patient outcomes.

Many companies provide products or services to providers in the sleep medicine market. ResMed takes it much further by supporting all parts of the diagnostic, treatment, and follow-up continuum, truly being a partner in health for providers and patients. Changing lives with every breath.

For more information on Narval and ResMed, visit www.ResMed.com or attend a free monthly webinar by registering at, www.NarvalCC.com/progress

BIGGERpicture

Abstract

T Fig. 1a: Patient before

his article reviews upper airway obstruction caused by hypertrophied adenoids and the possibilities of a subsequent malocclusion. Early diagnosis, and treatment, of pathological conditions that can lead to the obstruction of the upper airways is essential to anticipate and prevent alterations in dental arches, facial bones and muscle function. Correct nasal breathing facilitates normal growth and development of the craniofacial complex (Figure 1). Important motor functions such as chewing and swallowing depend largely on normal craniofacial development. Any restriction to the upper airway passages can cause nasal obstruction possibly resulting in various dentofacial and skeletal alterations.1 Upper respiratory obstruction often leads to mouth breathing (Figure 2). Habitual mouth breathing may result in muscular and postural anomalies which may in turn cause dentoskeletal malocclusions2 (figure 3). Hypertrophy of the adenoids, and palatine tonsils, are one of the most frequent causes of upper respiratory obstruction (Figure 4). Philosophies regarding the treatment of adenoid hypertrophy range from dietary control and environmental modifications to dentofacial orthopaedics, change of breathing exercises, and surgical procedures.

Introduction

Fig. 1b: Patient after

The aims of this article are (1) to highlight the skills and tools that assist the clinician in identifying upper airway obstruction; (2) to improve the diagnosis of adenoid hypertrophy; and (3) to improve the classification and treatment of associated malocclusions.

The methodology used in this literature analysis consists of a thorough review of narrowly tailored research and Journal articles. The paradigm explored in each article

involves upper airway obstruction, adenoid hypertrophy and malocclusion. The results and conclusions stemming from these articles generally fall into three categories: 1. That hypertrophied adenoids have a definitive effect resulting in skeletal malocclusion;3 2. That hypertrophied adenoids, coupled with other factors, may aid in the development of skeletal anomalies4; and

Fig. 2: Mouth breathing

Fig. 3: Mouth breathing

Fig. 4: Hypertrophy of the adenoids and palliative tonsils

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BIGGERpicture of that relationship and what it affects is still under debate. This paper attempts only to highlight the positive existence of this relationship and its possible effects regarding dentofacial growth and development.

Basic Facial Growth and Development

3. That adenoid hypertrophy has no effect on airway obstruction and malocclusion.

The research in this area is expansive, but largely inconsistent. Thus, the cause and effect relationship of adenoid hypertrophy and malocclusion must be carefully examined on a case by case basis5. Regardless of the various researcher’s conclusions, one theory remains common – that airway obstruction caused by adenoid hypertrophy and malocclusion are related. The degree Dr. Kevin Williams manages two general dentistry practices in Greenville and Spartanburg, South Carolina, with an emphasis on facial driven orthodontics and oral surgery. He received his dental degree from the Medical University of South Carolina in 1993. His interest in airway and malocclusion developed from his children’s airway issues. Dr. Williams is a Fellow in the Academy of General Dentistry and a Certified Senior Instructor in the International Association of Orthodontics. E-mail: drkwilliams@aol.com Dr. Derek Mahony is a graduate of the University of Sydney, Faculty of Dentistry, and an Alumnus of the University of London, Masters Programme in Orthodontics. He is a Fellow of the International College of Dentists and is considered a pioneer, throughout the world, in raising dentist’s awareness of the need for early interceptive orthodontic treatment.

Dr. Mahony has been actively involved in research that links constricted maxillary archforms to nasal breathing problems, adverse facial growth and systemic health problems such as nocturnal enuresis. He has presented over 400 lectures on orthodontic topics in more than 30 countries. As a practicing clinician, Dr. Mahony’s research interests are in the etiology of malocclusion and the guidance of facial growth.

Dr. Mahony is a member of the editorial board of five International Dental Journals and is the current Editor of the Australasian Association of Orthodontics and Orofacial Orthopaedics (AAOO) Journal. He practices the full remit of orthodontics and dentofacial orthopaedics including functional appliances, treatment of TMJ disorders and the diagnosis and treatment of obstructive airway problems such as snoring and sleep aponea. E-mail: info@derekmahony.com

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Developments in the understanding of human craniofacial growth have stemmed from histological and embryologic studies, radiographic cephalometry, correlation of growth and facial anomalies analysis of surgical interventions, animal research and other science fields.6 Despite these studies, we are still waiting for a definite consensus regarding the controlling mechanism of craniofacial tissue.

Postnatal facial growth is influenced by genetic and environmental factors.2 Most facial growth and development occurs during the two childhood growth peaks.

The first growth peak occurs during the change from primary to permanent dentition (between 5 and 10 years of age) and the second growth peak occurs between 10 and 15 years of age.2 The study of the early years of life shows that by the age of four (4), 60 percent of the craniofacial skeleton has reached its adult size. By the age of twelve, 90 percent of facial growth has already occurred.7 By age seven (7) the majority of the growth and development of the maxilla is complete and by age nine (9) the majority of the growth and development of the mandible is complete. Proper facial growth is affected either positively or negatively, early in life, by the sequential occurrences of four major factors: 1. The cranial base must develop properly; 2. The naso-maxillary complex must grow down and forward from the cranial base; 3. The maxilla must develop in a linear and lateral fashion; 4. A patent airway must develop properly.

The relationship between the naso-maxillary complex and the cranial base is significant for aesthetic reasons and proper facial bone, muscle and soft tissue support.

To allow proper downward and forward rotation of the mandible, the maxilla must be adequately developed, in width, for

BIGGERpicture acceptance of the mandible. Any limitation on mandibular rotation may affect the relationship of the condyle to the glennoid fossae (in the temporal bone) resulting in multiple TMJ problems. An improper airway will affect the global individual growth.8 The simultaneous growth of these factors is not nearly as significant as how these factors interrelate during facial growth and development. For example, the basic design of the face is established by a series of interrelated factorial developments. The naso-maxillary complex is associated with the anterior cranial fossae. The posterior boundary of the maxilla determines the posterior limits of the midface. This structural plane is significant to facial and cranium development. The basic structural format of facial growth and development is dependent on, and governed by, the interrelation of multiple functional matrices. These functional matrices include a phenomenon of bone displacement and growth at the TMJ with the maxillary forward and downward movement equaling mandibular growth upward and downward. The displacement and growth phenomenon is responsible for the spatial relationship necessary for functional joint movement resulting in the final result of facial growth.9 Additionally, muscle adaptions affect dentoskeletal development. The integration of the musculoskeletal system affects respiration, mastication, deglutition, and speech.2 This basic understanding of facial growth and development is relevant as adenoidal tissue enlargement coincides with major facial growth, i.e. they occur simultane-

Fig. 5: Abnormal breathing patterns

ously. Facial growth may be restricted by abnormal development of adenoidal tissue resulting in abnormal swallowing and breathing patterns (Figure 5).

Adenoidal Growth and Development

Lymphoid tissue is normally present as part of the Waldeyer’s tonsillar ring in the form of a nasopharyngeal tonsil (Linder-Aronson 1970). The Waldeyer’s ring is the system of lymphoid tissue that surrounds the pharynx. This system of tissue includes adenoids and pharyngreal tonsils; lateral pharyngeal tonsils; lateral pharyngeal bands; palatine tonsils and lingual tonsils (Figure 6). Tonsils and adenoids have disparate embryonic origins and cytology even though they are both part of Waldeyer’s ring.10 Bacteria may play a role in adenoid hyperplasia. Specifically, different pathogens, such as Haemophilus influenza and Staphylococcus aureus, have been associated with lymphoid tissue hyperplasia.

The adenoid lymphoid structures are lined with ciliated respiratory-type epithelium which is normally distributed throughout the upper and posterior nasopharynx walls.

During the presence of disease, the distribution of the dendritic cells (antigen presenting cells) is altered. The result is that there is an increase in dendritic cells in the crypts, and extrafollicular areas, and a decrease in surface epithelium dendritic cells.

Lymphoid tissue is normally not apparent in the early infant stage of life. Marked symptoms of adenoid development are most common in the childhood age range

Facial growth may be restricted by abnormal development of adenoidal tissue resulting in abnormal swallowing and breathing patterns.

Fig. 6: Main components of Waldeyer’s ring

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BIGGERpicture Fig. 7: Growth curves of tonsils and adenoids

child study patients were ineffective, with intranasal extensions of the adenoids obstructing the posterior choanoe. For this segment of the study population the “powdered-shaver adenoidectomy” was effective in the complete removal of the obstructive adenoid tissue ensuring postural patency.13

Upper Airway Obstruction and Mouth Breathing

Airway obstruction, resulting from nasal cavity or pharynx blockage, leads to mouth breathing which results in postural modifications such as open lips, lowered tongue position, anterior and posteroinferior rotation of the mandible, and a change in head posture.

24 DSP | Spring 2014

of 2 – 12. During adolescence a decrease in adenoid size is noted as current with the growth of the nasopharynx. Rarely is adenoid tissue present in adults and when it is noted it is usually in an atrophic condition.

The cause of the involution of the Waldeyer’s ring is still under investigation.12 The imbalance in the relationship between the enlargement of the nasopharynx/nasopharyngeal airway and the concomitant growth of adenoid tissue can result in reduced patent nasopharyngeal airway and increased nasopharyngeal obstruction.10 The growth of adenoidal tissue as demonstrated by a bell curve, peaks at or near age six (6) and also begins involution at or near this age as well (Figure 7).

Facial growth is coupled with adenoidal growth. As the cranial base forms the roof of the nasopharynx, a close examination of the growth and development of the craniofacial complex becomes significant for evaluation of the size and configuration of the nasopharyngeal airway. Any abnormal development regarding this craniofacial complex may affect the nasopharyngeal airway. Abnormal adenoidal growth that occurs during childhood may consume the nasopharnx and extend through the posterior choanae in the nose.13 This excessive adenoidal growth usually interferes with normal facial growth and can result in abnormal breathing patterns, congestion, snoring, mouth breathing, sleep apnea;4 Eustachian tube dysfunction/otitis media, rhinosinusitis, facial growth abnormalities, swallowing problems, reduced ability to smell and taste, and speech problems.12 Many clinicians believe the blockage should be removed as soon as possible through a surgical procedure called adenotonsillectomy. However, according to a study conducted by Havas and Lowinger, one third of traditional adenoidectomies in

During normal nasal respiration, the nose filters, warms, and humidifies the air in preparation for entry into the body’s lungs and bronchi. The nasal airway provides a degree of flow resistance in order to assist the movements of the diaphragm and intercostal muscles to create negative intrathoracic pressure, promoting airflow into the alveoli.7,15 Correct normal resistance is 2 to 3.5 cm H2O/L/Sec and results in high tracheobronchial airflow which enhances the oxygenation of the most peripheral pulmonary alveoli. In contrast, mouth breathing causes a lower velocity of incoming air and eliminates nasal resistance. Low pulmonary compliance results7. According to blood gas studies, mouth breathers have 20% higher partial pressure of carbon dioxide and 20% lower partial pressures of oxygen in the blood, linked to their lower pulmonary compliance and reduced velocity.7,16 Contributing factors in the obstruction of upper airways include: anatomical airway constriction, developmental anomalies, macroglossia, enlarged tonsils and adenoids, nasal polyps and allergic rhinitis.5 However, for purposes of this paper the focus shall be on enlarged adenoids as the major contributing factor. There are numerous studies that link adenoid hypertrophy with nasopharyngeal airway obstruction to the development of skeletal and dental abnormalities.14 Airway obstruction, resulting from nasal cavity or pharynx blockage, leads to mouth breathing which results in postural modifications such as open lips, lowered tongue position, anterior and posteroinferior rotation of the mandible, and a change in head posture. These modifications take place in an effort to stabilize the airway.

As previously discussed, facial structures are modified by postural alterations in soft tissue that produce changes in the equilib-

BIGGERpicture rium of pressure exerted on teeth and the facial bones (Figure 8). Additionally, during mouth breathing, muscle alterations affect mastication, deglutition and phonation because other muscles are relied upon.2

Malocclusion – The Issue Still in Debate

Is there a cause and effect relationship between adenoids, nasal obstruction and malocclusion?

Dentofacial changes associated with nasal airway blockage have been described

by CV Tomes in 1872 as “adenoid faces.”

Tomes coined this term based on his belief that enlarged adenoids were the principle cause of airway obstruction and resulted in noticeable dentofacial changes.7 Tomes reported that children who were mouthbreathers, often exhibited narrow V-shaped dental arches10 (Figure 9). This narrow jaw is a result of mouth breathers keeping their lips apart and their tongue position low.

The imbalance between the tongue pressure and the muscles in the cheek results in compression of the alveolar process in the premolars region. At the same time, the lower jaw postures back (Figure 10). These simultaneous actions have been termed the compressor theory11.

Tomes’ views were supported in the 1930’s by numerous leading orthodontists.

These supporting clinicians reported airway obstruction as an important aetiologic agent in malocclusion. Rubin advocated that in order for these patients to fully be assessed they must be thoroughly evaluated by both a rhinologist and orthodontist.7 Malocclusion is the departure from the normal relation of the teeth in the same dental arch or to teeth in the opposing arch.3 Airway obstruction, coupled with loss of lingual and palatal pressure of the tongue, produces alterations in the maxilla.

The positioning of the tongue also plays an important role in mandibular development.

The tongue displaced downward can lead to a retrognathic mandible; and an interposed tongue can lead to anterior occlusal anomalies.

Additionally, maxillary changes can be viewed in the transverse direction, producing a narrow face and palate often linked with cross bite; in the anteroposterior direction, producing maxillary retrusion;

and in the vertical direction causing an increase in palatal inclination as related to the cranial base and excessive increases of the lower anterior face height. The most commonly found occlusal alterations are cross bite (posterior and/or anterior), open bite, increased over jet, and retroclination of the maxillary and mandibular incisors.2 Mahony and Linder-Aronson’s findings were in agreement with the significant correlation between changed mode of breathing and diminished mandibular / palatal plane angle (ML/NL) found in adenodectomized children. 22 Several authors have taken the position that “adenoid faces” are not consistently found to be associated with adenoids, mouth breathing, nor a particular type of malocclusion; and that there is no cause and effect relationship between adenoids, nasal obstruction/mouth breathing and malocclusion.

Proponents of this position believe that the V-shaped palate was inherited and not acquired through mouth breathing. (Hartsooh 1946) on a review of literature related to mouth breathing, concluded that mouth breathing is not a primary etiological factor in malocclusion. Additionally, Whitaker (1911) found that in a study of 800 children, who underwent adenoidectomy or tonsillectomy only 30% had dental anomalies that needed orthodontic intervention. There is some suggestion that adenoids and hypertrophic tonsils are a consequence of a thyroid hormone deficiency. This hormone deficiency acts as a catalyst for activating the organism’s defense mechanisms which include hypertrophy of lymphoid tissue.11 Another orthodontic clinician, Vig, took the position that without documented total nasal obstruction, any surgery or other treatment to improve nasal respiration, is empirical and difficult to justify from an orthodontic point of view.7,17

Fig. 8: Facial structures are modified by postural alterations

Fig. 9: Narrow V-shaped dental arches

Fig. 10: Pseudo skeletal discrepancies

Nasal Respiratory Evaluation

The relationship of airway obstruction and dentofacial structures/malocclusion is still the subject of investigation and controversy amongst orthodontists. The correlation between functional problems and morphologic characteristics is yet to be solidified. Regardless of varied opinion in DentalSleepPractice.com

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BIGGERpicture this area practitioners should observe each patient carefully.

Fig. 11: Difficulty breathing possible deviation or turbinate

Fig. 12: Flexible optic endoscopes

Suggested protocol: 1. As the patient enters the room, facial and head posture should be noted to see if the lips are closed during respiration.

2. Signs of allergic rhinitis should be noted, as well as histories of frequent colds or sinusitis.

3. Assessment of family history for allergies is important.

4. Sleep history should be evaluated: sleep apnoea, loud snoring, open mouth posture while asleep.

5. Patient is asked to seal their lips – difficulty breathing through nose should be noted. One nostril can be occluded and the response noted – same procedure on the other side. (Figure 11) The evaluation of nasal airway patency is complicated, especially when the possibility exists that airways may clinically appear inadequate but be quite functional physiologically. Lip separating or an openmouth habit is not an infallible indicator of mouth breathing. Often complete nasal respiration is coupled with dental conditions that cause open-mouth posture.10

Adenoid Evaluation

Fig. 13: Lateral Cephalometric Radiograph with obstructive adenoids

Fig. 14: Rapid maxillary expander

Nasopharyngeal space and the size of adenoids have been evaluated using different methods of assessment: 1. Determination of the roentgenographic adenoid/nasopharyngeal ratio (a lateral cephalometric xray); 2. Flexible optic endoscopes (Figure 12); 3. Acoustic rhinometry; and 4. Direct measurements during surgery.

Direct measurements are considered to be the most accurate because space can be assessed in three directions.12 A lateral cephalometic radiograph is an added valuable diagnostic tool for the orthodontist in the evaluation of children with upper airway obstructions.14 (Figure 13).

Treatment of Nasal Obstruction

1. Adenoidectomy with or without tonsillectomy is indicated if hypertrophied adenoids (and tonsils) are the

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6.

7.

cause of upper airway obstruction.7 Powered-Shaver Adenoidectomy – Adenoidectomy coupled with Endoscopic Visualization will assist in achieving adequate removal of adenoids particularly high in the nasopharnx. Use of the poweredshaver technique allows for better clearance of obstructive adenoids.

The end result is more reliable restoration of nasal patency.13 Septal surgery (rarely indicated in the child) but may be considered in the presence of a marked nasal septal deflection with impaction. Conservative septal surgery in growing patients will not have an adverse effect in dentofacial growth.7,18,19,20 Maxillary expansion (RME or SAME) – an orthodontic procedure that widens the nasal vault.7,18 (Figure 14).

Cryosurgery or electrosurgery – this is a viable option for patients with vasomotor rhinitis.7 Bipolar Radiofrequency Ablation (allergic rhinitis) – performed under local anesthetic Inferior turbinectomy – Using powered instrumentation Use of nasal sprays.

Conclusion

The effect of adenoids on facial expression, malocclusion and mode of breathing has been a topic of debate and investigation by practitioners in the field for the last one hundred years. A review of the literature exposes several theories.

A healthcare provider, with a practice philosophy based on prevention of malocclusion development, cannot ignore the early years of the patient’s growth cycle. By age twelve, 90 percent of facial growth has already occurred. This is the age when many practitioners begin orthodontic treatment.7 This is the age when 80-90 percent of craniofacial growth is complete, so most formation and/or deformation has occurred.21 To wait until 90 percent of the abnormality has occurred, before beginning treatment, is not consistent with a preventive philosophy.

Interceptive measures must be initiated sooner. Early intervention requires an ac-

BIGGERpicture Fig. 15a: Frontal before

Fig. 15b: Frontal after

ceptance of a multidisciplinary approach to total patient health. An integrated approach to patient evaluation, diagnosis and treatment is most effective. Primary care physicians, dentists, allergists, otorhinolaryngologists, and orthodontists must all work together for early prevention and management of young patients with increased nasal airway resistance.

After diagnosis, a comprehensive risk benefit analysis regarding early intervention must be considered. Although hereditary and environmental factors must be considered, the universal goal is the promotion of proper nasal respiration throughout a child’s early years of facial growth.

Figure 15 (A-F) shows the before and after treatment results of a young girl who had her adenoids removed, then underwent maxillary expansion before full-fixed braces. She was treated as a second opinion against the removal of four premolar teeth to relieve dental crowding.

Fig. 15c: Upper before

Fig. 15d: Upper after

Fig. 15e: Face before

Fig. 15f: Face after

References 1.

Mattar, SE, Anselmo-Lima, WT, Valera, FC and Matsumoto, MA, Skeletal and Occlusal Characteristics in Mouth-Breathing PreSchool Children, J Clin Pediatr Dent 2004 28(4):315-318.

2.

Valera, FC, Travitzk, LV, Mattar, SE, Matsumoto, MA, Elias, AM, Anselmo-Lima, WT, Muscular, Functional and Orthodontic Changes in Pre-School Children with Enlarged Adenoids and Tonsils, Int J Pediatr Otorhinolaryngal 2003, Jul; 67(7):761-70.

3.

Khurana, AS, Arora, MM, Gajinder S., Relationship Between Adenoids and Malocclusion, J Indian Dental Ass., April 1986; 58:143-145.

4.

Pellan, P., Naso-Respiratory Impairment and Development of Dento-Skeletal, Int JO Fall; 16(3):9-11, 2005 5.

Soxman, JA, Upper Airway Obstruction in the Pediatric Dental Patient, Gen. Dentistry July-August; 313-315, 2004.

6.

Ranly, DM, Craniofacial Growth, Dent Clin NA, July; 44(3):457-470, 2000.

7.

Rubin, RM, Effects of Nasal Airway Obstruction on Facial Growth, Ear, Nose & Throat J, May;66:44-53, 1987.

8.

Pistolas, PJ, Growth and Development in the Pediatric Patient, The Functional Orth. 12-22 Winter 2004/Spring 2005.

9.

Enlow, DH, Hans, MG, Essentials of Facial Growth; 5, 79-98, 206, 1996 10. Diamond, O, Tonsils and Adenoids: Why the Delima? Am J. Orthod., Nov. 78(5) 495-503, 1980.

11. Linder-Aronson, S, Adenoids: Their Effect on the Mode of Breathing and Nasal Airflow and Their Relationship to Characteristics of the Facial Skeleton and the Dentition, Acta Oto-laryng Suppl, 265: 5-132, 1970.

12. Casselbrant, MC, What is Wrong in Chronic Adenoiditis/Tonsillitis Anatomical Considerations, Int J Pet. Oto 49(1):S133-S135, 1999.

13. Havas, T, Lowinger, D, Obstructive Adenoid Tissue an Indication for Powered-Shaver Adenoidectomy, Arch Otolaryngol Head Neck Surg: July 2002; 128:789-791.

14. Oulis, CJ, Vadiaka, GP, Ekonomides, J, Dratsa, J, The Effect of Hypertrophic Adenoids and Tonsils on the Development of Posterior Crossbite and Oral Habits, J Clin Pediatr. Dent, Spring; 18(3) 197-201, 1994.

15. Adams, GL, Boies, CR, Papaiella, MM, Boies’ Fundamental Oto. Philadelphia WB Sanders 1978.

16. Ogura, JH, Physiologic Relationships of the Upper and Lower Airways, Ann Otgl Rhinol Laryngol, 79; 495-501, 1970.

17. Vig, PS, Sarver, DM, Hall, DJ, et al, Quantitative Evaluation of Nasal Airflow in Relation to Facial Morphology, Am J Orthod, 79:263272; 1981.

18. Gary, LP, Brogan, WF, Septil Deformity Malocclusions and Rapid Maxillary Expansion, Orthodontist 4; 1-13, 1972.

19. Cottle, MH, Nasal Surgery in Children, Eyo, Ear, Nose and Throat Monthly; 30:32-38, 1951.

20. Jennes, JL, Corrective Nasal Surgery in Children: Long Term Results, Arch Otolaryngal; 79:145-151, 1964.

21. Mahony, D., Page, D. The Airway, Breathing and Orthodontics; Ortho Tribune,8-11.

22. Mahony, D., Linder-Aronson, S. Effects of adenoidectomy and changed mode of breathing on incisor and molar dentoalveolar heights and anterior face heights. AOJ; 20:93-98,2004.

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PRODUCTprofile

GALILEOS® Comfort Plus: The Most Efficient Clinical Workflow in Dentistry

T

his high-end CBCT unit with HD scan mode guarantees the highest image quality with extremely low dose, large field-of-view and integrated FaceScan offers maxillofacial surgeons, orthodontists, radiologists, general dentists and ENT doctors all the options they need for diagnosis, treatment and patient consultation.

GALILEOS Comfort Plus offers advanced features that are easy to use and provide the optimal workflow for your practice.

The optional HD mode of GALILEOS® Comfort Plus ensures the highest image quality for a clear and quick diagnosis, even in difficult cases.

• 15.4 cm spherical volume with MARS • Close-up feature with 125μ resolution for endodontic applications • Lateral and AP/PA cephalometric views • One of the lowest diagnostic doses per volume size available • Stable patient positioning, whether standing or sitting • 14-second scan for minimized patient movement • Seamless workflow integration • Software with superior diagnostic features

At a glance, GALILEOS Comfort Plus offers advanced features that are easy to use and provide the optimal workflow for your practice.

For the First Time GALILEOS Provides True Motion in Cone Beam with SICAT Function - only from Sirona.

New Perspectives for TMD Diagnostics

28 DSP | Spring 2014

PRODUCTprofile

Airway analysis with Dolphin 3D

Introducing SICAT Function – True Motion in Cone Beam

SICAT Function is a revolutionary software solution with an integrated 3D workflow. With GALILEOS and SICAT Function, you can use the patients 3D Cone Beam scan with their acutal recorded jaw motion. This allows for the visualization and a movement oriented treatment plan. The recorded jaw movement can be visualized and reproduced at any location in the dentition or mandible.

Integrated FaceScan

The FaceScan plots the patient’s facial surfaces at the same time the X-ray image is taken. With a realistic image of their own face, patients understand and accept treatment recommendations more readily.

Compatible with Dolphin software

The Dolphin 3D imaging software is a powerful tool for orthodontists and oral maxillofacial surgeons that make processing 3D data from any Sirona CBCT X-ray system extremely simple. Dolphin 3D features tools for on-screen manipulation and analysis of volumetric datasets. Images are easily oriented and rotated, and tissue density thresholds can be adjusted for detailed views of the craniofacial anatomy.

Measurements and digitalization can be

performed in both 3D and traditional 2D views. In addition to Dolphin integration, Sirona CBCT systems are also compatible with other popular orthodontic software programs.

Sleep Apnea

GALILEOS 3D scans can also be used for visualization of the airways. With Dolphin 3D, you can analyze the airway by drawing a border around your selected portion of the volumetric scan; the program will automatically fill in and display all the airway space within that border, then report back telling you the volume of airway space in cubic millimeters. It will also locate, display and measure, in square millimeters, the most constricted spot of that airway. A fast 14 second 3D scan from GALILEOS provides 3D data for your diagnostic needs.

Its ease of use, wide range of functionality and HD imaging capabilities make the Sirona GALILEOS Comfort Plus perfect for your practice.

Integrated FaceScan technology

This information was provided by Sirona.

Sirona and GALILEOS takes SCAN, PLAN and TREAT to another level. To learn more about the GALILEOS Comfort Plus visit Sirona3D.com or contact Sirona at 800.659.5977.

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MEDICALinsights

What’s the Problem with Oral Appliance Therapy for Obstructive Apnea?

by John E. Remmers, M.D.

E

ven though they are preferred by patients with obstructive sleep apnea (OSA) and such patients use them faithfully, mandibular protruding dental appliances (MPDA) are prescribed for OSA only in a small minority of cases. Only 5% of all treated OSA patients receive oral appliance therapy (OAT). That’s right, the rest are treated with continuous positive airway pressure (CPAP).

OAT gets a complete response in treating

48% of patients with OSA

CPAP gets a complete response in treating

00 1

%

of patients with OSA

30 DSP | Spring 2014

MEDICALinsights “Ahah!” you say, “that’s proof that MDs are getting some sort of financial kickback, otherwise why would they consistently prescribe a therapy that patients hate and only rarely use?” Sorry, only a minority of sleep physicians have a financial incentive to prescribe CPAP. This is not a sufficient explanation.

“Obviously”, you say, “this strong bias toward CPAP reflects the physician’s comfort with a treatment that uses air pressure and airflow, most sleep physicians being pulmonologists. Look, CPAP was invented by a pulmonologist!”. Closer to the truth, perhaps; certainly most MDs, whatever their speciality, do not cater to having their hands in the gooey, slimy oral cavity, even with gloves on. But, a gut-level preference for one genre of treatment over another cannot account for the vast disparity in treatment of OSA. OK, let’s have the truth. I believe the reason sleep physicians shun OAT is clearly stated in the recent consensus review commissioned by the ORANGE- registry. A group of international experts reviewed the evidence regarding efficacy of OAT in treating OSA and concluded that “complete response occurs in around 48% of patients”.

Now, here’s a reason not to prescribe OAT, particularly when you realize that CPAP produces a complete response in around 100% of patients. Why would a sleep physician choose a therapy that has marginal efficacy when a completely efficacious option, CPAP, is available? She/he wouldn’t.

Make no mistake about it; this is where the rubber meets the road. The prescribing physician will not be persuaded by counter-arguments, such as, “your patient prefers using an oral appliance” or “your patient will not consistently use CPAP.” No, the physician wants first and foremost to prescribe an efficacious therapy. She/he will worry later, if at all, about adherence to the prescribed therapy.

Dr. John E. Remmers is a well-known figure in sleep medicine, having contributed importantly to understanding of the pathogenesis of obstructive sleep apnea.

He is an inventor of modern CPAP and home sleep recorder technologies. Dr. Remmers has been active in the field of sleep dentistry for 15 years where his principal contribution has been the invention and development of the remotely controlled mandibular positioner, now available as the product MATRx. He works full time for Zephyr Sleep Technologies as their Chief Medical Officer.

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MEDICALinsights This is not an unreasonable stance; you cannot change the intrinsic efficacy of a drug or a medical device. The physician might be able to influence CPAP compliance somewhat by interacting with the patient or selecting a more suitable interface, but she/he cannot make a MPDA more efficacious. In other words, if the device leaves the patient with an apnea-hypopnea index (AHI) that is elevated, no amount of interacting with the patient will bring it into a normal range.

For the first time, we now have an alternative to CPAP, a therapy with similar efficacy and, likely, higher compliance. For patients who prefer OAT, we have a therapeutic option that is certainly as good as CPAP, probably better. And, this appears to open a new chapter in dental sleep medicine, one where use of OAT for OSA will increase from 5% to a much higher value.

But all is not lost. We can increase the overall efficacy rate for OAT since half of all OSA patients experience a completely adequate therapeutic response.

Perhaps, we could treat only those who respond fully to OAT if we could identify them in advance, i.e., we could achieve a very high efficacy rate if we could select for OAT those patients who will experience a therapeutically satisfactory response. This approach has been taken by a number of investigators, and the search for methods for patient selection for OAT has become a search for the Holy Grail of our field.

The Holy Grail has proved elusive, however. Clinical features such as AHI and BMI have not been found to accurately predict whether or not an individual patient will experience a satisfactory therapeutic response. Similarly, imaging the pharyngeal airway or quantitative evaluation of bony features or soft tissue of the head and neck have not been shown to be predictive of therapeutic outcome. While much research remains to be carried out with these meth-

32 DSP | Spring 2014

ods, the results to date have been disappointing.

Over the past decade we have taken a more direct approach. Rather than searching for some feature or characteristic of a patient that would predict therapeutic outcome, we have moved closer to the phenomena we are trying to predict. Specifically, we have developed a polysmnographic test that examines a patient’s breathing while using an adjustable MPDA. This allows us to evaluate the response of the patient’s sleep apnea to precisely the therapeutic intervention of interest, mandibular protrusion. The test uses a temporary appliance so that if mandibular protrusion is found to eliminate sleep apnea, a custom-fitted MPDA can be fabricated and set to a target mandibular position found to be efficacious.

We have carried out three prospective clinical trials using such a test, and all have shown that the approach has promise. The most recent was performed on 67 patients using the commercially available system, MATRx (Zephyr Sleep Technologies). The results revealed that the test has high predictive accuracy for identifying favorable candidates for OAT. Specifically, all patients predicted to experience therapeutic success with a custom-fitted MPDA (Somnodent) had an AHI value less than 10 hr. Thus, we now have a highly accurate method for selecting apneics for OAT, and for these individuals the efficaciousness rate approaches 100%. And what about the target protrusive position, was it efficacious? Yes, in 87% of cases the mandibular protrusion that was efficacious in the MTRx titration study was sufficient to yield a successful therapeutic response.

What are the implications for managing sleep apnea? For the first time, we now have an alternative to CPAP, a therapy with similar efficacy and, likely, higher compliance.

For patients who prefer OAT, we have a therapeutic option that is certainly as good as CPAP, probably better. And, this appears to open a new chapter in dental sleep medicine, one where use of OAT for OSA will increase from 5% to a much higher value.

But, rest assured that this will happen ONLY if OAT is 100% efficacious; sleep physicians will continue to ignore OAT until they adopt the MATRx system.

CEfocus

Dental Sleep Medicine…

What course or seminar should I take?

by Ashley Truitt

S

o you have been to a few Snoring or Sleep Apnea presentations and learned enough to know there is an epidemic out there and Dentists are in a prime position to identify patients at risk and offer therapy alternatives. Are you ready to take the plunge and jump in? Would you like to learn more about how you can help your patients and people in the community have a better quality of life and in some cases make significant life changes? Great!

Because there are many people out there suffering with untreated Obstructive Sleep Apnea (OSA) who need you!

My Dental career started as a Clinical Assistant and progressed to being the Practice Manager of a busy dental practice in Sydney, Australia. After 4 years in the den-

tal practice I ventured into the commercial world of Functional Orthopedics and Orthodontics, managing a well-known continuing education curricula in Australia, Asia and the United Kingdom. Functional Orthopedics gave me a great understanding of the “airway” and the positive effects that therapy can have on a patient’s ability to breathe well. This is what catapulted me into the world of Dental Sleep Medicine some 10 years ago where I was fortunate enough to have been appointed as one of the founding executives of an Australian medical device company that started in 2004 and launched in the USA in 2006.

Now as the Manager of the Sleep Complete initiative for Henry Schein Dental, I find myself in a rapidly growing and rewarding industry. To give you an idea, I remember the very first American Academy of Dental

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CEfocus

Today I see many highly successful Dentists effectively implement OAT and go on to build a solid Dental Sleep Medicine practice.

Take a little time to research, make a plan and agree on a unified commitment with your Team.

Sleep Medicine (AADSM) annual meeting I attended as a vendor in Denver, Colorado 2004 there were around 12 vendor exhibitors, 10 years later we will see approximately 80 vendor exhibits in 2014!

Therapy options have been limited in the past and some what restricted for sleep apnea due to diagnostic guidelines and reimbursement policies which often led patients down a path without treatment alternatives.

Generally they were prescribed therapy that was either not suitable or tolerable. A fair percentage of the population found themselves not knowing which direction to go next, and they had no idea who would be able to help them with an appropriate therapy. These barriers have now been diminished due to a number of developments. Firstly, there is now a wide scope of clinical research published that demonstrates the positive effects of oral appliance therapy (OAT), in addition to a highly receptive and prolific industry providing products, solutions, services and technology. Public awareness of the potential dangers of snoring and sleep apnea along with all of the associated disease has become a hot health topic to report on, and Dentists are at the forefront of therapy options. “A Medical Disease with a Dental Solution” says it best!

You have made the decision…

Where to go from here?

Continuing Education in Dental Sleep Medicine is offered widely across the United States by a number of different companies, organizations and speakers.

In planning your educational strategy and finding a seminar that is best suited for you and your practice, check into our industry organizations. These organizations are dedicated to improving patient care through education, maintaining the industry guidelines pertaining to Sleep Medicine and are strongly supported by the market leaders to assist you in the integration of

OAT into the general dental practice.

Industry meetings are a cost effective and exciting way to experience some of the key opinion leaders on the Dental Sleep Medicine lecture circuit. You will be able to see a number of short courses and identify with content and speakers that you would like to learn more from before making the commitment to a complete and integrated course for you and your Team.

A very new site that may be helpful to you is www.ratece.com. There are a number of programs listed on this site where you are able to see unbiased testimonials and ratings from prior attendees. This is also where you will find the Henry Schein Sleep Complete Courses listed. I am looking forward to seeing our testimonials grow as the site gains more members and traction! You can also visit www.sleepcomplete/ education programs.

In the past I have met with a number of Dentists who invested heavily in a dental sleep medicine program for their practice that came with the promise to deliver a host of new patients and a big revenue stream. In some cases this did not transpire and as an end result I saw disappointment, frustration and discontentment in their investment. This should not be the case in today’s environment! Today I see many highly successful Dentists effectively implement OAT and go on to build a solid Dental Sleep Medicine practice. Take a little time to research, make a plan and agree a unified commitment with your Team. Do some homework and look for a Webinar to help kick start your learning curve as there are plenty available at sites like www.vivalearning.com. Invest in education for you and your Team before making purchase decisions, understand the products that and services that are necessary (what you need for success), and finally make sure you have time to integrate a new treatment protocol into your practice. Let’s face it: the dentistry

Dental Sleep Industry Organizations

• American Academy of Dental Sleep Medicine – www.aadsm.org • American Sleep & Breathing Academy – www.americansleepandbreathingacademy.com • American Academy of Cranio Facial Pain – www.AACFP.org

34 DSP | Sping 2014

CEfocus Course Objectives You Should be Looking for:

• Screening for Obstructive Sleep Apnea in the Dental Practice o How to identify patients at risk; screening questionnaires, home sleep tests, subjective analysis.

• Patient Evaluation with Home Sleep Testing (HST) and attended Polysomnogram (PSG) Studies. o Understanding the diagnostic pathway utilizing HST & PSG according to the industry guidelines and reimbursement.

• How Does Oral Appliance Therapy Treat Obstructive Sleep Apnea? o Gaining understanding of oral appliance therapy, who to treat and who not to treat.

• Oral Appliance Designs and Fabrication o Many to choose from, understanding the appliance selection criteria for your patient’s needs.

• Implementation of Systems, Office Flow and Integration into Your Practice o An integral part of the process for the entire Team to learn.

• Documentation, Medical Billing and Reimbursement for the Dental Practice o A must for the Front Office Team.

• Marketing Your Dental Sleep Medicine Practice o Internal and external marketing strategies.

• Communicating with Physicians and Sleep Laboratories o Understanding the importance of a multi-disciplinary approach and how to achieve it.

is not difficult, this is much about systems, processes and communication.

All of the above are important facets in building a cohesive, successful and rewarding OAT practice, and you may need to go to a few seminars to gain the confidence in gathering all of the pieces of the puzzle.

Your Dental Team - An Integral Part of Implementation and Ongoing Success!

This is where the rubber meets the road.

If you are serious about implementing a successful Dental Sleep Medicine program into your practice IT IS ESSENTIAL that you include and empower your Team! Give them the knowledge, tools and responsibility they need to be able to support you in treating patients requiring therapy. OAT can be a great adjunct to the dental practice. It is rewarding, fulfilling and profitable. Choose a select few Team members and take them to a seminar. Choose one that encourages team participation as a part of the curriculum. You will need someone from your front office to learn about scheduling, documentation and medical billing

for successful reimbursement. A Hygienist and Clinical Assistant will be of great value as they will learn how to detect and recognize patients at risk for OSA to engage in discussion and gain case acceptance.

From the front office to the operatory, it is a TEAM EFFORT all the way.

There are also a number of online CE courses and programs being offered. This can be a great way for the practice to learn and is particularly powerful as a post seminar exercise to continue and solidify your educational experience. Certainly there are advantages to online learning, including eliminating the financial burden of travel expenses. However; if you are anything like me, then the advantages of learning in a seminar environment with colleagues and vendors maximizes your education experience overall.

This is a great time to get involved in one of the fastest growing industries in the dental arena, so jump on board and get started today! I look forward to reporting on more CE opportunities available to you in the next edition of Dental Sleep Practice as you begin and or continue your journey.

If you are serious about implementing a successful Dental Sleep Medicine program into your practice IT IS ESSENTIAL that you include and empower your Team! Give them the knowledge, tools and responsibility they need to be able to support you in treating patients requiring therapy.

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PRACTICEmanagement

How to Implement

New Initiatives

in Your Practice!

(An antidote for the “Coat Rack Syndrome”) by Amy Morgan

W

hether you are getting ready to introduce Oral Sleep Appliances into your practice, purchasing a cone beam scanner or preparing to go completely paperless, I am sure that you and your team are agitated by mental pictures of practice changes that have failed in the past. At Pride institute, we call this the “Coat Rack Syndrome”. The syndrome occurs when a dentist spends lots of resources to purchase and implement the latest, coolest piece of technology and three months later it is sitting in the corner of an operatory gathering dust and patients’ coats. Very rarely is the new equipment the reason behind the lack of implementation. Most often it is the integration strategy that is at fault!

There is not one office that has not encountered some change resistance and lack of success when it comes to new innovation. So the question is not how do we survive the pain and itch of the syndrome, the question is how to pro-actively avoid the syndrome all together!

Start with a Clear Picture of what has been and what will be!

Before you whip out a credit card or loan application for your next investment in upgraded technology or clinical, management or marketing skills, it is vital to answer the following questions: Why do we need to innovate?

What specific improvement will meet our needs?

When do we expect to see a return/or ideal outcomes from this improvement?

How will we implement the strategy from introduction to mastery?

Who amongst my team/patients will be impacted during and after the improvement?

Once you have a clear answer to these questions, then and only then are you ready to set your five-step strategy for success.

36 DSP | Spring 2014

The Five-Step Strategy

1. Develop and Communicate Your Vision for the New Innovation 2. Define and Plan for a Realistic ROI 3. Partner/Train Your Team and Be Prepared for Change Resistance 4. Talk to Your Patients (market effectively)!

5. Anchor the New Culture by Celebrating Success Let’s apply these five steps to a case study in introducing sleep apnea solutions into a mature, general practice. Meet Dr. Newday! She has a thriving practice in a suburban setting, twenty minutes outside a major city. She has been in practice over 15 years and as of last count has an active patient base count (anyone seen for anything over the last 18 months) of over 1800. She’s running nine hygiene days a week and her patients are interested in all aspects of functional and cosmetic oral health solutions. Part of Dr. Newday’s overall vision is to continuously strive to improve and innovate by offering state-of-the-art, high-tech, high-touch solutions that exceed her patients’ expectations. To support her vision, she has decided to research the possibility

PRACTICEmanagement of introducing oral sleep appliances as a new service offering for her new and existing patients. She starts her exploration by applying The Five-Step Strategy.

Develop and Communicate Your Vision for the New Innovation

Dr. Newday knows that a majority of her practice falls into the baby boomer demographic. She has been doing her research and is aware of the percentages of that demographic who may be suffering from some form of sleep disorder. Her vision and brand promise is to provide new solutions that support her patients’ desire for ideal oral and overall health. Therefore, implementing oral appliances that support the treatment of sleep apnea is a logical next step. She announces this to her team in her annual strategic planning meeting and brainstorms with them an action plan for implementation.

Define and Plan for a Realistic ROI

In that same meeting the team reviews the “wish list” budget for the year. They explore all the costs involved in training and implementing sleep solutions into the practice and set an appropriate timeline of six months, to be fully “up and running”.

Dr. Newday clarifies that the return on investment she is looking for is not just an increase in productivity and profitability to offset the costs of this new offering. She is also very interested in attracting a new target profile patient who will be inspired to come to the practice for both their sleep apnea needs and also become an enthusiastic, general dental patient. The team sets a goal of starting 25 new oral appliance

Amy Morgan is CEO of Pride Institute, a nationally acclaimed results-oriented Practice Management consulting company. Amy and her team of highly qualified consultants have revitalized thousands of dental practices using Pride’s time-proven Management Systems, resulting in dentists becoming more secure, efficient and profitable.

Pride Institute, founded in 1976, is dedicated to substantially improving doctor’s professional, financial and personal lives. Specifically, Pride has taught over 20,000 dental offices how to excel in effective Leadership, Staff Management, Treatment Presentation, Scheduling, Patient Financing, Cash Flow/Goal Setting, Social and Traditional Marketing and Transition Strategies. For more information, please contact the Pride Institute at 800-925-2600 or info@prideinstitute.com.

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PRACTICEmanagement People get busy getting busy and unfortunately, it erodes enthusiasm and commitment. The key is to be hyper vigilant in celebrating the incremental efforts large and small.

patients, $90,000 in increased productivity, by the end of the year as the statistical interpretation of initial success.

Partner/Train Your Team and Be Prepared for Change Resistance

Dr. Newday knows that leadership is something you do with people, not to people. She began the process of creating what the famous author on change, John Kotter, refers to as a “guiding coalition” the minute she called the initial meeting and invited full team participation. For the training plan, the team starts by looking at which office systems would be impacted by introducing sleep medicine solutions into the practice.

The systems impacted include: scheduling, insurance (medical vs. dental), financial arrangements, clinical evaluation, treatment presentation and, of course, the actual delivery of the appliances themselves. Each individual’s job description tasks are updated and prioritized and coaching plans for training, practice and mastery are put in writing, with expected dates of completion.

Talk to Your Patients (market effectively)!

In a separate marketing meeting, the team creates a strategy and calendar to generate awareness, engagement and commitment regarding sleep apnea solutions for new and existing patients. They look at internal marketing strategies including ed-

The Five-Step Strategy to Implementing New Initiatives

1. Develop and Communicate Your Vision for the New Innovation 2. Define and Plan for a Realistic ROI 3. Partner/Train Your Team and Be Prepared for Change Resistance 4. Talk to Your Patients (market effectively)!

5. Anchor the New Culture by Celebrating Success

38 DSP | Spring 2014

ucation in the continuing care department, e-newsletter articles, brochures and testimonials in the reception area and postings online. They make plans to upgrade their website to include a sleep solution tab and set up focused Facebook and Twitter posts, as well as creating You Tube educational videos and patient testimonials. They also work with the company that supplies the sleep appliances to create material for an outreach campaign. These are sent to the local medical community who are directly involved in sleep medicine, generating referral sources. The Dr. and team feel the plan will help them achieve their goals for the year.

Anchor the New Culture by Celebrating Success

No matter how excited a Dr. and team may be in implementing new technology or clinical innovations, change resistance is real. People get busy getting busy and unfortunately, it erodes enthusiasm and commitment. The key is to be hyper vigilant in celebrating the incremental efforts large and small. Dr. Newday knows that she has to catch the team doing things right, almost right or not completely wrong because what gets acknowledged gets repeated. As part of their budget, the team knows that there is money allocated for reward and recognition for both individual and group achievements. They have brainstormed the type of rewards that they enjoy and have statistical interpretations of success points to tie the rewards to. As patients begin to achieve results, it is also vital to celebrate their success as part of the on-going awareness campaign. If Dr. waits till the end of the year to say thank you, she will be waiting a very long time….

With careful application of these five steps, Dr. Newday avoids “Coat Rack Syndrome” and more importantly gets to provide patients a solution that truly is a life-changer! The Pride Institute constantly hears messages of frustration and doubt when it comes to implementing new skills and strategies. Our message to you is if you “fail to plan, you are planning to fail”. Plan well and there is every reason to believe you will succeed!

PRACTICEmanagement

Why Dental Sleep Medicine is Important to Rose

T

his inaugural issue of Dental Sleep Practice profiles several pioneers in our field. Establishing the practice of dental sleep medicine includes connecting with medical billing, something quite foreign for many dental offices, even today. From the early days, no one has done more to help bridge this gap in process more than Rose Nierman, RDH, CEO, Nierman Practice Management and DentalWriter™ Software. DSP asked Rose to share some perspective with our readers: You’re a pioneer in teaching dentists medical billing skills for sleep apnea appliances. How did you get started?

Sleep DentalWriter screen

40 DSP | Spring 2014

A visit to the dentist is not just about your teeth anymore. Dental professionals can now help save lives and assist patients with medical insurance reimbursement for oral appliances for obstructive sleep apnea (OSA). I’ve had the honor of working with dentists who treat orofacial pain and obstructive sleep apnea for many years. Starting around 1980, I was actively billing medical insurance for a progressive dental practice treating temporomandibular disorders (TMD) and sleep

breathing disorders and we saw the importance of collaboration with our patients’ physicians. I realized we were treating medical conditions with dental solutions and we wanted to rule out other conditions for our pain patients, so working with physicians became very important. The insurers would reimburse for our services as a medical necessity when the claim was sent with the proper narrative reports. Frankly, not much has changed since then regarding the need for narratives of medical necessity. The first medical billing manual for dentists was written by me in 1988 and many dentists have seen the benefit of assisting patients with medical reimbursement so that their patients can gain access to these important treatments. A need for a system was realized and our developers created DentalWriter™ software in 1990 for medical claims, insurance narratives, documentation and progress reports to physicians.

You have a real passion for assisting dentists in helping their patients have access to this important treatment.

It is rewarding and exciting to be on the leading edge of the nationwide explosion and acceptance of oral appliance therapy (OAT) and to be able to work with others

PRACTICEmanagement in the profession to create change, promote laws, and establish rules regarding insurance reimbursement, which can have a positive effect on the entire profession for years to come.

Snoring and insomnia was something that was laughed off in my family but we all know apnea is no laughing matter and can contribute to depression, cognitive disorder, daytime sleepiness, heart arrhythmia and stroke, all of which affected my father.

Sleep-breathing problems became a passion for many of us in the dental profession after observing family members and patients struggle with symptoms that which could have been resolved by consultation with a sleep physician and appropriate treatment.

It makes such a difference in an individual’s life to get diagnosed and treated.

Whether the treatment is Continuous Positive Airway Pressure (CPAP), surgery or an oral appliance, it’s exciting that each dentist I work with may add quality years to the lives of hundreds of patients. By helping dentists assist their patients with medical insurance, I can help more individuals than if I worked in one dental office.

How frequently are oral appliances for OSA reimbursed through medical insurance?

A turning point in reimbursement was Medicare’s approval of oral appliances for OSA in January of 2011. Once Medicare approved oral appliances as medically necessary, many commercial insurers developed policies for reimbursement under the category of Durable Medical Equipment (DME).

90 percent of commercial insurers are reimbursing for oral appliances, according to Nierman Practice Management’s 2013 survey of dentists who are billing medical insurance.

Are Medicare and commercial carriers billed the same codes and fees for OAT?

Both Medicare and commercial carriers reimburse for HCPCS code E0486, for a custom-made oral appliance for OSA. There are some differences between commercial carriers and Medicare. Keep in mind in order to bill Medicare for oral appliances, the dentist must enroll as a Medicare DME supplier. Under Medicare guidelines, the patient must have a face-to-

face exam with a physician prior to placing an oral appliance and meet other documentation requirements. According to the Medicare Part B contractor Palmetto GBA, Medicare bundles the initial exam and radiographs into the OSA appliance code as figure 1 illustrates.

Jurisdiction 11 Part B HCPCS E0485-E0486: ORAL DEVICES FOR OBSTRUCTIVE SLEEP APNEA HCPCS codes E0485 and E0486 describe oral devices or appliances used to reduce upper airway collapsibility, adjustable or non adjustable, prefabricated (E0485) or custom fabricated (E0486). These devices are typically used to treat obstructive sleep apnea. Both codes include all fitting and adjustment. These are codes reimbursed as Durable Medical Equipment by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Medicare claims related to the fitting, initial/subsequent adjustments, and repairs of an oral device should be submitted to the appropriate DME MAC and not as Evaluation & Management (E/M) services to the AB MAC. Additionally, any radiological or other services performed in order to guide the adjustments of the oral device should not be submitted separately to the AB MAC, as the Medicare Program payment associated with HCPC Codes E0485 and E0486 already includes any required adjustments to ensure a properly fitted device.

Figure 1 Medicare Jurisdiction 11 Part B Policy

You mentioned that oral appliances for sleep apnea are covered as DME. Are TMD appliances reimbursed as Durable Medical Equipment?

It’s interesting that appliances used to treat TMD are not covered as DME, as a rule. The medical code that is most descriptive for TMD appliances is HCPCS code S8262, defined as Mandibular orthopedic repositioning device, each. This code was placed in the “temporary codes” of the CPT/HCPCS procedure coding manual, not the DME category. Nonetheless, insurance carriers do tend to accept the S8262 for orthotics. It’s important for dentists to know that TMD medical codes beginning with “2” may be considered surgical codes by the insurer for removable orthotics (for example CPT 21110, interdental fixation device).

Narrative screen

Sleep narrative for insurance

What’s the most important thing you can pass on to dentists billing medical for OAT?

Document, document, document! If it’s not written down, it doesn’t exist!

CEO of Nierman Practice Management, Rose Nierman is the creator of DentalWriter™ and CrossCode™ Software and a provider of seminars for Implementing Dental Sleep Medicine and Cross-coding from dental to medical insurance. Rose’s systems and teachings have helped thousands of dentists grow their practices through the implementation or expansion of Dental Sleep Medicine, TMJ treatment and oral surgeries.

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PRACTICEmanagement

Physician’s written order for oral appliance

Our company created the medical billing and report/letter writing software because we saw a need not only for medical billing, but for documentation. Dentists also need to keep physicians in the loop and send initial reports of findings and progress reports.

SOAP narrative reports are created from an online or paper questionnaire and exam and document patient subjective complaints, objective exam findings, assessment and the plan.

For oral appliances for OSA, documentation also includes a sleep study, the beneficiary’s signature showing proof of delivery, a physician written order and other items required by insurers. For Medicare patients, records are kept on file including documentation that a Medicare approved appliance and laboratory were used.

Medicare’s guidelines, outlined in the LCD for Oral Appliances for OSA, spell out additional specific documentation requirements and should be followed in detail.

What tools do dentists need when billing medical insurance?

Dentists need comprehensive solutions and tools for Dental Sleep Medicine (DSM) that maximize reimbursement while minimizing risk. Medical coding and reimbursement skills are essential to DSM practices as well as systems for documentation and communication with physicians. Getting the word out to patients is an important component and requires a well thought out patient education program.

Providing sleep apnea appliances is a team approach with the physician as the “quarterback” of the team. A diagnostic sleep study and follow up sleep study, after the appliance is calibrated, are needed.

Many physicians are impressed with the recent literature concerning the effectiveness of sleep apnea appliances and refer to dentists to provide these appliances for their patients who cannot use CPAP. Physicians may refer more easily to qualified dental practices that are trained to bill medical and help their patients with reimbursement.

It’s important that billing is done correctly and ethically and to have your “ducks in a row”, which is our company motto. The support, care and services provided by Nierman Practice Management is something we want dentists to be able to count on.

42 DSP | Spring 2014

LEGALledger

s n o i t c u “Introd Please”

by Ken Berley DDS, JD, FAGD, FICOI

I

bet you have never spoken to an attorney that understood what you go through on a daily basis and could identify with your struggles. Without understanding the plight of practicing dentists, it is hard for an attorney to be an effective advocate. Generally, attorneys don’t know how or what to do to help a dentist. Therefore, the typical strategy applied by most attorneys is to help you get out of trouble, not prevent the calamity in the first place.

I am a licensed attorney in Arkansas and Texas, but most importantly, I am a wet fingered dentist with over 30 years of dental experience. Just like you, I go to my dental office each morning. So, I understand what you are going through and I am on your side! It is my personal goal in this quarterly column, to keep YOU out of trouble! How am I going to do that, you ask?

In every article I will discuss an issue in sleep medicine that is bothering me from a legal prospective. If it bothers me as a DDS/JD, trust me, it should bother YOU! Let’s fix the problem before a lawsuit is filed not afterwards!

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LEGALledger

Good attorneys are paid well to worry.

They spend countless hours playing the “what if game!” It is a well known fact that everyone wants to avoid all legal risk, but unfortunately, if you own a car, home, business or practice any profession, avoiding all risk is impossible. The concept of risk management was birthed as a result of the “what if game.” What if: one of my sleep patients’ falls asleep while driving, can I be sued? What if: one of my patients’ complains to Medicare, what are my risks?

What, if anything, can Medicare do to me?

What if: one of my patients complains to the State Board of Dental Examiners, what is my true scope of practice and what are my legal rights? What if: I end up in court defending a malpractice claim; could a Sleep Physician testify against me regarding my (dental) standard of care? In this column we will delve into the many areas where risk abounds in the Dental Sleep Medicine arena.

Rarely is an attorney given a forum to express his opinions without a face-to-face encounter with an opposing attorney dogmatically arguing the counterpoint with great zeal. However, I have been given a unique opportunity and permission, to pontificate to my heart’s desire in this quarterly column. I feel that I am equal to the challenge and accept this opportunity with open arms. This column provides me with a platform to voice my opinion and draw attention to those areas that concern me legally. So let the pontification begin!

And for those who might not be familiar with the term pontificate it means to: Dr. Ken Berley is a practicing general dentist with over 30 years of private practice experience focusing on complex reconstruction and 20 years of experience as an attorney licensed to practice law in Arkansas and Texas. He has extensive experience as a litigator and was a full partner in Travis, Borland and Berley, Attorneys’ at Law before moving to Northwest Arkansas.

Dr. Berley lectures in the area of sleep medicine risk management. He has provided TMD treatment for many years and has incorporated Sleep Medicine in his office for the last 3 years.

44 DSP | Spring 2014

“talk in a dogmatic and pompous manner.

To pontificate properly, you need to be a know-it-all with very strong opinions and the urge to share them.” No definition could describe me better. As you are hereby and forever forewarned, and with that introduction, I will let the concerns of my inner being loose with reckless abandon.

“Cry Havoc, and let slip the dogs of war!”

To start the discussion, I want to address an issue that needs immediate attention. I personally don’t like, and don’t use, the AADSM Informed Consent! While the AADSM consent form is better than some that I have read, it is seriously flawed in two areas: (1) The AADSM Informed Consent does not provide a place for a witness to sign the document! It is imperative to have a witness sign the informed consent to identify the member of your staff that witnessed the patient sign the document. More importantly, you need to know who was present in the room with the patient answering any question the patient might have. You should have the witness (staff member) go over the document with the patient asking the patient if they understand each paragraph.

You should establish this routine within your office so your witness can testify to the office policy and routine regarding obtaining informed consent. The witness (staff member) can testify to any specifics that they can remember about the patient in question, then back this up with details regarding office policy and routine. It is my office policy to personally question the patient about any lingering questions that they might have.

When all questions are answered, I sign the document in the margin.

(2) The AADSM Informed Consent does not ask the patient for explicit consent. The only place in the form that uses the word “consent” is in the title of the document.

Therefore, if you use the AADSM document you are relying on the doctrine of implied consent to provide treatment. In my “opinion, opinion, opinion” as my friend JT says, it is imperative for the patient to affirmatively agree and consent to the treatment.

The last two paragraphs of the consent that I drafted for use in our office states as follows:

LEGALledger

WHEREFORE: I give my consent for the treatment of my OSA using a mandibular advancement device (MAD). I agree and consent to allow Dr. Berley and his staff to examine my mouth, teeth, jaws, gums, and associated structures. I give consent for the taking of x- rays, photos, impressions and any other procedures necessary for the treatment of my OSA. I, also, give consent for a home sleep study, if necessary, for the adjustment of my appliance. I consent for the contents of my record to be shared with my physician and insurance company.

I affirm that I have read this document and have been given adequate information regarding the treatment of my condition to give my informed consent. I understand the proposed treatment of my OSA using MAD therapy and I have been given the opportunity to ask questions. All my questions have been answered and I am ready to proceed with treatment.

Patient Signature:___________________________ Date:___________ Print Name:_______________________________________________ Witness:__________________________________ Date:___________

The informed consent document is your “get-out-of-jail-free card!” In my 34 years of practicing dentistry and 20 years of practicing law, I have never had a patient refuse to sign an informed consent. So why not use this document to the fullest extent possible. Put any and everything possible in this document. My Sleep Informed Consent mentions “DEATH” more than once. This form can be the document that stops a malpractice suit or at the very least, presents a significant obstacle to overcome in finding a dentist to be medically negligent.

With that in mind, I am placing a copy of my sleep informed consent on my web site (DrKenBerley.com) if any of you are interested in downloading a copy. It does not have a copyright and you are free to adapt it to your needs. Additionally, please join me in encouraging the AADSM to modify this vital document.

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INSIDEtheLAB

Great Lakes Orthodontics: Helping dentists navigate the waters of dental sleep medicine

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mong the clinicians, innovators, and scientists who help establish dental sleep medicine are the laboratory professionals who have stood with the clinicians from the first days. Christina LaJoie and her company Great Lakes Orthodontics have been there from the beginning.

When I reflect back over my 24 years since I began my career in dental sleep medicine, I had no idea how many people suffered from sleep-related disorders. I could have never envisioned the growth of or my involvement in this field.

During the early years of my career, snoring was often considered just a nuisance to be dealt with. Today, we now know that snoring is a symptom of a potentially serious health problem. In fact, snoring and sleep-related disorders affect a significant percentage of the adult population.

My foray into the world of sleep began at Great Lakes Orthodontics, when a doctor named Harry Tepper approached the company with his snoring device, the Tepper Oral Proprioceptive Stimulator (TOPS). The year was 1989 and I was intrigued. At that time, the only snoring device on the market

lab

46 DSP | Spring 2014

was an appliance called the Snore Guard.

It wasn’t long before more sleep appliances were introduced. Dr. Peter George, an orthodontist, invented an appliance named the NAPA (Nocturnal Airway Patency Appliance), a single-positioned mandibular repositioner that is still being prescribed today. The hugely popular George Gauge™ was also developed. This device enables the clinician to have an actual recordable start position, without relying on the patient and the guess work to obtain the interincisal clearance between the upper and lower anteriors.

In 1994, orthodontist Dr. Alan Lowe, one of the most influential clinicians and sought-after authorities in the medical and dental field, took me under his wing. Dr. Lowe, Professor and Chair, Division of Orthodontics in the Department of Oral Health Sciences, University of British Columbia, Vancouver, Canada, had been involved in government funded cross-country clinical trials that bolstered the importance of the KlearwayÂŽ, an adjustable mandibular device. Under his tutelage, I gained a wealth of knowledge that prepared me to educate dentists on how to get started helping their patients with sleep-disordered breathing.

More than two decades later, I now have the satisfying role of coordinating sleep physicians with dentists, further perpetuating the two specialties for the co-management of their patients. My goal is to spread the word about sleep, lecturing with key clinicians on oral appliance therapy and the procedures and suggested devices to enhance and raise the level of care in their practices. I also believe it is critical to stay involved with the Academy of Dental Sleep Medicine, the Associated Professional Sleep Society, the American Thoracic Society, and many study clubs. This presence in the sleep community has allowed dentists to familiarize themselves with our laboratory and sleep-related products.

INSIDEtheLAB

So, how does a dentist get started treating sleep?

Frequently, a dentist will be prompted into treating sleep-disordered breathing by their sleep-deprived patients who are looking for help. Commercials about snoring and treatment devices have flooded the media and have driven consumers to seek relief from their dentists.

Today, Great Lakes has become the “go to” resource for thousands of dentists looking to get started treating sleep. Our team can provide guidance with: records, selecting the best appliances for their patients, insurance and Medicare information, patient maintenance, and what to observe as they titrate patients to their therapeutic position.

When a dentist contacts Great Lakes, we will first explain how the dentist and physician relationship works and what their role is. We will also provide patient and professional information, as well as educational resources. The American Academy of Dental Sleep Medicine (AADSM) offers essential/beginner courses twice a year and is an excellent place to hone skills and keep up to date on the latest trends. The AADSM (at this writing) is the only institution where a dentist can become board certified in dental sleep medicine.

The proper bite is critical

Once a patient has been has been medically evaluated and found to be a candidate for an oral appliance, it is then up to the dentist to choose the appropriate appliance based on what the patient presents dentally and anatomically. Great Lakes will work with the dentist to determine which appliance to prescribe. From a laboratory perspective, we also advise dentists on how to take the proper bite for their specific sleep appliance—a crucial step for successful treatment.

Although dentists are familiar with bite registrations, if the bite is not in a protrusive and accurate alignment of the midlines, it

will be an issue when receiving and seating the appliance. Natural deviations in the midline should also be noted. An improper bite can ultimately affect appliance durability.

Also, vertical opening between the upper and lower incisors is key in the overall fit and efficacy of the appliance. We recommend the George Gauge as a highly effective tool in obtaining a precise record.

Once we receive the bite registration and models, we will evaluate the case and consult with the dentist as needed.

Motivating the Patient

Treatment doesn’t stop once a patient is provided with a sleep appliance. Patient encouragement and education is important for treatment success. Dentists can explain which habits to adopt, for instance, sleeping on their side--or to avoid, such as refraining from alcohol or caffeine a few hours prior to bedtime. It is important to know about medications the patient is taking or other physical conditions, such as a deviated septum—variables that can affect the overall progress with the appliance.

From a laboratory perspective, we also advise dentists on how to take the proper bite for their specific sleep appliance— a crucial step for successful treatment.

Improving Quality of Life

It is truly an amazing feeling when I look around a room at an annual sleep meeting, and see all the doctors who are now helping their patients. To know that Great Lakes has and will continue to play an integral role in this evolution makes me proud. With the right guidance, it is easy to begin treating sleep-ordered breathing and improving the lives of thousands of patients.

Christina M. LaJoie, sleep specialist for Great Lakes Orthodontics, Ltd. is a nationally-recognized advisor and speaker on appliance use for sleep-related disorders. She coordinates and designs protocols with dentists, sleep panels, and insurance companies for the prescribing and therapeutics of sleep appliances.

DentalSleepPractice.com

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SLEEPhumor

...The Lighter Side of Sleep Apnea

48 DSP | Spring 2014

1 2

Patient Scan

Diagnosis

GALILEOS 3D: The Most Efficient Clinical Workflow in Dentistry ™

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Treatment Plan

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Advanced technology that’s easy to use First, perform initial diagnosis using GALILEOS 3D, then proceed to implant planning and surgical guide with the built-in GALILEOS software. Continue with CEREC® for chairside restoration design and fabrication, and you’ve accomplished in a single appointment what would normally take several appointments with any other system.

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Surgical Guide

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CEREC® Integration

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