Dental Sleep Practice - Spring 2015 Issue

Putting It All Together

by Dr. Dale Sorenson

Whole Body Alignment Physical Therapy for TMD

by Kathy Johnson, PT

Spring 2015

Update on Temporomandibular

Disorders

Associated with Airway Restriction

Rose’s Reimbursement Rules

by Rose Nierman

Clinician Spotlight

Supporting Dentists Through PRACTICAL Sleep Apnea Education

Dr. Jamison Spencer

INTRODUCTION

Nothing’s Free

O

ur patients come to us with a need to sleep better, specifically to breathe better while they sleep. They and their bed partners want a quiet, restful night’s sleep. They want the benefit of energy during the daytime, lower blood pressure, and comfort from treating their critical medical condition.

What they don’t ask for, we often give them: complications. Specifically, jaw joint related complications. Pain. Lack of function. Changing bites. Moving teeth. Clicks when they move their jaw. These unwanted guests to the party are inevitable so we must be ready to address them before and during our therapy.

My friends in dentistry basically come in three flavors: Some dentists actively embrace treating temporomandibular disorders (“TMD”), others make nightguards and splints for the patient who grinds their teeth, has headaches, and occasionally complains of jaw soreness. The third kind of dentist knows just where to refer anyone from their practice who mentions anything related to the TMJ. That last category must not include anyone treating airway issues with mandibular advancement devices. When I talk with a dentist who thinks like that in a learning environment, I advise them to get involved with sleep medicine to the ‘screen and refer’ level.

All of us who actually provide MAD to our community must become adept at handling jaw discomfort. This issue of the magazine is focused on helping identify those patients ahead of time, preparing them for what might happen, and what to do if (when) it happens to them. If you need to refresh your mastery of this vital area of health care, there are venues where scientific, reasonable and time proven diagnostic and treatment skills are taught.

If we provide prescribed, appropriate therapy for one problem (SDB) and that therapy triggers another (TMD) what is our obligation as providers? Do we treat the second problem for free? If we diagnose the TMD and

propose a course of therapy to address it, is that not application of our care, skill and judgment, what Dr. Pankey called “Apply your Knowledge?” Is that not worth charging for and being paid? While reasonable doctors and their teams may agree on this point, communications can get a bit bumpy with the unhappy patient, jeopardizing the relationship. Survival depends on everyone on the team being able to Steve Carstensen, DDS build value for the necessary services.

Diplomate, American Board of We never escape the influence of Dental Sleep Medicine ‘who pays for all of this?’ How many times have you heard of insurance getting better, of providing payment for services previously denied? Rose Nierman has some good news for you, if you live in one of 34 states. Dental Sleep Practice provides practical information – such as how to make sure We are doctors you aren’t committing insurance fraud while you’re trying to open the airway – Dr. Ken of the whole Berley tells us how. stomatognathic We are doctors of the whole stomatognathic system. The rewards that accrue from system. changing people’s lives by opening their airways come with the burden of responsibility for managing unwanted side effects. Focusing only on the airway appliance is the way fraught with peril. Embrace the whole and you’ll partner with your team and your patients to see these challenges as merely small problems to solve along the way towards better health.

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

DentalSleepPractice.com

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CONTENTS

10

Cover Story

Update on Temporomandibular Disorders Associated with Airway Restriction

by Michael L. Gelb, DDS, MS, and Payam C. Ataii, DMD, MBA Treating airway affects both health and appearance in all ages

6

Clinician Spotlight

Dr. Jamison Spencer Having fun providing some of the best dental sleep education available

32

Education Focus

Putting It All Together

by Dr. Dale Sorenson Need to brush up on TMD skills?

Pankey Institute is ready to help

Focus on Diagnosis

36 2 DSP | Spring 2015

Temporomandibular Disorders

by Steven D. Bender, DDS What should you be looking for in your sleep patients before you start?

46

Adjunctive Care

Whole Body Alignment: Physical Therapy for TMD

by Kathy Johnson, PT Do you use physical therapy to solve patient’s jaw problems? Maybe you should – find out why

CONTENTS

14

Clinical Focus

Open Airways Open Bites – Important Choices for Patients

by Paul M. McLornan DDS, MS Side effects happen with any medical treatment. Prepare for it.

18

Medical Insights

Mandibular Advancement Devices

by Donald R. Tanenbaum, DDS, MPH The dentist must be prepared for many possible outcomes using MAD therapy. What do you need to know before and during your treatment?

28 Inside the Lab

Magic Happens at the Dental Lab

50

Practice Building

Building Partnerships with Physicians when Treating Craniofacial Pain

by Dr. Mayoor Patel You know what to do; how do you make connections with other doctors?

53 Practice Management The Four Pillars of DSM

What dental lab artists want you to know about starting sleep cases

by Dr. Richard Drake You, your team, and your colleagues must master these steps to make a difference in your community

34 Education Spotlight

56 Team Focus

ASBA Dental Division – A Breath of Fresh Air

I Stopped Snoring, but Now My Jaw Hurts!

Collaborative Care improves when health care professionals learn together

by Glennine Varga, AAS, RDA, CTA Setting expectations in your patients is a fantastic way for your team to help

39 Pharmacology Foucs

58 Practice Management

XyliMelts oral adhering discs in the management of oral dryness associated with treating sleep apnea

by Jeff Burgess, DDS, MSD Don’t forget about other problems like dry mouth. Here’s a way to help lots of your patients.

42 New Devices

Three Night Comparison Study of the BRX Pro™

by Jeffory J. Wyscarver, RPSGT In this case report, a novel bruxism guard improves the airway

4 DSP | Spring 2015

Rose’s Reimbursement Rules

by Rose Nierman The Affordable Care Act adds important coverage for dental services

Spring 2015 Publisher | Lisa Moler Email: lmoler@medmarkaz.com Editor in Chief | Steve Carstensen, DDS Email: steve@medmarkaz.com Managing Editor | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com Editorial Advisors Steve Bender, DDS Ken Berley, DDS, JD David Gergen, CDT Ofer Jacobowitz, MD Christina LaJoie Dale Miles, DDS Amy Morgan John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Glennine Varga, AAS, RDA, CTA

General Manager | Adrienne Good Email: agood@medmarkaz.com National Account Manager | Michelle Manning Email: michelle@medmarkaz.com National Account Manager | Kimberly Burke Email: kimberly@medmarkaz.com Creative Director/Production Manager Amanda Culver Email: amanda@medmarkaz.com Front Office Manager | Eileen Lewis Email: elewis@medmarkaz.com

61 Legal Ledger

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

by Ken Berley, DDS, JD, DASBA Learn how to protect yourself from “foreseeable consequences” – a legal term you need to know

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TMJ – “Don’t Take That Risk!”

64 Sleep Humor

$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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CLINICIANspotlight Did you always see yourself as a teacher?

I have taught in various capacities for years. I have always enjoyed public speaking (and have never understood why most people would rather have a root canal without anesthetic than speak in public--literally). In dental school I worked as a tutor for junior high and high school students in math and science. After dental school I developed a head and neck anatomy program, using the cadavers that were being used in the Kinesiology department, for pre-med and pre-dental students at Boise State University (winners of the 2014 Fiesta Bowl). During that time, I also started lecturing to other dentists on the topics of anatomy, TMD, and sleep apnea. I spoke at dental offices, free public community education courses, support groups, and anywhere else that I could. If I’m a good speaker it’s because I’ve worked at it A LOT over the years.

Your teaching style is unique – it seems you put as much emphasis on being entertaining as you do on the data. Is this intentional or just your nature?

Dr. Jamison Spencer

T

reating sleepy patients often brings us those who have jaw discomfort to go along with disordered breathing.

Having an ability to address both problems together is key to success. This magazine seeks to bring knowledge closer to you and no educator meets this challenge better than Jamison Spencer. You may have experienced one of his practical, informative lectures; Dental Sleep Practice brings you even more you may not know.

6 DSP | Spring 2015

I’ve been a bit of a jokester with a quick wit since I was a child. I’ve always enjoyed making people laugh. I personally HATE boring lectures. I try to mix in humor along with the art and science of what we are doing. I am passionate about helping dentists and others learn more about obstructive sleep apnea and TMJ disorders. There are too many boring lectures on these topics, so I try to be a little different. I’m sure my style isn’t for everyone, but I personally learn better from teachers that are engaging and funny, so I try to emulate this in my teaching style. Also, I’m probably not smart enough to fill my lectures with all sorts of scientific references and actually understand what they mean…so I just keep it simple and try to make it enjoyable.

Your training is in TMD and sleep – how do you see these two areas of health care interrelating?

I took over a practice limited to TMD right out of dental school. Crazy, I know!

My mentor had never treated sleep apnea… at least not intentionally. I became involved with sleep early on, but for many years separated the two fields. I either saw a patient

CLINICIANspotlight for TMD or a patient for sleep apnea. About 10 years ago I finally made the connection that TMD and sleep were often related, and sometimes causally related with the sleep apnea driving the jaw pain and dysfunction.

After I purchased my cone beam CT machine my eyes were further opened as I started to be able to evaluate the airway as part of my regular examination. I have definitely come to believe that one cannot really understand TMD/craniofacial pain without understanding sleep, and that one cannot be completely comfortable treating sleep apnea without understanding TMD/craniofacial pain.

When a patient seeks your care with both sleep and pain complaints, how do you go about beginning to help them? What comes first?

Obviously if the patient is in acute pain we will address that first. An accurate diagnosis is the most critical component to develop any TMD/craniofacial pain treatment plan. While that may seem like a ridiculously obvious statement, I find that most dentists either have no idea what is going on with the patient’s jaw, or what they think is going on is actually wrong (and often times the opposite of what is really happening). Once you are comfortable with your tentative diagnosis, then the next step is to consider the etiology of the condition. If the jaw pain was caused by being hit in the jaw playing basketball, the patient’s sleep apnea most likely is not directly contributing to the current issue. On the other hand, if the patient has more of a chronic issue, has wear patterns on the teeth consistent with grinding or clenching, has scalloping on the borders of the tongue, temporal headaches and/or temporal tendonitis, or other specific signs and symptoms that are consistent with sleep apnea possibly being an etiology of the jaw problem, then we refer for a sleep evaluation…and HOPE that the patient has sleep apnea. If they do, we treat the sleep apnea (CPAP or oral appliance) and hope that their jaw problem improves. Our experience has been that in specific cases where all these things line up, the patient’s jaw discomfort improving with sleep apnea therapy is very common. Of course there are certain things, like internal derangements for example, that may need to be addressed in addition to sleep therapy.

So in an over simplified nutshell, if we believe that the patient’s TMJ problem (this

term, of course, being an over simplification itself) is likely related to an underlying obstructive sleep apnea issue, we refer the patient for evaluation. Depending on their level of pain, in these cases we may perform or recommend palliative therapies while we dial in the diagnosis.

From a very practical view point, sometimes we address the sleep apnea first because sleep apnea therapy tends to be covered by the patient’s medical insurance, where therapy and treatment of TMJ problems, at least where I practice, are only rarely covered. When a patient has sleep apnea and we treat them for it, causing an improvement in their TMJ problem, we find it to be a more financially conservative option for the patient…which most people appreciate.

Who has inspired you?

I have been inspired by a lot of people.

I’ve had the privilege of getting involved in this field right out of dental school, so I tend to be a bit younger than most of my colleagues. I have stood on the shoulders of giants, starting with my mentor Dr. Ed Matthes.

He went through all of the “TMJ battles” of the 70’s and 80’s and I was able to learn from his experience, which compressed decades of learning into days. I have changed my practice paradigm several times, which I attribute to actually applying the things that I have learned along the way. I am a firm believer that there is a huge difference between having 20 years of experience and 1 year of experience that you’ve repeated for 19 years!

My practice has changed dramatically from when I first started, always aiming to improve the care that we provide for our patients and make this care more affordable at the same time. My father taught me through his example to always try to help people and be of service. My profession is how I put food on the table, but it’s also my passion to help people and to inspire others to do the same.

On an ongoing basis I am inspired by my wife Jennifer and our 6 children.

Dr. Spencer sees patients at The Center for Sleep Apnea and TMJ in Boise, Idaho.

One thing many people may not know is that you’re an inventor of a mandibular positioning device. How did this happen?

I was working with a company out of California that was helping sleep labs. The owner of this company was from the Philippines.

He asked me one day if I had any “inexpenDentalSleepPractice.com

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CLINICIANspotlight

Dr. Spencer entertaining another group of learners

sive” options for treating people with oral appliances, because people in the Philippines couldn’t typically afford CPAP or custom oral appliances. I talked to him about the various “boil and bite” appliances that were on the market at the time, but gave him my concerns with these types of appliances. I realized that what I felt was a good, inexpensive, customizable oral appliance option didn’t really exist…so I created one. The Easy Airway, originally called the Silent Sleep, was the result of my attempt to come up with an easy to fit, comfortable, inexpensive, long lasting, non-custom oral appliance that didn’t have the disadvantages I felt the boil and bite appliances had. It was the first device to be fit with a VPS material (GC Reline) rather than a thermoplastic material. Today, for the North American market, I feel that the Easy Airway is just another tool to have in your oral appliance therapy toolbox. However, in areas where patients cannot afford custom fabricated appliances, it provides a needed option.

“I try to inspire others because I hate the thought of people not People who have success at practice, getting the care at manufacturing, at education and they need” now at inspiring a whole network of clinics must have deep-seated motivations and a sense of lack of limitations on ability to make an impact. How would you describe that for you?

As I mentioned above, Jenni and I have 6 children. Most people looking at my travel schedule will wonder how we ever had time to have 6 kids! When I lecture I always start out by showing a picture of my family.

I do this partly because I’m proud of them, but also to remind myself and impress upon others why I am there. Now you’re probably thinking, “if you have six kids you’re obviously on the road lecturing to get away from home and get some peace and quiet!”

But you’d be wrong. I teach, coach, consult and try to inspire others to help more and more patients because I hate the thought of people not getting the care they need. I can only treat so many people myself. I can only pick up on an undiagnosed sleep apnea case in the patients that I see. But if I can spark others to evaluate and diagnose, or participate in the diagnosis and management, of a sleep or TMJ problem my reach is extended to thousands of patients. Over time this will become tens of thousands. With other proj-

8 DSP | Spring 2015

ects I’m working on this may be extended to even hundreds of thousands or millions. That is what drives me. It’s not a matter of motivation or about me, really; it’s a matter of principle and values.

Please tell us what you think about the future of DSM.

I believe the future of Dental Sleep Medicine is extremely bright…unless we screw it up ourselves. Insurance companies are going to drive more patients toward home sleep testing. Auto-set PAP machines will be used more regularly. This is great as it will likely increase the number of patients being evaluated and treated, and will decrease the expense to do so. However, a natural side effect of this will be more people failing PAP therapies, or being in a position were an oral appliance is the logical first line of therapy.

Americans are not getting any thinner…and the rest of the world is following our greasy fingered lead. Sleep apnea is not going to go away; it’s not going to be treated with a pill; and surgeries will only be for a select group of patients. Oral appliance therapy is a logical and efficacious treatment option for many patients. As we become more involved in working with “the medical model” we will also gain the respect of our medical colleagues and learn the needed skills to play the game by the rules that the insurance companies and government have set up. This is the huge advantage that the DME companies have that sell CPAP…they know the rules and have played the game for a long time. We are novices.

The danger lies in us and our sometimes overzealous colleagues inadvertently (or, unfortunately, sometimes on purpose) not playing by the rules and by extension giving every dentist a bad name. I recently had a conversation with a nurse reviewer at a major insurance company about some claims that she had seen. She asked me about a company that mails the patient material to take their own impressions, send them back to the company who then makes them a custom appliance and mails it back for the patient to fit themselves. Imagine this nurse thinking this kind of garbage was what many dentists did! Luckily, she was smart enough to realize that this company is not treating patients at the standard of care that should be expected. I believe that all of us owe it to our patients, our colleagues and our commu-

CLINICIANspotlight

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After coaching dentists for years and leading the Tufts/AACP DSM Mini Residency, I met a North Carolina dentist who owns a large group practice. Dr. Lane wanted to add DSM services but had not found the right match.

After meeting him and his team I offered to teach a few of the dentists and consult from a distance. They wanted me full time – which meant moving from Idaho! I eventually agreed to visit every other week for “a few months.”

Quickly I realized there was a huge opportunity to do something exceptional. My family wasn’t too happy with me being gone so much so we decided as a family to move to Raleigh.

My practice in Boise is in good hands and I spend most of my time now helping the awesome dentists and over 400 staff members of Lane and Associates Family Dentistry. They are literally saving lives and I’m having a blast. My life is blessed and I’m grateful every day.

Dr. Spencer with his wife, Jennifer, and their six children

RE

nities to inspire others to do their best work.

We should become colleagues with the insurance companies and help them to recognize that oral appliance therapy is an excellent option that can be delivered affordably and with predictable results. We are all in this together, and we should strive for excellence and treat everyone like we would treat our own family.

I believe that someday sleep testing will be part of a regular physical and workup for adults, along with a physical exam, taking blood pressure, blood tests and urinalysis. To receive a home sleep study as a screening exam, starting young, will just be the normal thing to do.

Those found to have mild to moderate OSA will be offered an oral appliance or PAP therapy. I hope for a day in the near future where sleep and airway issues are routinely evaluated by the primary care doctors. In the meantime, we dentists are ideally positioned to help in the screening, evaluation and management of adults and children with sleep apnea. These people come in to our offices every day, and it is our responsibility to educate and guide them toward accurate diagnosis and effective management. For children, especially – identifying compromised airways that we as dentists can help grow to normal size – how cool is that?

Can you imagine how much money we would save in the US if we were able to diagnosis and treat OSA BEFORE all of the comorbidities developed or worsened! Treating sleep is one of the most cost effective treatments available, with almost no side effects or morbidity.

U

R O P

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www.SMLglobal.com DentalSleepPractice.com

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COVERstory

Update on Temporomandibular Disorders Associated with Airway Restriction

by Michael L. Gelb, DDS, MS, and Payam C. Ataii, DMD, MBA

W Dr. Michael Gelb is an innovator in airway, breathing, sleep, and painful TMJ disorders pioneering Airway Centric™ — a comprehensive approach to treating patients with airway-related disorders. Dr. Gelb co-founded the American Academy of Physiologic Medicine and Dentistry (AAPMD) and the Foundation for Airway Health, a non-profit, to prevent the proliferation of chronic disease in the U.S. based on airway, sleep and breathing awareness, research and education.

10 DSP | Spring 2015

omen speak in code and men are in denial – I guess that John Gray explains that better in his bestselling book, Men are from Mars, Women are from Venus. So the next time a woman comes in complaining of clicking, painful temporomandibular joints, headaches, jaw, back and neck pain – you need to dig deeper. For instance, cues from the medical history, such as reflux, fatigue, difficulty concentrating and insomnia, are indicative of a sleep disorder. Cone-beam (CBCT) imagery (Fig. 1) will show patient and doctor the airway in 3 dimensions and help evaluate the role of the nose, tongue and soft palate as well as the tonsils and adenoids. Sleep testing provides a definitive diagnosis and is the current gold standard.

Fig. 1 By now, many of us understand the connection between temporomandibular disorders and sleep apnea. Plenty of peer-reviewed articles have shown this connection. However, there is a still a major informational gap and patients are not aware of this connection.

Often times, patients come to us after they have attempted to resolve their headaches

with multiple physicians, medications and even other dentists, to no avail.

With the cases presented in this article, Dr. Gelb and Dr. Ataii plan to show you the correlation of the symptoms reported by patients and how proper identification and treatment of a sleep disorder stabilized the patient.

COVERstory Patient Bryan by Dr. Ataii

Patient Bryan (Fig. 2) was seen after having a long history of TMJ pain and multiple doctors refusing treatment due to the discrepancy of dental arch, open bite, and possible need for a surgical approach of Class III malocclusion and soft tissue pharyngeal involvement. Upon comprehensive examination, patient stated he did not want to have any wire bracket treatment, and had been on upper and lower expanders and myofunctional treatments from childhood. However, the patient did want to have a cosmetic solution for the anterior open bite and to have a better smile line.

Treatment options included splint therapy combined with Invisalign® Clear Aligner treatment. Given his various signs and symptoms, he was judged to be high-risk for obstructive sleep apnea; an evaluation of the airway and a sleep study were recommended.

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    

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  

 • • • • •

      

 •

  

 •  

 •   •  •  •  

Fig. 4: iTero™ Scan of initial Occlusal Contacts  

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

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       

     



 

 

Fig. 3: Pretreatment sleep report

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

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  

 •        •   •  •  •   •   •  •  •  •   •     •    •   •  •  • 

     

Fig. 5A

Fig. 5B: ASA post-treatment sleep report

Fig. 2: Initial

Treatment

Phase 1 addressed patient’s immediate pain with a CR (centric relation) splint therapy for six to eight weeks. In the interim, patient was screened and prescribed a sleep study thru Ez Sleep Home Testing System™ due to reported symptoms of fatigue, spouse complaining of snoring, and gasping for air during sleep, as well as visible indications of a large tongue and Class IV Mallampati. Sleep testing results indicated patient with mild obstructive sleep apnea (OSA) (Fig. 3), however, patient’s bite needed to also be put in proper occlusion, since patient only had 4-6 contact point of occlusion (Fig. 4). Due to patient refusal of bracket and wires, clear aligner

Fig. 6: Final

treatment was suggested using the Invisalign® treatment system. Patient’s physician was also contacted and the patient’s sleep study results were shared with his primary care provider.

An FDA-cleared oral sleep appliance known as the ASA (aligner sleep appliance™) (Fig. 5A) was chosen to be worn at night during sleep while still in treatment with Invisalign.

Dr. Payam C. Ataii has been in practice for the past two decades having treated just under a thousand Invisalign® cases in combination with sleep appliances, of which a portion of the patients utilized the Ez Sleep™ solution. Dr. Ataii has multiple publications in dental journals and has been lecturing for the past decade to over 17,000 of his peers, bringing forth changes in dentistry, where patients can reap the rewards of modern technology.

DentalSleepPractice.com

11

COVERstory Patient Nancy

Fig. 7

Patient Nancy (Fig. 7) wakes up with a headache every morning possibly related to taking out her partial at night. She also has numbness in her face and head as well as her gums, teeth and skull. Shoulder pain radiates into the occipital region. Cervical and masticatory muscles were exquisitely tender to palpation. There was pain in both posterior joint spaces when compressed through the external auditory meatus. On joint auscultation, we found coarse crepitus on terminal closure. The mandible was displaced by 1 mm to the right. Interincisal opening was normal at 42.5 mm. Initial cues pointed to a TMJ and musculoskeletal diagnosis. CBCT (Fig. 8) shows reduced joint space bilaterally, moderate to severe osteoarthritic changes in the left mandibular condyle with an anterior osteophyte. Airway space is somewhat decreased in axial and sagittal views (Figs. 9 and 10).

A lower modified Gelb mandibular repositioning appliance was inserted for

Fig. 8

daytime wear (Fig. 11) and a Farrar anti retrusion appliance was inserted for use during sleep.

Symptoms slowly subsided and 4 years later follow up photos and CBCT were taken (Fig. 12).

The new intercuspal position was still maintained by an appliance due to limited finances, living in Virginia and the ill health of her husband. Pre and post condyle images (Fig. 13) and sagittal and axial airway images (Fig. 14) give us insight into how and why the eyes, skin and face look more vital and glowing. Sleep testing is standard practice in my protocol with an efficacy study at maximum medical improvement 3-6 months later.

Physiological testing such as heart rate variability can also be used to assess autonomic and cardiovascular health. Endothelial dysfunction is also a physiologic metric and a major risk factor for cardiovascular disease.

15 years ago dentists were claiming seemingly incredible results from repositioning therapy which can now be attributed to increasing oxygen saturation and decreasing intermittent hypoxia with follow up sleep testing. Sleep fragmentation or disturbed sleep is also improved as the patient spends more time in stage 3 restorative and REM sleep.

This is verified by either overnight sleep study (PSG) or unattended home sleep study.

Fig. 9

Fig. 10

Fig. 13

12 DSP | Spring 2015

Fig. 11

Fig. 12

Fig. 14

COVERstory An even more dramatic example of AirwayCentric® TMJ protocol is seen in Ellen’s case. She is a 56 year old woman who presented with left TMJ locking, clicking and popping (Fig. 15). Left jaw pain radiates into the left ear and maxillary sinus. A severe aching headache starts in the left eye, ear and sinus and radiates into the jaw and mental nerve region. Nausea, vomiting, phono- and photo-fobia are denied.

Clicking had occurred for 15 years, exacerbated in the last 3 years.

Clinical exam revealed exquisite left cervical and masticatory pain as well as severe pain and compression in the left lateral TMJ capsule and the posterior joint space.

Joint auscultation produced a late closing click in the left temporomandibular joint.

The mandible is displaced to the left by 1.5 mm with interincisal opening of 48.5 mm.

Past medical history includes depression, insomnia, sinus infections/congestion, reflux and fatigue.

Tongue is level 2, Mallampati is class IV, with an elongated uvula. CBCT reveals mild osteoarthritic changes in the left mandibular condyle with decreased joint space bilaterally (Fig. 16). Overjet and mandibular retrognathia were extreme although the airway was not compromised (Fig 17).

Upper and lower repositioning appliances were inserted (Fig. 18). The ramp on the Farrar appliance was modified to prevent the mandible from retruding in the supine position (Fig. 19). Today an unattended sleep study would be performed to diagnose a breathing related sleep disorder and repeated once symptoms were improved.

Facial photos show us changes that are only possible with a profound decrease in systemic inflammation, reduced intermittent hypoxia and improved sleep architecture (Figs. 20-23). An AirwayCentric® orthodontist in NYC treated this case non surgically with unique orthodontic therapy. Orthognathic surgery is an alternative treatment plan.

Diagnostic cues from the medical history, facial analysis, and CBCT often indicate sleep studies should be included in the diagnostic process.

Conclusion

Next time you have a patient complaining of headaches or any sign and symptom of TMD/TMJ, prescribe a sleep study using the Ez Sleep System™ confirming sleep apnea. Note

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

that it is not uncommon for patients to be unaware of the sleep condition they might be suffering from. And, given the high prevalence of TMD in patients who suffer from sleep apnea, addressing the compromised airway will generally lead to happier and more stable patients.

Many dentists believe orthodontic techniques are effective methods to expand the maxilla and mandible to increase intraoral volume, make room for the tongue, and reduce sleep disordered breathing. To achieve the best results with temporomandibular disorders consider maintaining the mandible in a neutral or protrusive position at night to decompress the temporomandibular joints, and increase oxygen saturation while improving restorative and rem sleep.

Best practices require a follow-up sleep test with the recommended oral appliance to ensure control of sleep related breathing events (Fig 5B).

Fig. 20

Fig. 21

Fig. 22

Fig. 23

DentalSleepPractice.com

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CLINICALfocus

by Paul M. McLornan DDS, MS

14 DSP | Spring 2015

CLINICALfocus

I

magine committing three years of your life and money to learn fine occlusion, then be told you are going to mess it all up in some patients.

That was me 10 years ago as a first year Prosthodontic resident who had just been introduced to the use of Mandibular Repositioning Devices (MRDs) to treat Sleep Disordered Breathing (SDB) conditions. I was informed by my dental sleep mentors that in certain patients these devices, with prolonged wear, can cause permanent tooth movement and/or occlusal changes. I also discovered there was evidence in the literature of occlusal changes occurring in some patients with the use of MRDs.1, 2 This fact still does not sit well with me 10 years and many hundreds of satisfied sleep patients later. What is different now is that I have witnessed the profound positive effect that successful treatment of SDB with MRDs has on the quality and quantity of my patients’ lives. I also have learned how few alternative treatment options SDB patients have and how for many a MRD is the only tolerable option. I understand also that the main alternative treatments options, CPAP and Orthognathic surgery, also have significant potential side effects.

During the past several years some of my patients have experienced dental related side effects resulting from long term wear of their MRD. They represent a small percentage of the overall number of patients. Dental changes resulting from prolonged MRD wear described in the literature include reduction in overbite, reduction in over jet, decrease

in mandibular crowding, development of an anterior cross bite and development of a posterior open bite.1 The most common change I have observed is what I call “anteriorization of the mandible”. After wearing the MRD all night, some patients find it difficult to get the mandible into its normal position where the teeth meet in maximum intercuspation. They feel the anterior teeth with increased contact and the posterior teeth not touching at all.

Many patients experience this temporarily on removal of the appliance; for most it either resolves spontaneously or with the help of biting with a repositioner device in place.

In a small number of users, this occlusal change can quickly become permanent.

It is interesting that the majority of my patients with permanent occlusal changes do not notice or report these changes but rather I have identified the change at a follow up appointment. Nearly everyone to whom I have pointed out this side effect has fortunately responded that they remember reading and me discussing with them that risk as part of the informed consent process prior to treatment. I feel this is because I do not shy away from addressing this potential problem up front and laying it out clearly in my written consent forms.

After identifying an occlusion change what follows in my office is an important conversation between the patient and I in which we again discuss the risks versus ben-

Dr. Paul McLornan is a board certified Prosthodontist in private practice in San Antonio, Texas. He is also an assistant professor at the University of Texas Health Science Center San Antonio (UTHSCSA) Dental School. He is a member of the graduate faculty of the UTHSCSA Graduate School of Biomedical Sciences, where he serves as a research adviser to a number of OSA related studies.

Dr. McLornan obtained his dental degree from Queens University, Belfast and his specialty certificate in Prosthodontics from UTHSCSA. The treatment of Obstructive Sleep Apnea (OSA) using oral appliances was the subject of his master’s of science research project during his residency and has been a special interest of his since.

Dr McLornan has lectures extensively at local, national, and international dental meetings and study clubs. He teaches the Dental Sleep Medicine course at the Pankey Institute and is on the teaching faculty of the Dental Institute of Sleep Medicine. He is a Diplomate of the American Board of Prosthodontics and a Fellow of the American College of Prosthodontists. He is also a member of the American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine.

DentalSleepPractice.com

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CLINICALfocus Our patients often rank the ability to breathe when they are asleep as more important than a perfect occlusion.

efits of MRD therapy. I always start this conversation by revisiting the patient’s original chief complaint or diagnosis and compare that their current status, both how they feel (subjectively) and what results the various follow up sleep tests with the appliance in place showed (objectively). We also revisit the alternative treatments that could possibly treat the patient as well as the appliance.

In my experience my patients are better at weighing up the dental side effects risks versus social and health benefits than I am. I, like many other sleep dentists I talk to, are over concerned or too focused on the dental changes because it seems to fly in the face of our dental education and ethics. Our patients often rank the ability to breathe when they are asleep as more important than a perfect occlusion. As one of my mentors Dr. Keith Thornton has said “Breathing trumps eating every time”.

Of course some of these patients want to know how their occlusion can be returned to normal. There are several options available depending on the individual patient’s situation including jaw exercises, physical therapy or manipulation, equilibration/ adjustment of the teeth, placement of fixed restorations to reestablish occlusion or orthodontics. Each of these solutions could warrant an essay to discuss but I will focus here on the Orthodontic solution because in my experience it is the most appropriate solution for many of my patients. When I present this option invariably the patient’s first questions are “can I wear my oral appliance when I have the braces on and what about after the braces are removed?” This is a very important question for the patient. After experiencing the social and health benefits of treatment of their SDB condition, most are very reluctant to give it up.

In the past my short answer to that question has been no, for two reasons: First,

16 DSP | Spring 2015

during orthodontic treatment braces on the teeth prevent the OA from fitting, and second, when the occlusion is corrected and braces removed it is advisable not to resume wearing a MRD because of the risk of further occlusal changes. I suggest CPAP would be the alternative treatment. When given these choices, so far none of my sleep patients have pursued braces and have rather continued to wear their MRDs and accepted the occlusal change. However more recently there have been several reports from dentists of using MRD therapy during Invisalign therapy. This could certainly help during the orthodontic treatment phase but long term I would still be concerned that use of the MRD could lead to unstable occlusion.

As in all fields of medicine prevention is better than cure. So can we prevent these dental side effects from occurring in all of our patients? Over the years dentists have used a number of techniques to help patients maintain their occlusion. These techniques are typically used after the MRD is removed and include biting with a repositioning device in place, chewing gum or stretching exercises.

Research studies have shown the effectiveness of these techniques short term but not long term.3, 4, 5 A recent study also shows that occlusal changes can be progressive with long term wear of a MRD.1 Future research will hopefully give us more guidance on how to prevent occlusal changes and maybe also answer whether appliance design has an effect on dental side effects and if there are patient factors that make them more susceptible to these occlusal changes.

The two techniques I currently instruct all my MRD patients to use are a morning repositioning device every day and chewing gum when necessary. The device my patients use is the AM Aligner from Airway Management. I like that it is simple to make and simple for the patient to use. I instruct the patients to insert the AM Aligner every morning after removing the MRD and bite firmly on it until they can see in the mirror their anterior teeth fitting perfectly in to the indentations on the device. I also explain that if the teeth are not perfectly fitting they must continue to bite on the device until they are. If they cannot achieve that I ask them to contact my office because that means their occlusion is starting to change.

Anecdotally my patients who have experi-

CLINICALfocus enced occlusal changes nearly all confess to not using the AM Aligner every morning.

However I also have a quite a number of patients who freely admit to never using the AM Aligner and their occlusion has experienced no changes. A statement I make to all new patients on the use of the AM Aligner is “Your new MRD has the ability to act like an orthodontic device and move your teeth or change your bite. You must use the AM Aligner every morning to reverse the orthodontic effect”. I also instruct patients to chew gum (sugar free of course!)if they are having difficulty getting their teeth to fully fit into the indentations on the AM Aligner or if their bite feels off or unusual anytime during the day after wearing their MRD. Every month that goes by the body of evidence confirming the effectiveness of MRDs in alleviating SDB continues to grow. This evidence coupled with the high incidence of SDB, poor compliance with CPAP and increasing awareness among patients and physicians of MRDs means there is going to be increasing demand for MRD therapy. As dentists we are the only professionals who can provide this valuable therapy.

However no matter where I speak to dentists on this topic at meetings and study clubs around the country the risk of occlusal changes is the “elephant in the room”, one of the main reasons dentists are reluctant to provide this service to patients. As Dr. Alan Lowe has said publically many times, we as dentists have to “get over it!” The risk of occlusal change is real and should not be down played. We must be clear in explaining that risk to our new patients and clearly describe the risk in our written informed consents. That way a patient who finds that risk unacceptable can consider alternative therapies. We should use MRDs whose design we feel minimizes the chance of these occlusal changes and instruct our patients in techniques to try and prevent them occurring. If changes do occur we must help our patients decide if their social and health concerns regarding SDB outweigh their dental concerns and advise them on procedures that could correct the occlusal changes if that is desired. That way we as dentists can continue to provide a life changing and often lifesaving treatment while doing our best to inform and protect our patients from adverse dental side effects.

REFERENCES 1.

Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR, authors. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med. 2014; 10:1285–91.

2.

Marklund M, Franklin KA, Persson M, authors. Orthodontic side-effects of mandibular advancement devices during treatment of snoring and sleep apnea. Eur J Orthod. 2001; 23:135–44.

3.

Marklund M, Legrell PE, authors. An orthodontic oral appliance. Angle Orthod. 2010; 80:1116–21.

4.

Ueda H, Almeida FR, Chen H, Lowe AA, authors. Effect of 2 jaw exercises on occlusal function in patients with obstructive sleep apnea during oral appliance therapy: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2009; 135:430.

5.

Cunali PA, Almeida FR, Santos CD, et al., authors. Mandibular exercises improve mandibular advancement device therapy for obstructive sleep apnea. Sleep Breath. 2011; 15:717–27.

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MEDICALinsight

by Donald R. Tanenbaum, DDS, MPH

A

s the dental profession continues to define its role in the assessment and management of sleep related breathing disorders, the need to provide education based on research and clinical experience is clearly recognized. Though scientific investigations and technology have provided systems and protocol to diagnose a wide spectrum of sleep disorders, a full understanding of how the profession of dentistry can provide effective therapy continues to evolve.

Snoring, upper airway resistance syndrome (UARS), respiratory effort related arousals (RERA), and obstructive sleep apnea (OSA), have become the focus of dental providers who have developed interest and expertise in sleep disorders. As oral appliance therapy (OAT) designed to advance the mandible has gained a foothold within the therapeutic regimens offered for these conditions as a result of scientific investigations and research, efforts continue to unveil not only best practices, but strategies to limit the potential consequences of using these devices. As a result, careful assessment of the dental structures, jaw muscles and temporomandibular joints from a clinical and imaging perspective is essential before starting OAT.

What You Need to Consider

Before discussing the specifics of the assessment process and how one should go about identifying patients who may be at risk of complications from MADs some general commentary about snoring and obstructive sleep apnea is important. The intent of treatment in patient populations with these problems is to reduce airflow turbulence and facilitate airflow. Snorers without apnea are desirous of a quieter environment for their bed partners.

They may also want to reduce the severity of their snoring to spare their airway from the potential structural and neural consequences that have been documented in the literature as a result of long-term airflow turbulence. Beyond

18 DSP | Spring 2015

MEDICALinsight these concerns, the patient with OSA is looking for treatment that will reduce or eliminate problematic AHI scores, and prevent persistent oxygen desaturations during sleep.

With the knowledge that MADs can put the teeth, jaw muscles and temporomandibular joints at risk, the goal is to maximize benefit and minimize complications over what may be an extended period of time. If, however, despite the best of efforts and practices, dental, occlusal, or jaw problem arise as a result of wearing a MAD, particularly in the patient with OSA, concern must be balanced with recognition of the benefits achieved by keeping the airway patent and preventing oxygen desaturations. In this light, TMD symptoms, open contacts between teeth, or a bite change, may be of little consequence to the patient who has bigger medical concerns.

We as dentists must get comfortable with these outcomes.

A Broad Minded Approach

As the complications from OAT are likely the result of forward jaw positioning and it’s influence on the teeth, muscles and TM joint anatomy (disc, retrodiscal tissue) the clinician must always be looking to utilize a broad minded approach to treatment. Continued collaboration with our medical colleagues is therefore essential to employing a combination of treatment strategies to facilitate airflow during sleep. If weight loss is a possibility it should be pursued. If a patient has poor nasal airflow, collaborative ENT consultations and interventions may be in the patient’s best interest, if simple strategies like nasal strips or lavage fall short. Encouraging side sleeping with props should always be a consideration, but certainly used to help the patient avoid the dreaded supine position during REM. Most importantly CPAP therapy and OAT should not be considered as separate unrelated therapies. Marrying these two strategies should be a routine consideration. It should not be uncommon for some of your patients to use CPAP from 10 pm to 3 AM and then if awakened for one reason or another, to put their oral appliance in for the rest of the night if resuming CPAP is objectionable. Others use CPAT and OAT together nightly to help reduce the force of airflow from their CPAP machine. Still others split the week between CPAP and OAT. Lastly, if a MAD is working well, you may

want to dial back the appliance position and retest with pulse oximetry or a Home Sleep Test (HST). If a less protrusive position works, the appliance should be reset, reducing the likelihood of complications arising. With these concepts in mind, your ability to help patients will be greatly facilitated.

The Assessment Process – Taking a thorough history

Identifying the patient who may struggle to wear an oral appliance or develop complications down the line is a function of taking a good history. Typical questions that should be asked include; 1. Did you ever use retainers after orthodontics and were you comfortable wearing them?

2. Are your teeth presently shifting, particularly across the upper or lower front regions.

3. Do you have an easily excited gag reflex?

4. Do you easily develop canker sores, (as this may influence appliance design avoiding metal hardware.)

5. Do you sleep on your back, side or stomach?

6. Do you or can you breath through your nose when you sleep or is your mouth open?

7. Do you clench or grind your teeth at night? As a result of these activities do you have any morning symptoms of tooth soreness, jaw muscle pain, restricted jaw motion, TMJ noises, jaw locking, joint soreness. If so do these symptoms linger or pass quickly?

8. Have you ever been treated for a TMJ problem? What was the outcome and were your problems focused more in the muscles or TMJs. 9. Do you currently wear a night guard?

Does it help?

10. Do your TMJs click? Is so, are the noises longstanding? Does your jaw lock or get jammed at any time? Are the noises accompanied by pain?

11. Are your teeth very sensitive?

Answers to these questions will help determine if OAT is a viable treatment option or whether it may be contraindicated. Information that is communicated up front that pertains to the patient’s ability to wear, be comfortable, and have success with an appliance is viewed as knowledge. InformaDentalSleepPractice.com

19

MEDICALinsight tion provided after concerns develop is often viewed as an excuse and is not well received by patients.

The Assessment Process – The Clinical Exam and Imaging

The place to start is always the teeth, periodontal environment and intraoral tissues. A screening panoramic x-ray should be viewed as the standard of care as it provides a quick glimpse into possible tooth related red flags or contraindications to OAT. Periodontal deficits, and compromised restorations must be identified at the outset, as these problems will require careful clinical scrutiny and may prompt management before the oral appliance is fabricated. The panoramic x-ray will also provide an opportunity to appreciate condylar size and shape that can be correlated with examination findings. Significant alterations in the bony anatomy of the TMJs identified on the panorex may prompt a cone beam scan or MRI if there is clinical evidence of functional limitations. The use of 3D CBCT imaging can independently be utilized to identify airway anatomy that may influence the ability of MADs to assist airflow in patients who have a confirmed obstructive sleep apnea (OSA) based on past PSG and of HST. The use therefore of CBCT technology should be viewed as part of the screening process and not a way to diagnose sleep related breathing disorders.

Intraoral Exam

A thorough intraoral exam will help identify factors that will assist in the process of choosing an oral appliance strategy. For instance, the presence of short teeth that will

likely compromise retention of the appliance rims should prompt the use of an interlocking appliance design which limits dislodgement of an appliance when the mouth drops open. Worn teeth with wear facets may indicate a long term sleep bruxism pattern that will prompt the use of specific appliance designs that will help support the TMJs. Anatomy such as narrow dental arches, and a large tongue with scalloping may prompt the selection of an appliance design that allows for small and non-bulky upper and lower rims or a single arch appliance. Encroaching on tongue space often can lead to the onset of jaw pain or intolerance to using the appliance. On the other hand, oversized tonsils (grade3/4) that may predispose to more aggressive forward jaw positioning to open the airway should prompt collaborative medical consultations. Mouth breathers should have their nasal airway assessed to determine if airflow could be improved. If open mouth breathing is the reality of the situation, appliance designs that use elastics to limit mouth opening must be avoided. Evaluating and thinking in this manner can often lead to more effective OAT with less forward mandibular positioning required.

Jaw Function, Comfort and Occlusion

Evaluation of jaw function is essential prior to the use of MADs. Normal jaw motion occurs with fluidity in a smooth, silent and straight path. Jaw range of motion for men is approximately 40-50 mm and for women in the 35-43 mm range. Lateral motions are typically 9-13mm. All motions should occur without pain and the absence of TM joint noises. When measuring protrusion, this

Donald R. Tanenbaum, DDS, MPH, received his DDS from Columbia University School of Dental and Oral Surgery in New York City. While there, Dr. Tanenbaum envisioned having a practice that focused on facial pain, TMD and sleep related breathing disorders. Since opening his doors over 25 years ago, he has achieved that goal. His continual training and ongoing education have enhanced his knowledge and helped him stay on top of the latest diagnostic and treatment methods. He has also authored scientific articles and given lectures at medical grand rounds and to numerous dental societies and study clubs.

Dr. Tanenbaum currently holds several prominent positions, including: Clinical Assistant Professor at the School of Dental Medicine at the State University of New York in Stony Brook; Section Head of the Division of Orofacial Pain/TMD/Dental Sleep Medicine in the Department of Dental Medicine at the Long Island Jewish Medical Center; and Clinical Assistant Professor, Hofstra North Shore, LIJ School of Medicine.

Dr. Tanenbaum is the Immediate Past President of the American Academy of Orofacial Pain and an active member of some of the most respected organizations in this field, including the American Academy of Orofacial Pain, American Board of Orofacial Pain, American Headache Society, American Pain Society, New York Academy of Dentistry and American Dental Association.

20 DSP | Spring 2015

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MEDICALinsight

A full understanding of how dentistry can provide effective therapy continues to evolve.

22 DSP | Spring 2015

is a good time to use a gauge, (e.g. George Gauge or Pro Gauge) which will allow measurement of the full extent of retrusion and protrusion. This information is essential in determining whether the patient has the structural capacity to bring the jaw forward enough to justify OAT. At times in patients with jaw relationships that establish edge-toedge incisal relationships, there is minimal forward positioning potential of the lower jaw. In these cases using the oral appliance to prevent the tongue from falling back as opposed to bringing the jaw forward may be the best that can be achieved. Once the full extent of retrusion-protrusion is determined, the initial bite position can be set (usually somewhere between 50-60 % of the maximum forward potential), and captured with a bite registration.

Palpation of the jaw muscles will often reveal the presence of hypertrophy in the masseter and or temporalis region with no associated soreness or pain. As over built but non- symptomatic muscles are likely the result of overuse day behaviors (including clenching) and sleep bruxism, these factors must be considered when choosing a MAD. Unfortunately, there are clenchers and grinders in this world who never develop jaw symptoms until a MAD is placed to address an airway problem. This potential complication can best be avoided by careful appliance design that will be discussed under the section on complications. If muscle or joint soreness is discovered, but without daily symptoms, the same overuse factors may be responsible, and similar appliance designs considered.

If grinding tendencies (lateral bruxism) are identified while sleeping, the appliance design chosen must not only protect the TMJs but be capable of withstanding nightly forces which can be of significant magnitude.

Joint noises if present without pain or marked pathway alterations may represent a common deviation from normal (Estimated that 30% of the US population experiences joint noises), and may not impact your choice of appliance design. Joint noises that are accompanied by pathway deviations and intermittent jamming or locking events should raise red flags as well as any patient who reports a history of a TMD problem, especially if there was joint pain or instability. A regimen of formal jaw therapy may be required to prepare these patients for OAT

inclusive of exercises, formal physical therapy, cessation of daytime overuse behaviors that may be overworking the jaws, and/or a bruxism guard for a period of time. Despite these efforts some of these patients remain poor candidates for OAT. At best it may be possible to use OAT in these patients simply to prevent jaw retrusion.

Assessing the dental occlusion prior to OAT is essential. This is the time to clinically evaluate the patient’s habitual centric occlusion position and chart contact zones that if altered will prompt an awareness of a changing bite. With today’s technology, photographs along with digital representations of the occlusion should be included in the record for future reference. Study models and or elastomeric impressions that remain stable can also be used for this purpose.

There does not appear to be any one specific occlusal relationship that will predispose to a bite change in the morning, nor are there any readily identifiable occlusal factors that will consistently predispose to either transient or long term bite changes. Patients, however, who start with habitual bites that have variable contact zones seem to develop changes more readily, as evidenced by premature anterior contacts and a reduction of the grip of posterior contacts on articulating paper. Patients with lingually inclined maxillary incisors and deep bites may also develop this change more readily but not predictably.

The presence of heavy and premature anterior contacts and a reduction of gripping contacts posteriorly or a posterior open bite is the typical scenario with most bite changes that can occur as a result of MADs.

Complications of MADs

As previously mentioned, mandibular advancement devices (MAD) are presently used with the intent of moving the lower jaw and tongue base forward and or preventing the tongue from moving back into the oropharynx. This specific action reduces the collapsibility of the airway, minimizing or preventing snoring and/or airflow compromise leading to OSA. Forward jaw posturing, maintained over several hours repeated daily, however, is not normal, and can lead to symptoms in the teeth, jaw muscles or TMJs. The extent to which the oral appliance must move the mandible forward in order to achieve the designated goals is a point of important con-

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MEDICALinsight

Evaluation of jaw function is essential prior to the use of MADs.

sideration and will likely influence the development of complications over time.

Complications that occur as a result of using OAT include; tooth sensitivity, tooth movement leading to open interproximal contacts and anterior interferences, muscle stiffness and soreness, joint pain, the onset or escalation of joint noise, and changes in the way the teeth articulate. For most patients these problems are minor, transient in nature and easily managed. There are, however, risk factors that can increase the potential for complications and or make them more difficult to manage. As a result, identifying a history of a TMJ problem, ongoing nocturnal clenching or lateral bruxism, and patterns of nasal/mouth breathing while sleeping are invaluable to the clinician to assist in choosing a specific appliance design. Though all oral appliances to address OSA are intended to bring the jaw forward or prevent the tongue from falling back, there are a number of designs. By identifying risk factors at the outset, the clinician is in a position to choose a design that will afford the greatest protection to the teeth and jaw structures. The careful clinician becomes familiar with the various designs available, so that patient-appliance matching can be as predictable as possible.

The Teeth

Tooth sensitivity is the most likely symptom due to stress that is placed on the periodontal ligaments. The upper and lower anterior teeth are the most common site of discomfort/pain especially if an anterior stop appliance is used. Reducing the extent of facial surface coverage is at times all that is needed to address these complaints. At other times relief of the internal aspect of the appliance is helpful particularly if an all-acrylic appliance is used. Laminate appliance designs with a soft inner lining often limits tooth sensitivity but may be more contributory to open contacts developing in the premolar and molar region. Frequent floss checks by patients are essential to identify this concern early on. At times tooth shift anteriorly can occur, but usually in periodontally compromised people. A component of the examination assesses potential tooth anchorage for anteriorly posturing the mandible; if suspect, careful appliance choice to distribute force and minimize stress put on individual teeth is even more important.

24 DSP | Spring 2015

Muscle Problems

Muscle symptoms of soreness and stiffness can occur in the masseter region particularly when OAT is first initiated. This may be the result of muscle bracing occurring in the awkward forward jaw position or the result of contact of the occlusal rims creating masseter contraction even without defined bruxism. If the appliance chosen is too big and obliterates freeway space (evidenced by loss of lip seal), the patient is almost forced to clench with possible pain symptoms emerging. Changing the appliance design would therefore be required. Muscle symptoms, however, are more profound in the patient who clenches or grinds their teeth. For these patients using an appliance that provides two broad posterior contacts and anterior contact without obstructing the anterior opening is desirable. The Herbst, Suad, Somnodent, Respire and EMA can all be used in this situation with predictability. The use of an anterior point contact design may over time load the anterior compartment of the TMJ so this would not be an ideal option, unless posterior contact pads are added. In general, a hot shower and repeated circular massage of the masseters for six seconds followed by six unassisted jaw opening movements is usually sufficient to address sore masseters in the morning. One specific isometric exercise can be used as well: Have the patient lock the tip of their tongue against the palate and have them open their mouth while placing the thumb under the chin for resistance. Hold this resistance for 6 seconds and repeat six times. This will relax the temporalis and masseter muscles. If specific appliance designs plus morning exercises falls short, then injection of between 50-100 units of Botox can be considered. Though this may seem excessive, in a patient with OSA that cannot tolerate CPAP or benefit or chose surgery, making an oral appliance work is the ultimate goal.

For the lateral bruxer, posterior contact supports are desirable, but avoid dorsal fin designs, along with Herbst and Suad devices as the upright wings and metal arms respectively can break. The aggressive lateral bruxer typically does well with an EMA appliance as long as posterior contacts are built into the design. The elastic straps will require frequent change as they will stretch and allow the jaw to slip back. The TAP 3 Elite, which allows lateral shift anteriorly, is a reasonable

MEDICALinsight option as long as posterior occlusal pads are built into the design.

Joint Problems

A short regimen of physical therapy can help a sprained joint to recover...

26 DSP | Spring 2015

TM joint problems are often difficult to manage and may require a period of time during which the appliance is discontinued.

As with all orthopedic joint systems, ligament sprains can occur with and without inflammation. Sprains can occur simply as a result of forward jaw positioning with the MAD, but can be a consequence of clinician error as well. If the centric occlusion midline position is violated as the mandible is advanced, joint sprains can occur. Care must be taken during bite registration to avoid this complication.

Once initiated, joint sprains and inflammation may be stubborn to resolve. If a three or four day regimen of NSAIDS doesn’t solve the problem along with a thoughtful diet and some ice massage, there may be good reason to reduce the forward positioning. As most of the appliances used to address a mild to moderate OSA problems are initially set at a position that represents 50-60% of maximum protrusion, there is ample room to back track and allow for healing to occur. If a period of time without the appliance is required this is an option that may have to be considered particularly if a patient has a CPAP machine that they can use. A tongue-repositioning device (Aveo tongue stabilizing device or MPowRX) can also be tried for a short period of time until the joint has healed. When symptoms have passed and appliance therapy is reinitiated, an every other night approach with less than optimal positioning should be pursued for a period of time. There have been times when a short regimen of physical therapy has helped a sprained joint to recover allowing the resumption of effective OAT. The potential for joint problems to occur and linger increases in the lateral bruxer over time.

Occlusal (bite) changes that are mild to profound appear to occur in approximately 20% of patients that are followed beyond one year. For the dentist newly involved in OAT this is a dreaded complication. For the experienced dentist and patient with OSA, this consequence, if explained before treatment was started, is a mere trade off with the benefits being realized in reduced blood pressure, weight loss, gastrointestinal health, refreshing sleep and improved daily energy levels to name just a few positive outcomes.

There are a number of strategies and techniques that can be employed to address these anticipated bite changes. The most useful requires obtaining a durable centric occlusion bite registration prior to OAT. This can be done with strong elastomeric materials or baseplate wafers. The AM Aligner from Airway Management has worked exceptionally well, particularly if you cut back the length allowing the second molars to contact naturally and the rest of the bite to captured in the baseplate wafer. In the morning, the patient puts the Aligner in their mouth and while in a hot shower, bites into the bite registration with moderate effort over a three to five minute period of time. This coupled with some gentle circular massage of the masseter and temporalis muscles usually resets the centric occlusion position. If this falls short, gentle gum chewing while getting dressed helps fully recapture the bite. If needed, employing an isometric exercise can be helpful. Have the patient open their mouth halfway and then close against resistance provided by the index and middle finger for 6 seconds, and then repeat 6 times. This isometric exercise should assist relaxation of the lateral pterygoid muscles that may be guarding after hours of forward jaw posturing. Despite these efforts it may take until mid morning for the bite to settle back to normal. If this is the scenario, it is likely that the morning bite change may relate to shape changes of the articular disc or retrodiscal tissues as a result of the condyles being moved forward for several hours. This often is a harbinger of more profound bite changes occurring over time and may be inevitable.

Conclusion

As OAT provided by dentists to address snoring and obstructive sleep apnea gains more public visibility and acceptance by our medical colleagues, standards of care and best practices will need to evolve based on research and clinical experiences. Though MADs have proven to be effective and embraced by patients looking for alternatives to surgery or CPAP therapy, much work needs to be done. Future efforts should focus not only on how to more predictably determine the start position for MADs but to establish systems and strategies that allow patients to use these devices over extended periods of time with minimal complication.

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INSIDEtheLAB

W

hen the boxes are opened, they may at first only seem to hold impressions and bites. What’s really there are years of longer life, improved health, lower medical expenses, and vastly improved quality of life for many people in each box. It’s the lab professionals who create medical devices that help people breathe better at night from the potential from what’s dropped off by FedEx and UPS. To unravel a bit of that magic and to help the dental team learn how they contribute to the quality they seek, Dental Sleep Practice sat down with Jason Wilson and Bill Jarnagin of Gergen’s Sleep Lab. Bill graduated from sleep technology school in 1978 and Jason has been working with David Gergen for 21 years, so these guys have some insight to share!

28 DSP | Spring 2015

INSIDEtheLAB DSP: Guys, walk me through what happens when a dentist sends a case to the lab.

Jason: Each case is opened by me or my team, and logged into our system. Because these are medical devices, FDA regulations require that every step of the process has to be documented and signed off by the technician who completes it. Every part, every material, and even the color has to be logged in; the lot numbers are recorded and if the doctor has asked for special details, those are noted as well.

DSP: What do you look for from the dental office?

Jason and Bill: Mostly what we need are quality impressions and good, clear bites.

There has to be a prescription, of course – every week we get one or two without one.

Some doctors send models – that’s just fine, but we wish they were always packed well.

It’s too bad when we have to patch a model together or ask for a new one when all it would have taken is better shipping! Impressions don’t break in shipping.

DSP: Say more about the impressions Bill: What we look for is distorted teeth – you can see where there was a pull, or the shape of the teeth just doesn’t look right, the tray wasn’t the right size or there’s not enough of the gums on the palate or outside of the teeth. Sometimes, it looks like the material wasn’t fully set or it was moved around on the teeth before it was ready. We’d like every impression to be inspected carefully by the doctor before it’s sent; many of these problems are pretty obvious.

DSP: Why do you need a palate?

Aren’t all of these devices just over the teeth?

Bill: Our Sleep Herbst cover only the teeth, but TAPs need that anterior palate area to be made right. And we want to see as much as we can past the teeth on the buccal so we can set our hardware in a spot that will be comfortable for the patient. Plus, if all we have is a small little horseshoe of teeth, we have to make up some kind of base so it can be mounted on the articulator.

DSP: Do you have a favorite impression material?

Bill: Any of the current vinyl impression materials will do – I have to constantly catch myself from calling them ‘rubber base’ when I’m talking with doctors – that’s how long I’ve been doing this! Even alginates if they are done well will make a good model. We sell one, Kromopan 100, that can actually be sent to us for pouring, but we don’t really encourage that. We just want the doctors or their assistants to know how to use whichever material they choose.

If the doctors take some time to inspect the impressions before the patient leaves, or check the models carefully before they go in the box, that would save a lot of time getting the product back to them.

Bill Jarnagin

DSP: What’s next, then?

Bill: We set up the models in an articulator so we can build the right strength into the sleep device. Our biggest problem in the lab is the kind of bites we see. We know that the lower jaw has to be set somewhere about 60% of the maximum protrusion so the patient won’t snore, and we have to have about 4mm minimum thickness between the back teeth for any of our devices to be strong enough.

Jason Wilson

DSP: Seems pretty straightforward.

What are you seeing in the cases doctors send in?

Bill: Sometimes we get just the models and some numbers telling us what the pro-

Lab Tips Impressions:

• Know your material, and follow directions • Fit the tray well • Inspect the impression or model carefully before sending it to the lab

Bites:

• Use a positioner to set the jaw where you want to start • Make sure you know if the midline shifts • Look at the most posterior teeth and be sure there is 4mm or more clearance • Use enough stable material so the lab can set the models right

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INSIDEtheLAB trusion is and the doctors expect us to set the models. We get wax bites, bites that obviously have the teeth shifted over to one side or the arches are tipped. One big problem is supererupted teeth – we sometimes have teeth so out of line that we can’t even make the first choice device and have to call the doctor to see if we can make something different.

DSP: What coaching advice would you give to the doctor about bites?

Bill: Using some kind of positioning device makes it better. We think any of the guides are good – George Gauge we see a lot, PRO gauges, Andra, Moses Bites, – they all can be good, but we definitely need enough hard-setting polyvinyl bite material that we can set the models in the articulator without having to guess how they fit or where they should be. If the bite can be taken with enough space between the back teeth, we don’t have to open the articulator in the lab, which always makes it less accurate. If the doctors are getting appliances that hit too hard in the second molars, that’s a sign that the bite wasn’t taken with enough room for us to make the device.

Please ask the doctors to check the midlines and make a note on the prescription if the midline is off or shifts over when the jaw goes forward. If the mounting matches the note, we know we have it right and that saves time. If we have questions, we are going to call the doctor – that’s an interruption.

DSP: So now that you’ve mounted the models in the right bite position, then what happens?

Bill: We block out the undercuts, wax up the shape, put ball clasps in and position the hardware, then the acrylic techs use a high quality powder and liquid buildup to form each appliance by hand. The acrylic is processed in a pressure pot, finished and polished. The QC department inspects each one before shipping. The whole process takes about a week – we open about 35 new cases every day. Our acrylic is FDA cleared and David insists we get the best on the market for our devices. That makes it easier for us to turn out a quality product.

DSP: You guys are known for the blue sleep Herbst. Why blue?

Bill: Back to the FDA process – they’ve only cleared a few colors. We’ve chosen clear or blue, but we have purple and red to use if the doctor wants. Sometimes we get some crazy requests in like we do for ortho retainers, but we just can’t make a medical device in school colors or polkadots! Unless they are blue or red!

DSP: Tell me about scanning technology – wouldn’t that take care of the impression problem?

Jason: We have two doctors so far who are sending in scans for their cases, and we have a printer here to make the models, which end up being treated just like any other model. It adds about a day to the process and we still need that bite, but we think we’ll see more and more of this going forward. So far, these are going well – mostly because David invested in a pretty good printer.

DSP: Thank you, Jason and Bill. I hope this helps all our sleep dentists work better with their lab professionals so patients end up with better sleep appliances. Any final thoughts?

Jason: Thank you for your time. Anyone interested in working with Gergen’s Sleep Lab can get our Start-Up-Kit, which has everything a new doctor needs to get started making sleep appliances.

Gergen sleep Herbst appliance

30 DSP | Spring 2015

EDUCATIONfocus

Putting It All

Together I

by Dr. Dale Sorenson

magine how boring your dental practice would be if all our patients were the same. No patient would present with an array of problems that took some time to sort out or encouraged us to collaborate with colleagues, expanding that usual circle of dentists to include physicians of many disciplines.

We’d never grow or learn through each patient experience and none of them would help us recognize gaps in our own knowledge.

Luckily we don’t live in that world. Every new patient experience has the potential to challenge us and by doing so, encourages us to continually add to our knowledge and skills.

There’s perhaps no better example of the kind of patient that requires broad thinking and helps us augment gaps in our knowledge than the sleep patient. As dentists, we

can assess oral health readily, but considering placement of a mandibular advancement device requires an understanding far beyond teeth and gums as noted by several essays in this issue of Dental Sleep Practice.

We must have confidence in our abilities to assess the temporomandibular complex so that we can properly inform our patients of

Dr. Dale Sorenson attended Wabash College for his undergraduate education where he earned All-American honors in swimming. He received his D.D.S. degree from the Indiana University School of Dentistry. He is a member of the Northeast Regional Board of Dental Examiners and served nine years on the Indiana State Board of Dentistry. He is an active member of The American Academy of Restorative Dentistry, The American Academy of Fixed Prosthodontics, American Equilibration Society, Fellow in the American College of Dentists, Fellow in the Pierre Fauchard Academy, ADA, IDA, and First District Dental Society. He is a recognized speaker and educator and has lectured throughout the United States and Canada. He is Director of Essentials Education at The Pankey Institute.

In addition to this role, Dr. Sorenson has a strong history with The Pankey Institute. He was named Chairman of the Institute’s Provost Committee in 2005. He also served as the L.D. Pankey Alumni Association President from 2005-07. In 2008, he was elected to serve on the Board of Directors and served as Secretary during his term. He has served as Visiting Faculty since 1992.

Embracing education, he is one of a select group of only 38 dentists to achieve the designation of Pankey Scholar. He also is a current member of the Class One Triple Plus Club, which is a group of individuals who make financial pledges which ensure the growth of The Pankey Institute for future generations of dental professionals.

32 DSP | Spring 2015

EDUCATIONfocus the risk that forward-posturing their jaw may hold. We must be able to integrate medical findings related to sleep, comorbidities, and pharmacotherapy with the dental services we are trained to provide. And because patients aren’t just their physical complaints and examination data points, but real people with unique personalities, values, circumstances and objectives—we need to be able to connect with them too. We need to encourage them to feel free to tell their story so that we can recommend the best and safest recommendations for their situation.

For us to make a difference in our community health, we must seek sleep patient education on our own through postgraduate programs. There are numerous offerings to choose from, but the one place you can be assured that your learning experience is catered to your needs is The Pankey Institute, a not-for-profit organization that has been offering visionary dental education in a non-commercial environment for over forty-five years. The Institute was founded in

honor of Dr. L.D. Pankey who was a passionate advocate of comprehensive, patient-centered dentistry and his passion for helping other dentists understand the happiness and fulfillment they could gain by creating closer relationships with patients is a fundamental part of all The Institute’s courses.

Pankey offers a four-day Dental Sleep course where a maximum of 16 participants will work side-by-side with 6 experts who will prepare both novice and experienced sleep dentists to treat their sleep disordered breathing patients. This course will open your eyes and heart to an entirely new world of thinking. If you think it’s satisfying to help save someone’s teeth, just wait until you’ve saved someone’s life! Tuition for this course also includes your own custom made appliance, a remoldable professional temporary appliance, and personal sleep study.

If you read this issue and wonder how you, too, can be skilled at treating sleep patients with confidence, seek out more information at www.Pankey.org

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DentalSleepPractice.com

33

EDUCATIONspotlight

ASBA Dental Division – A Breath of Fresh Air

S

leep Apnea Dentistry has been characterized as the greatest opportunity for dentistry, post caries epidemic, since tooth whitening. The benefit to the patient is clear – Oral Appliance Therapy is an effective, non-invasive, and inexpensive treatment for Obstructive Sleep Apnea. Dentists are seen more and more as part of the medical community by assisting in providing early diagnosis and treatment of medical conditions.

David Gergen, Executive Director of the American Sleep and Breathing Academy Dental Division, has said that the greatest barrier to entering the field of sleep apnea dentistry for most dentists has been a lack of objective, non-vendor sponsored training.

Mr. Gergen (pictured with Andre Collins Director of the NFLPA) is well known for his efforts to proDavid Gergen, Executive Director of the American mote sleep apnea diagnosis and Sleep and Breathing Academy Dental Division (right), therapy within the NFLPA. He with Andre Collins, Director of the NFLPA (left). recently was appointed Sleep Apnea director of the NFLPA HOPE program; his mission is to provide diagnosis and therapy for retired NFL players nationally. These efforts, combined with his 30 years of experience working in the dental field as president of Gergen’s Orthodontic Lab, inspired the founding of the ASBA DenSleep professionals tal Division.

The ASBA has been an interdisciplinary of all disciplines CE provider in the medical space for some focus on patient 17 years. Monthly webinars, eLearning and health and treat- exam prep courses have been a part of the academy since its inception. David Gergen ment options. and the ASBA have collaborated and developed a combined medical and dental education gathering that is without equal in the sleep apnea dentistry arena. Sleep professionals of all disciplines focus on patient health, treatment options, and improving working together to optimize care.

This year the ASBA conference will be Friday, April 10, 2015 - Saturday, April 11, 2015 at DoubleTree Resort Paradise Valley in Scottsdale, AZ. Nationally recognized speakers including Dr. Robert Talley (also President of the Dental Division,) and Rod Willey DDS, widely regarded as America’s most

34 DSP | Spring 2015

successful sleep apnea dentist, will be laying out in detail the steps to building a Million-Dollar sleep practice. John Tucker DMD will be discussing oral anatomy, physiology and breathing disordered sleep. Dr. Stacey Layman will be reviewing medical billing for dentists - quite possibly the most popular segment of the meeting, especially given recent changes to medical billing as part of the Affordable Care Act. The interdisciplinary nature of the meeting will provide plenty of opportunity for interaction between dental teams and MD’s, RRT and RPSGT. Rudi Ferrate, MD, will be presenting a section on home sleep testing, working with a sleep physician and aging the sleep process. Bradley Eli DMD will be presenting his ideas around “Disease Management and the Dental Office”. Dr. Eli and his team were recently featured on the cover of the AARC times.

The ASBA Dental Division has established a clear focus on the future of the community dentist and his/her patients. The daily activities and requirements of running a dental practice and incorporating the care of a qualified sleep apnea patient are well understood by the board of the ASBA dental division. Take a few minutes and review the website for the Dental Division, become a member, and sign up for the meeting. Your patients will be glad you did! www.asbadental.com/membership • www.sleep-conference.com

w

N EW MicrO2 SLEEp DEvIcE. More sLeep. Less HassLe. DIGITAL PRECISION provides retention by mirroring dentition LINGuAL-FREE DESIGN offers more tongue space

TWIN 90º ANGLE MECHANISM-FREE POSTS Keeps jaw forward at night CONTOuRED LIP AND CHEEk bORDERS provides comfort

The lingual-free MicrO2 is engineered to treat your patients with greater comfort, predictability and simplicity. what are recognized leaders in dental sleep medicine saying about their initial MicrO2 cases?

“The CAD/CAM design optimizes outcome but minimizes bulk—a true break through advancement in the treatment of snoring and sleep apnea.” Dr. Anne-Maree cole, bdsc, lvim cle ared

Patent Pending design

“We found that with the added tongue room the mandible did not have to be brought as far forward. The patient felt overall it was less bulky and more comfortable.”

Dr. Nancy Addy, dds, diplomat aadsm

“With it’s airway constriction preventing fins and unobtrusive size, this device is a winner.”

Dr. william G. Dickerson, dds, faacd, lvim

“It’s small, tough, and reliable. Having no tiny adjustment mechanism is helpful for some patients —the easy way to bring the jaw forward and keep the airway open.” Dr. Steve carstensen, dds “The MicrO2 sleep appliance is so simple, effective and easy for patients to wear.“ Dr. Mark T. Murphy, dds, fagd

Discover if MicrO2 is simply a great fit for your practice.

©2015_MDL_1501110

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FOCUSonDIAGNOSIS

by Steven D. Bender, DDS Abstract

Temporomandibular disorders (TMDs) are common in the general population. Patients who suffer with sleep disordered breathing (SDB) may have existing signs and/or symptoms of TMDs or develop these disorders during treatment with mandibular advancement type oral devices (MADs). When treating SDB patients with MAD therapy, it is critical to properly evaluate the temporomandibular structures to asses a baseline status as well as give the patient adequate informed consent prior to therapy. The aim of this paper is to provide a brief overview of TMDs and suggest a cursory examination protocol that the clinician can easily incorporate into their examination and consultation protocol.

Introduction

Temporomandibular disorders (TMDs) are prevalent conditions in the general population.1-4 TMDs are defined as a collection of symptoms and signs involving masticatory muscles, the temporomandibular joints (TMJs) or both.5 The pain reported by TMD patients is typically located in the muscles of mastication, in the preauricular area, or in the TMJs.6 Other symptoms of TMD may include restricted mandibular range of motion and a functional alteration or deviation of the jaw opening or protruding motions. Screening questions for TMDs may include;7 1. Do you have difficulty, pain, or both when opening your mouth, for instance when yawning?

2. Does your jaw “get stuck,” “locked,” or “go out”?

3. Do you have difficulty, Pain or both when chewing, talking, or using your jaws?

4. Are you aware of noises in your jaw joints?

36 DSP | Spring 2015

5. Do your jaws regularly feel stiff, tight, or tired?

6. Do you have pain in or near the ears, temples, or cheeks?

7. Do you have frequent headaches, neck aches, or toothaches?

8. Have you had a recent injury to your head, neck or jaw?

9. Have you been aware of any recent changes in your bite?

10. Have you previously been treated for unexplained facial pain or jaw joint problems?

Population studies have reported the prevalence of TMDs to be from 8% to 15% for women and from 3% to 10% for men2, suggesting that TMDs are significant causes of pain in the head and face region. While the etiology of TMDs is still not well described in the literature, it is generally thought that they are conditions comprising both psychosocial and neurophysiologic entities.8 Inflammatory mechanisms have been shown to be involved in temporomandibular joint pain and dysfunction.9 Milam proposed a possible etiology for inflammatory mechanism of the temporomandibular joint structures by what was described as a hypoxic-reperfusion injury.10 This process occurs when the capsular pressure of the temporomandibular joint exceeds the end-capillary perfusion blood pressure of the feeding vasculature. The area then undergoes reperfusion via mouth opening or relaxation of the elevator muscles. Capsular nociceptive fibers triggered by pathologic loading

FOCUSonDIAGNOSIS of the highly innervated synovial tissues may also stimulate the release of calcitonin gene-related peptide and substance P, leading to further inflammatory processes. Albeit a sometimes controversial suggestion, pathologic loading of the joint structures is often attributed to sleep parafunctional behaviors such as sleep bruxism.11 Sleep bruxism has also been suggested to be at least partially responsible for stomatognathic muscle pain.12, 13 Christensen reported that muscle pain was noted in subjects who voluntarily clenched for 20-30 seconds.14 Kydd and Daly reported that nocturnal clenching events can last as long as 20-40 seconds.15 Clark demonstrated that the average bruxing event was up to 60% of the force generated during voluntary maximum clenching prior to sleep.16 It may be inferred, then, that these parafunctional events could lead to tissue injury and subsequent nociceptive signaling from both the myogenous and arthrogenous components of the temporomandibular joint complex.

Evaluation

As part of a comprehensive workup, a systematic approach to patient evaluation is key to an accurate diagnosis and ultimately, therapeutic success. The examination should include an assessment of the stomatognathic musculature, the condition of the TMJs and the measurement of the mandibular movements. The most widely used and accepted method for evaluating the condition of the stomatognathic musculature is by digital palpation.17-19 Application of about 4-5 pounds

of pressure (the pressure necessary to blanch the finger nail bed) applied with the palmer surface of the index, middle and ring fingers across the muscle fibers can be diagnostic of muscular abnormalities.20 The examination should identify tender areas as well as potential trigger points, which are thought to arise from abnormal motor end-plate A systematic activity releasing excessive amounts of acetylcholine.21 Trigger points are focal- approach to patient ly tender spots in taut bands of skeletal evaluation is key muscle that refer deep, aching pain to distant sites, often including non-mus- to diagnosis and cular structures. A cursory stomato- success. gnathic muscle examination would include the following muscle groups; temporalis, masseter, sternocleidomastoid, splenius capitis, semispinalis capitis and the anterior portion of the trapezius muscle. The lateral pterygoid muscle, involved in opening and protruding the mandible, must be functionally assessed as it is not possible to manually palpate this muscle.22,23 The parafunctioning patient may not necessarily present with painful masticatory symptoms.

Examination of the oral structures may reveal worn dentition as well as scalloping of the oral tongue lateral borders and ridging of the buccal mucosa.24-27 The temporomandibular joint can also be assessed by digital palpation. The location of the mandibular condyle can be identified in the area anterior to the tragus of the ear by having the patient open and close sev-

Dr. Steven D. Bender earned his Doctorate of Dental Surgery degree from Baylor College of Dentistry, in 1986.

He has completed postgraduate dental education at the L.D. Pankey Institute and the Dawson Center for Advanced Dental Study. He studied orofacial pain and temporomandibular disorders at the Parker E Mahan Facial Pain Center at the University of Florida College of Dentistry under the mentorship of Doctors Henry Gremillion and Parker Mahan.

Since 2001, Dr. Bender has maintained a private practice devoted to pain management of the head and face, as well as sleep medicine dentistry. He has earned Fellowship in the American Academy of Orofacial Pain, the American Headache Society, the International Academy of Oral Oncology and the American College of Dentists. He holds the office of president-elect of the American Academy of Orofacial Pain and is the president of the Fourth District Dental Society of Texas. Dr. Bender is a clinical assistant professor in the department of Periodontics Stomatology Center at Texas A&M University Baylor College of Dentistry in Dallas, Texas where he has started a facial pain clinic. He has published numerous articles in peer reviewed journals on the topics of sleep related breathing disorders, bruxism, headache and other related topics. He also serves as a reviewer for numerous medical and dental journals. He has lectured around the country on the topics of Dental Sleep Medicine, Anatomy, Facial Pain, Headache, Pharmacology, and Oral Medicine.

DentalSleepPractice.com

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FOCUSonDIAGNOSIS eral times and feeling for the movement of the lateral aspect. It is important to have the patient then clench their teeth in order to ensure proper positioning of the finger tips. If muscle contraction is felt, it is probable that the fingers are resting on the area of the deep portion of the masseter muscle and not the lateral aspect of the condyle. Joint popping or crepitation can also be assessed by light digital palpation or by using the bell end of a standard stethoscope.

Measurement of the mandibular range of motion can be easily accomplished utilizing a millimeter ruler. It is important to first measure the over jet and over bite when calculating the range of mobility. Normal range of motion for mouth opening in men and women is 42 mm and 38 mm respectively.28, 29 When analyzing lateral movements, the midlines should be noted. Normal lateral movements are approximately 8-9 mm while protrusive movements are considered normal in the range of 6-7 mm.30 It should be noted if there are deviations with opening and protrusive movements. It should also

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11.

12.

13.

Jensen, R., et al., Prevalence of oromandibular dysfunction in a general population.

Journal of Orofacial Pain, 1993. 7(2): p. 175-82.

LeResche, L., Epidemiology of temporomandibular disorders: implications for the investigation of etiologic factors. Critical reviews in oral biology and medicine: an official publication of the American Association of Oral Biologists, 1997. 8(3): p.

291-305.

Lipton, J.A., J.A. Ship, and D. Larach-Robinson, Estimated prevalence and distribution of reported orofacial pain in the United States. Journal of the American Dental Association, 1993. 124(10): p. 115-21.

Ciancaglini, R. and G. Radaelli, The relationship between headache and symptoms of temporomandibular disorder in the general population. J Dent, 2001. 29(2): p. 93-8.

Dworkin, S.F. and L. LeResche, Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord, 1992. 6(4): p. 301-55.

McNeill, C., et al., Temporomandibular disorders: diagnosis, management, education, and research. Journal of the American Dental Association, 1990. 120(3): p.

253, 255, 257 passim.

Leeuw, d., ed. Orofacial Pain: Guidlines for assesmment, diagnosis and management. Fourth ed. 2008, Quintessence Publishing Company: Hanover Park, IL. Suvinen, T.I., et al., Review of aetiological concepts of temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. European Journal of Pain, 2005. 9(6): p. 613-33.

Graff-Radford, S.B., Temporomandibular disorders and headache. Dental clinics of North America, 2007. 51(1): p. 129-44, vi-vii.

Milam, S.B., G. Zardeneta, and J.P. Schmitz, Oxidative stress and degenerative temporomandibular joint disease: a proposed hypothesis. J Oral Maxillofac Surg, 1998. 56(2): p. 214-23.

Hirose, M., et al., Three-dimensional finite-element model of the human temporomandibular joint disc during prolonged clenching. European Journal of Oral Sciences, 2006. 114(5): p. 441-8.

Lucas Bde, L., et al., Electromyographic evaluation of masticatory muscles at rest and maximal intercuspal positions of the mandible in children with sleep bruxism.

Eur Arch Paediatr Dent, 2014. 15(4): p. 269-74.

Nagamatsu-Sakaguchi, C., et al., Relationship between the frequency of sleep bruxism and the prevalence of signs and symptoms of temporomandibular disorders in an adolescent population. Int J Prosthodont, 2008. 21(4): p. 292-8.

38 DSP | Spring 2015

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

be noted if lateral movement ranges are not symmetrical.

Conclusion

Temporomandibular disorders include a variety of musculoskeletal disorders that may affect mandibular function. MAD therapy may cause transient TMD symptoms when the device is first worn, but usually these symptoms resolve within a few days.

If the problem persist, it is important for the clinician to discern whether the problem was caused by the MAD, the problem occurred coincidentally with use of the MAD or if is the expression of a problem that was there previously. Incorporating a systematic approach to assessment of the stomatognathic structures as part of the evaluation protocol will help the practice to identify patients who may be at risk for development of signs or symptoms. Ultimately, the practice will be better prepared to provide the patient with a thorough informed consent and better manage problems should they arise.

Christensen, L.V., Facial pain from experimental tooth clenching. Tandlaegebladet, 1970. 74(2): p. 175-82.

Kydd, W.L. and C. Daly, Duration of nocturnal tooth contacts during bruxing. J Prosthet Dent, 1985. 53(5): p. 717-21.

Clarke, N.G., G.C. Townsend, and S.E. Carey, Bruxing patterns in man during sleep. Journal of Oral Rehabilitation, 1984. 11(2): p. 123-7.

Burch, Occlusion related to craniofacial pain, in Facial Pain, M.P. Alling CC, Editor.

1977, Lea & Febiger: Philadelphia. p. 165-180.

Krogh-Poulsen, O., Management of the occlusion of the teeth, in Facial pain and mandibular dysfunction, C. Schwartz, Editor. 1969, Saunders: Philadephia. p. 236-280.

Schwartz, C., The history and clinical examination, in Facial Pain and mandibular dysfunction, C. Schwartz, Editor. 1969, Saunders: Philadelphia. p. 159-178.

Fischer, A.A., Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain, 1987. 30(1): p. 115-26.

Meunier, F.A., G. Schiavo, and J. Molgo, Botulinum neurotoxins: from paralysis to recovery of functional neuromuscular transmission. Journal of Physiology, Paris, 2002. 96(1-2): p. 105-13.

Turp, J.C. and S. Minagi, Palpation of the lateral pterygoid region in TMD--where is the evidence? J Dent, 2001. 29(7): p. 475-83.

Johnstone, D.R. and M. Templeton, The feasibility of palpating the lateral pterygoid muscle. J Prosthet Dent, 1980. 44(3): p. 318-23.

Sapiro, S.M., Tongue indentations as an indicator of clenching. Clin Prev Dent, 1992. 14(2): p. 21-4.

Long, R.G., L. Hlousek, and J.L. Doyle, Oral manifestations of systemic diseases.

Mt Sinai J Med, 1998. 65(5-6): p. 309-15.

Gray, R.J., et al., Physiotherapy in the treatment of temporomandibular joint disorders: a comparative study of four treatment methods. Br Dent J, 1994. 176(7): p. 257-61.

Kampe, T., et al., Reported symptoms and clinical findings in a group of subjects with longstanding bruxing behaviour. Journal of oral rehabilitation, 1997. 24(8): p. 581-7.

Agerberg, G., Maximal mandibular movements in young men and women. Sven Tandlak Tidskr, 1974. 67(2): p. 81-100.

Mezitis, M., G. Rallis, and N. Zachariades, The normal range of mouth opening. J Oral Maxillofac Surg, 1989. 47(10): p. 1028-9.

Celic, R., V. Jerolimov, and D. Knezovic Zlataric, Relationship of slightly limited mandibular movements to temporomandibular disorders. Braz Dent J, 2004. 15(2): p. 151-4.

PHARMACOLOGYfocus

XyliMelts oral adhering discs in the management of oral dryness associated with treating sleep apnea

O

bstructive sleep apnea syndrome (OSAS) occurs during sleep and causes hypoxia, sleep fragmentation, and excessive sleepiness during subsequent awake hours. The condition has also been associated with cognitive impairment, mood disorders, hypertension, cerebrovascular incidents, and ischemic heart disease.1,2,3

Dentists are in a unique management position with respect to the treatment of OSAS because they can provide primary care via the prescription of intra-oral appliances in cases of mild to moderate OSAS and, in addition, they can aide in managing the dry mouth that frequently occurs during treatment with continuous positive airway pressure (CPAP), the most common medical intervention for OSAS. Mouth dryness resulting from leakage of air around the mouth during CPAP is a frequent side effect reported by patients, regardless of the type of delivery system mask used.4 Study results vary but one study suggests that the proportion of patients reporting side-effects may be significantly larger with oronasal masks than with nasal masks.5 Regardless of which mask system provides the least leakage, the problem of oral dryness is significant enough that some CPAP users have discontinued therapy because of it. Multiple studies report that between 29-83 percent of patients were non-compliant with CPAP use because of dry mouth.6 Poor compliance resulting from oral dryness occurring because of mouth breathing with nasal CPAP represents a serious challenge to effective treatment and increases the risk of related long term comorbidity when treatment is discontinued.7,8,9,10 In one relevant study that highlights the problem of dry mouth, 275 patients age 45DentalSleepPractice.com

39

PHARMACOLOGYfocus 70 recruited from centers in China, Australia, and New Zealand with a previously documented experience of transient ischemic attack, stroke, or coronary artery disease and OSA (4% oxygen desaturation index (ODI)>12) were randomized into a CPAP arm of a broader study termed the SAVE trial.

Subjects in this arm reported mouth dryness as an adverse event (along with nasal symptoms, mask fit, and leaking problems). In fact, the most common CPAP side effect at one month was dry mouth. The problem of dry mouth occurred The problem in 38% of the subjects from China and 58% of the subjects of oral dryness from Australia and New Zeais significant land (overall 42%, 115 subjects of 275). enough that Given these results, the ausome CPAP thors involved in the above research concluded that: “In our users have study, increasing side effect discontinued score (including dry mouth) therapy was found to be independently associated with reduced CPAP because of it. adherence at 12 months”. They further state that “interventions to optimize early CPAP use and minimize side effects may be helpful in improving longer term CPAP adherence in patients with CVD and moderate to severe OSA”.11 Other studies have demonstrated that patterns of CPAP adherence are established very early following treatment initiation, even as early as by the fourth night of therapy – further supporting the need for early control of adverse events such as dry mouth.12 The management of dry mouth occurring during the day is fairly straightforward and a number of OTC products are available to assist the patient in reducing dryness.

Excessive dryness occurring during the night that is not caused by disease (e.g. Sjogren’s disease, other autoimmune diseases, etc.) is more difficult to manage but there are now two products on the market which have documented efficacy for managing excessive night time dry mouth, including dry mouth associated with CPAP use.

XyliMelts® for Dry Mouth (OraHealth Corporation, 13440 SE 27th Pl; Bellevue, WA 98005) is one of these products. It is available as an adhering disc which can be adhered to the gingiva or teeth. A XyliMelts oral adhering disc combines 500mg xylitol, a natural non-fermentable carbohydrate that tastes like table sugar, with cellulose gum (cellulose with added carboxy, hydroxy, methyl, and propyl groups plus a sodium ion) and is lightly flavored with peppermint oil. This material is shaped into a disc that slowly dissolves over time. One side is coated with a vegetable gum adhesive, which provides adhesion to the oral surfaces.13,14 Empirical assessment has shown that individuals using XyliMelts oral adhering discs during sleep continue to have the taste of the mild mint flavoring upon awakening. This gustatory effect coupled with possible mechanical stimulation provided by the disc itself has been found, via one study, to reduce the perception of oral dryness upon awakening.15 A similar product has also been shown to increase salivation.16 A number of unsolicited reviews of XyliMelts discs’ efficacy are posted on the internet. Most of these anecdotes report improvement in night time dry mouth not associated with CPAP use. However, several individuals using CPAP have also described their positive experiences when using the product.

These patient anecdotes uniformly praise XyliMelts discs for reducing oral dryness associated with CPAP use.

The following is an example of one such review submitted by an educator in Charlotte, NC. “I wear a full face mask with BiPap sleep therapy nightly for the past year and one-half. The first few months were unbearable, due to dry mouth from the ventilation of the machine. Dry enough to cause tongue sores and to be unable to lift my tongue to speak. Very uncomfortable the first 4 months. Used various moisturizing mouth washes before bed and upon rising, but it did not help prevent the issues – just offered some relief. I stumbled upon the product when I did an online search for dry mouth due to CPAP and BiPap machines. I ordered it immediately from national online health care provider drugstore. When our provider changed, I could no longer get it through my usual sources. I tried other brands at retail drugstores and they were very unpleasant tasting and did not work. I could not tolerate the taste and

Jeff Burgess received his DDS from the University of Washington school of Dentistry, Seattle, and his MSD in Oral Medicine from the University of Washington. He completed a two year post-doctoral fellowship in the Department of Anesthesiology and the University of Washington Medical Center and served 15 years as an Consultant/Attending at the Medical Center Pain Center. He also practiced general dentistry for 10 years and was a Research and Clinical Research Assistant Professor in the Department of Oral Medicine for 15 years. In addition, he had a private practice in Oral Medicine for 18 years. He has been a co-investigator on numerous studies and authored and co-authored multiple chapters in Medical and Dental texts and articles in peer-reviewed journals. He is currently the Director of Oral Care Research Associates which provides research and writing activities for contracted pharmaceutical companies and is the Editor in Chief of the Dental Hub of Health Imaging Hub, an Editor and writer for Medscape and Healthfirst, the Section Chief in Oral Medicine as well as a writer for Consultant, an online Medical Journal, and a writer of continuing education articles for Pennwell .

40 DSP | Spring 2015

PHARMACOLOGYfocus took them out. I did another online search for the product which led me to drugstore.com.

Please keep this product in stock. I have told many respiratory therapist and sleep medicine doctors to make their patients aware of this product. I also tell other CPAP and BiPap patients. The product helps me to adhere to my therapy without dreading the side-effects of the machine”.

Another reviewer from Nashua, NH reports improvement even with co-use of a humidifier.

He/she also comments on concern that CPAP may be contributing to dental caries: “I use a CPAP with full face mask and had a problem where I’d get dry mouth even with a humidifier. I started to get more frequent cavities because this setup a good environment for the bacteria to attack my teeth. These help to keep my mouth from getting dry. We’ll see if the cavities stop”.

A ‘Marianne’ from Green Valley Arizona (along with several others) notes that she is awakened at night because of dry mouth associated with use of the CPAP. All of these individuals commenting report that XyliMelts use helps to reduce dryness and allows them to get back to sleep. She writes: “this product is GREAT, creates saliva flow, and helps me fall back to sleep when my CPAP machine dries out my mouth and wakes me up. It also produced a better check up with my hygienist with less plaque that is caused by dry mouth”.

When considering the efficacy of any pharmaceutical product, reported anecdotes and case series must be interpreted cautiously.

However the above research revealing that CPAP is associated with dry mouth, the studies suggesting XyliMelts oral adhering discs are effective in preventing dry mouth during sleep, and the anecdotal reports supporting the coupling of CPAP intervention with XyliMelts discs as an effective strategy for reducing oral dryness, provide evidence that XyliMelts discs may be a good addition to therapy for improving CPAP comfort. Given that patient compliance has been shown to be directly related to the reduction in dry mouth that occurs during CPAP therapy, the co-use of XyliMelts for Dry Mouth may well contribute to effective long term CPAP use and resulting patient well being. There may also be additional benefit with respect to root surface caries reduction in CPAP users from inclusion of xylitol (which has been shown to reduce risk of disease in this area).

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Yaggi HK, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005; 353:2034-2041 Kim JH, et al. Compliance with positive airway pressure treatment for obstructive sleep apnea. Clin Exp Otorhinolaryngol. 2009; 2(2):90-96.

Ryan S, et al. Effects of heated humidification and topical steroids on compliance, nasal symptoms and quality of life in patients with obstructive sleep apnea syndrome using nasal continuous positive airway pressure. J Clin Sleep Med. 2009; 5(5):422-427.

Baltzan MA, et al. Evidence of interrelated side effects with reduced compliance in patients treated with nasal continuous positive airway pressure. Sleep Med. 2009; 10:198-205.

Borel JC, et al. Type of mask may inpact on continuous positive airway pressure adherence in apneic patients. PLoS One. 2013; 8(5):e64382.

Gay P, et al. Ealuation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep.

2006; 29:381-401.

Bachour A, Maasilta P. Mouth breathing compromises adherence to nasal continuous positive airway pressure therapy.

Chest. 2004; 126: 1248-1254.

Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008; 5(2):173-178.

Hui, et al. Determinants of continuous positive airway pressure compliance in a group of Chinese patients with obstructive sleep apnea. Chest. 2001; 120:17-176.

Engleman HM, et al. Self-reported use of CPAP and benefits of CPAP therapy: a patient survey. Chest. 1996;109:14701476.

Chai-Coetzer CL, et al. Predictors of long-term adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea and cardiovascular disease in the SAVE study. Sleep; 2013; 36(12):1929-1937.

Weaver, et al. Night-to-night variability in CPAP use over the first three months of treatment. Sleep. 1997;20:278-83.

Lee P, Burgess J. XyliMelts time-release adhering discs for night time oral dryness; Abstract accepted for presentation at the Oral Medicine Meeting, May 2009.

Kerr A R, et al. Use of a mucoadhesive disk for relief of dry mouth. A randomized, double-masked, controlled crossover study. JADA, 2010. 14(10):1250-1256.

Burgess J, Lee P. XyliMelts time-release adhering discs for night-time oral dryness. Int J Dent Hyg. 2012 May;10(2):11821) Kerr A R, et al. Use of a mucoadhesive disk for relief of dry mouth. A randomized, double-masked, controlled crossover study. JADA, 2010. 14(10):1250-1256.

A.V. Ritter, et al. Tooth-surface-specific Effects of Xylitol: Randomized Trial Results. J Dent Res. 2013 June; 92(6): 512–517.

for dry mouth

All-natural XyliMelts discs Relieve dry mouth — day and night, even while sleeping!

Long-lasting adhering discs temporarily relieve dry mouth* Available at:

500 mg of Xylitol and oral lubricant coats, moisturizes and lubricates* Increases saliva* Provides relief throughout the entire night* May reduce risk of tooth decay* Freshens breath

Patient samples, wholesale product pricing available.

Call 877-672-6541 or email sales@orahealth.com

Visit XyliMelts.com to learn more * These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.

OR50-108779_PrintCreative2015_Xylimelts_DentSleepPractice.indd 1

41 DentalSleepPractice.com 1/12/15 12:52 PM

NEWdevices

Three Night Comparison Study of the BRX Pro™

by Jeffory J. Wyscarver, RPSGT

Case Study #1

BRX Pro™ appliance

42 DSP | Spring 2015

The patient in this case study is a 57 year old female currently being treated for symptoms associated with TMD and damaged teeth related to nocturnal bruxism with a Full Lower arch occlusal splint prescribed by her dentist. The patient has been wearing the Full Lower Arch bruxism guard for over 15 years but symptoms of jaw pain and ongoing headaches persist. The patient is nearly 100% compliant wearing the guard for tooth protection. The patient was studied using the DDME Bruxism Monitor over 3 nights: 1. Baseline Diagnostic Test: No therapy 2. Current Treatment Test: Lower Full Arch to protect the teeth 3. BRX Pro™ Efficacy Test: Adjustable Dual Arch Occlusal Splint The DDME Bruxism Monitor is FDA approved to be used for the differential diagno-

sis of sleep disorders. The monitor measures oxygen saturation, nasal airflow, abdominal and chest wall volume and synchrony as well as detects the presence of snoring, the magnitude and frequency of nighttime bruxism as well as the other parameters required for the diagnosis of Obstructive Sleep Apnea.

The purpose of the 3 night study was to evaluate DDME’s BRX Pro* appliance for reducing night time Bruxism in comparison to the patient’s current treatment using a Full Lower Arch bruxism guard. It is commonly known that single arch bruxism guards can actually increase airway instability causing increases in severity of Obstructive Sleep Apnea.1 The patient’s three nights studies were reviewed by a Board Certified Sleep Physician and the interpretation of those studies are in the discussion section. *Patent Pending

NEWdevices Data Comparing a Lower Full Arch to the BRX Pro™

The current study was conducted over 3 nights evaluating the patient at baseline using no treatment appliance, while using her current single full lower arch treatment and the third night was conducted using the BRX Pro. Below are definitions of parameters that the DDME Bruxism Monitor quantifies.

• The Bruxism Burst Index (BBI) is the total number of EMG events (of any kind) that occur per hour • The Bruxism Episode Index (BEI) is the total number of EMG events with an area under the curve of the masseter muscle exceeding a proprietary set magnitude threshold.

• A Tonic (Clench) corresponds to at least a 2 second EMG burst.2 • A Mixed (Grind) is an EMG burst characterized as a combination of Phasic and Tonic EMG burst activity which is sustained.2 • The Mean Waking Bite Force (MWBF) is a calibration value measured in microvolts (uV) by asking the patient to bite (clench) down as hard as they can 5 times, relaxing between each clench. These 5 EMG bursts are measured and averaged.

• Phasic, Rhythmic Masticatory Muscle Activity (RMMA) corresponds to at least 3 EMG bursts lasting from 0.25 to 2.5 seconds separated by two inter-burst intervals.2 • Apnea Hypopnea Index (AHI) is the number of apnea and hypopnea events per hour.3 • Oxygen Desaturation Index (ODI) is the number of oxygen desaturations of 3% or greater per hour of sleep as measured by an oximeter.

Figure 1: Summary of Results Baseline

Full Lower Arch

BRX Pro

Apnea + Hypopnea Index

11/hr

7.6/hr

3.7/hr

Oximetry Desaturation Index

7.0/hr

6.0/hr

3.8/hr

Snore %

2.40%

0.70%

0.90%

Bruxism Episode Index

8.1/hr

6.7/hr

4.5/hr

Bruxism Burst Index

19.4/hr

23.5/hr

5.0/hr

Clench

2.7/hr

1.4/hr

1.2/hr

Clench > Mean Waking Bite Force

19%

25%

10%

Grind

1.4/hr

1.4/hr

1.1/hr

Rhythmic Masticatory Muscle Activity

3.9/hr

4.1/hr

1.9/hr

7h 38m

5h 49m

8h 55m

Figure 2: Sleep and bruxism measurements for the three studies

Figure 3: Baseline Clench Energy is 100%; Full lower arch and BRX Pro are % of baseline energy

Test Time

Jeff Wyscarver is a registered polysomnographic technologist (RPSGT) and president of DDME (www.ddmeonline. com • 1-800-513-9337), a company that brings sleep lab technology and services to the dental community.

Figure 4: Baseline EMG Burst Energy is 100%; Full lower arch and BRX Pro™ are % of baseline energy

DentalSleepPractice.com

43

NEWdevices cle activity. A lower frequency of episodes is usually found in normal subjects than in bruxers.4 A lower RMMA indicates good consolidation of sleep as seen in normal subject while a higher RMMA indicates the presence of arousals and bruxism. In this patient, the Full Arch splint actually increased the RMMA episodes compared with baseline, while the BRX Pro significantly reduced the RMMA episodes when compared with baseline.

Figure 5: Airway Stability Improvement as measured by the AHI and ODI

Discussion: Reduction of Bruxism Activity

Using the BRX Pro decreased total energy expended by 73% compared with baseline energy use.

The BRX Pro significantly reduced the total jaw muscle activity when compared to baseline as well as when compared to the full lower arch therapy. This is demonstrated in all of the bruxism parameters, the BEI, BBI, number of clenches, and number of grinds and Rhythmic Masticatory Muscle Activity, (RMMA). When normalized to the total energy expended by the masseter muscle activity at baseline, using the full arch showed there was an increase of 21%. Using the BRX Pro decreased total energy expended by 73% compared with baseline energy use. Assuming that jaw and facial pain is correlated to energy expended through the night, it is likely that the use of the BRX Pro would decrease the patient’s complaint of jaw and facial pain.

Maintaining Airway Patency while treating Bruxism

The three night study was reviewed by a Board Certified Sleep Physician and the patient was diagnosed with mild obstructive sleep apnea. Although use of the Full Arch Splint did lower the AHI and ODI, it did not resolve the condition to bring the patient into a normal range. In this patient, the use of the BRX Pro did resolve the OSA condition and was diagnosed as successfully treated with the BRX Pro. The BRX Pro is not yet approved for treatment of OSA. It is designed to be used for Bruxism treatment while minimizing airway obstructions caused by Full Arch Splints. In this patient that goal was accomplished. The AHI and ODI parameters were used to confirm that it did not increase airway obstruction as has been associated with other bruxism guards.

Rhythmic Masticatory Muscle Activity, (RMMA) is a measurement of masseter mus-

44 DSP | Spring 2015

Summary

The results found in this patient demonstrate that symptoms of TMD and damaged teeth as a result of nocturnal bruxism may be best managed with a device that offloads the contact between the rear teeth while taking into account the position and stability of the mandible. This is evidenced by the overall improvement of sleep quality using the BRX Pro compared to the traditional single arch splint.

In this case the patient has been using a single full lower arch for many years which was successful at protecting her teeth although some TMD symptoms persisted. We believe the continued tooth-to-arch-to-tooth contact while wearing the single arch splint exacerbated the persistent TMD symptoms. While using the BRX Pro the offloading of the toothto-tooth contact and the maintaining of the mandible in its natural neutral position further reduced the overall Parafunctional EMG activity compared to the Parafunctional EMG activity measured while wearing the single arch splint. Further research is needed to see if this same effect is seen in disparate patients.

BRX Pro Description

The BRX Pro™ is an adjustable dual partial arch occlusal splint designed to alleviate nocturnal bruxism while maintaining the position of the mandible. This is achieved utilizing 2 key design components: First the BRX Pro maintains the mandible in a neutral and natural position by utilizing a four position adjustable anterior hinge that allows both lateral and anterior-posterior mandibular movement to prevent a fixed tension on the masseter muscles, a known cause of oral appliance discomfort. Secondly, the trays used to fabricate the customized appliance are only partial arches covering approximately 80% of the tooth arch, which effectively leaves the posterior teeth separated by an air gap that prevents both direct tooth-to-tooth contact as

NEWdevices well as the force contact that occurs through a full arch bruxism guard. The result is effective tooth protection without compromising the performance of the airway seen in many patients using single arch splints as well as a significant reduction in masseter muscle activity.

The fabrication of the appliance is extremely simple so that a hygienist or other trained office staff can construct the appliance using a process that is identical to taking impressions to send to a dental lab. The position on the interlocking trays is set by the dentist following a consultation with the patient. The position of the interlocking arches is a key component and places the mandible in its natural neutral position. Maintaining the mandible in this position obviates the effects of the single arch occlusal splints often interfering with the patency of the airway

during sleep. The correct setting of the trays is of primary concern as there is a known correlation between airway patency and the frequency of nocturnal bruxism for many patients.1 (see appendix A) The BRX Pro should be the first choice for patients with persistent bruxism or who demonstrate characteristics known to present with a propensity for increased airway obstruction using single arch appliances.

References 1.

Gagnon et al., Aggravation of Respiratory Disturbances by the Use of an Occlusal Splint…The International Journal of Prosthodontics, volume 17, number 4, 2004 2.

G.J. Lavigne*, et al., Sleep Bruxism: Validity of Clinical Research J Dent Res 75(1): 546-552, January, 1996 3.

Division of Sleep Medicine at Harvard Medical School, Feb 11, 2011, http://healthysleep.med.harvard.edu/sleep-apnea/ diagnosing-osa/understanding-results 4.

G.J. Lavigne*, et al., Rhythmic masticatory muscle activity during sleep in humans. J Dent Res. 2001 Feb;80(2):443-8.

Appendix A: 14 Patient Evaluation of Pre and Post Occlusal Splint and the Effects on AHI and Bruxism AHI Baseline

AHI Splint

BBI Baseline

BBI Splint

BEI Baseline

BEI Splint

ODI Baseline

ODI Splint

SNI Baseline

SNI Splint

Arch Type

1.

22.2

34.2

17

31.2

22.2

7.6

21

21

33.1

31.2

Upper

2.

16.7

12.5

12.1

3

4.4

10.6

10.2

14.2

30.2

27.3

Full arch

3.

9.1

17.6

2.2

12.5

1.4

4.8

8.6

18.4

25.8

18.6

Full arch

4.

7.9

15.7

21.3

9.6

5.1

3.1

8.7

9.6

19.5

27.5

Full arch

5.

4.6

11.1

9.3

36.3

3.9

6.8

4.7

13.6

9.1

0.1

Lower

6.

6.4

4

31.4

55.6

9.1

15.5

3.3

3.6

9

9.8

Upper

7.

6.4

7

31.4

60.2

9.1

15.4

3.3

6.1

9

13.2

NTI

8.

13.3

25.5

3.1

16.9

1

5.2

13.5

24.4

44.9

11.1

Upper

9.

3.4

6.2

14.1

21.2

4.7

6.7

3.6

7.1

0.3

0.1

Lower

10.

13.1

26.2

4.1

0.6

1.7

0.6

6.6

19.8

44.8

48.5

Lower

11.

8.5

9.6

11.4

4.8

3.5

1

7.6

11.5

5.1

1.7

Full arch

12.

24.6

12.4

12.1

11.9

4.5

2.2

19.8

10.8

30.3

45.3

“Orthotic”

13.

9.9

12.6

3.3

41.9

1.8

6.8

9.9

12.9

0

0

NTI

14.

0.8

1

17.5

5.4

7.3

3.2

0

0.6

0.4

7.5

Full arch

10 of 14 worsened

8 of 14 worsened

9 of 14 worsened

11 of 14 worsened

6 of 14 worsened

This chart supports the pilot study by Gagnon ET. Al., in that 10 out of 14 patients prescribed a single arch splint experienced a worsening of the AHI. AHI = Apnea + Hypopnea Index BBI = Bruxism Burst Index

BEI = Bruxism Episode Index ODI = Oximetry Desaturation Index

SNI = Snore Index

DentalSleepPractice.com

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ADJUNCTIVEcare

Whole Body Alignment: Physical W Therapy for TMD

by Kathy Johnson, PT 46 DSP | Spring 2015

hat percentage of patients that you have fit with an anterior mandibular positioning device return complaining of jaw and/or face pain? One study reports the incidence as high as 40% in longterm users, and up to 50% of all patients quit using the device because of dissatisfaction with side-effects.1 What if you could increase compliance by addressing undesired pain without increasing the patient’s time in your office?

Referral to a qualified Physical Therapist may be the answer.

ADJUNCTIVEcare Physical Therapists (PTs) are health professionals who specialize in the evaluation and treatment of pain and dysfunction arising from the neurological, cardiopulmonary, integumentary, and musculoskeletal systems.

Since 2002, all graduates of accredited Physical Therapy educational programs hold a DPT, or Doctor of Physical Therapy, degree.

This requires completion of 3 years of physical therapy training after achievement of a bachelor’s degree. In addition to didactic and clinical training, there is a strong emphasis on reading, reviewing, and conducting research to fit with the American Physical Therapy’s mandate for Evidence Based Practice.

Physical Therapists treat physical pain and dysfunction with modalities such as heat, cold, electricity and light, and use manual techniques of therapeutic massage and joint and soft tissue mobilizations. PTs are experts in addressing posture and body mechanics as causative or contributing factors and excel in patient education and the prescription of specific therapeutic exercises. All states require continuing education as a requirement for licensing. Some PTs voluntarily chose to gain additional certifications in their field of choice.

Over the past 10 years my patients and I have benefitted from the close working relationship established between myself and dentists that specialize in the evaluation and treatment of occlusal muscle dysfunction, oral-facial pain, and TMD. Just as I know that some of my patients will not reach their comfort and functional goals without dental intervention, I also believe that some TMD and facial pain patients benefit from Physical Therapy intervention in addition to the dental component. This is supported in the literature.1,2,3,4 The primary indication for dental

referral to PT is TMD with concurrent neck pain.5,6 Due to the high prevalence of asymptomatic cervical spine dysfunctions identified in their study group of TMD patients, Fink et al recommend a thorough examination of the neck even in the absence of reported pain or problems.7 Patients that develop occlusal muscle dysfunction with use of a mandibular advancement device may present with complaints of pain at one or both TMJ in the absence of joint pathology. Pain and tenderness may also be present in the superficial and deep masseter on one or both sides. Other complaints may seem unrelated, but are actually common referred pain patterns arising from trigger points in the face and neck muscles. These include complaints of occipital or temporal headaches of new onset, pain behind the eyes, mastoid pain, a feeling of pressure, stuffiness, or ringing in the ears, pain in the vertex of the head, and teeth that hurt (upper or lower) in the absence of tooth pathology. Other indications for referral to a PT include: forward head positioning,8,9 and pain caused or influenced by static postures or movement.10 Many dentists ask the patient on the intake form for the names of any ancillary health professionals that they are currently seeing. If they list a PT, a phone call to that provider can establish whether that person has the interest and ability to provide adjunctive care. The most elucidative question is simply; how would you evaluate and treat this patient with oral-facial pain or TMD? The answer would preferably include a wholebody approach. For example, I always address overall posture, not just forward head positioning or head tilt, and often make recommendations for foot orthotics if needed for optimal positioning or stability. It is

Kathy Johnson graduated from the University of North Dakota with a BS in PT in 1981. Her passion for helping patients with orthopedic and postural dysfunctions led her to pursue many hours of continuing education and additional training. She received her Postural Restoration Certified (PRC) designation in 2009. Kathy has provided education to dentists with a multi-disciplinary approach in the treatment of TMD as visiting faculty at the Pankey Institute and Spear Education, and throughout the country and abroad at dental study groups.

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ADJUNCTIVEcare mandatory to address static posturing, such as neck positioning with the use of personal hand-held devices; think smart phones, and parafunctional habits like propping their chin on their hand, stomach sleeping, or sleeping with their hand under their jaw. In addition, a thorough review of their work and leisure activities will help to identify and correct underlying problems in body mechanics that can have an adverse impact on the head and neck. Although the use of physical agents or modalities such as various types of heat energies can be helpful to reduce pain and inflammation, the use of PTs are experts in posture manual techniques has been provand body mechanics and en to be effective in the treatment of neck and oral-facial pain.11,12 excel in patient education Manual techniques include soft tissues mobilizations and massage, as well as mobilizations to the TM and neck joints. The dental professional should direct any mobilizations to the temporomandibular joint based on the perceived or diagnostically confirmed position of the disc and condyles, and the desired result; i.e. improved MO or excursive movements. Communication between the dentist and PT is an essential component to achieving optimal results.

Finding a qualified PT need not be a time-consuming effort. Checking with your peers may yield leads in your area. On-line resources are also available. PTs who are members of the American Physical Therapy Association (APTA) may list their name and brief biography. This can be accessed at apta.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

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org. Click on “For the Public”, then “Find a PT”. Refine your search by choosing ‘Musculoskeletal’ as the Practice Area. Look for individuals in your area that indicate proficiency in TMJ/jaw and facial pain, or those with Orthopedic Clinical Specialist (OCS) designation. My specialty area is in Postural Restoration™. Therapists with the designation of Postural Restoration Certified (PRC) can be found at posturalrestoration.com.

Click on “Find a Provider”. Physical Therapists who are members of the American Academy of Orofacial Pain can be found at aaop.org. Click on “Patient Resources”, then “AAOP Member Directory”. Finally, PTs that have completed a post-graduate proficiency in Cranio-Facial can be accessed via usa. edu. Click on “Continuing Education”, then “Certification Graduate Listing”. Look for the CFC (Cranio-Facial) designation. If there are no specialists in your geographic area, you can cultivate good working relationships by inviting local PTs to your office for educational networking, or including them in a study group meeting.

The partnership between a dentist and a Physical Therapist can be rewarding from the professional standpoint of offering your patient another avenue for improved health and wellness, and also from a personal standpoint of advancing your own knowledge base as you reach out to another health care professional. Although a goal of 100% compliance with your MADs may be unrealistic, we owe it to our patients to optimize their comfort as they pursue sleep apnea treatment.

Clark GT, Sohn JW, Hong CN. Treating obstructive sleep apnea and snoring: assessment of an anterior positioning device. J Am Dent Assoc 2000 Jun;131(6):766-71. de Toledo EG Jr, Silva DP, de Toledo JA, Salgado IO. The interrelationship between dentistry and physiotherapy in the treatment of temporomandibular disorders. J Contemp Dent Pract. 2012 Sep 1;13(5):579-83.

Wright EF, North SL. Management and treatment of temporomandibular disorders: a clinical perspective. J Man Manip Ther.

2009;17(4):247-54.

Di Fabio RP. Physical therapy for patients with TMD: a descriptive study of treatment, disability, and health status. J Orofac Pain. 1998 Spring;12(2):124-35.

Weber P, Corrêa EC, Ferreira Fdos S, et al. Cervical spine dysfunction signs and symptoms in individuals with temporomandibular disorder. J Soc Bras Fonoaudiol. 2012;24(2):134-9.

Olivo SA, Fuentes J, Major PW et al. The association between neck disability and jaw disability. J Oral Rehabil. 2010 Sep;37(9):670-9.

Fink M, Tschernitschek H, Stiesch-Scholz M. Asymptomatic cervical spine dysfunction (CSD) in patients with internal derangement of the temporomandibular joint. Cranio. 2002 Jul;20(3):192-7.

Wright EF, Domenech MA, Fischer JR Jr. Usefulness of posture training for patients with temporomandibular disorders. J Am Dent Assoc.

2000 Feb;131(2):202-10.

Makofsky HW, Sexton TR, Diamond DZ, Sexton MT. The effect of head posture on muscle contact position using the T-scan system of occlusal analysis. Cranio. 1991 Oct;9(4):316-21.

Mannheimer JS, Rosenthal RM. Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dent Clin North Am. 1991 Jan;35(1):185-208.

Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006 Oct;24(4):283-91.

Tuncer AB, Ergun N, Tuncer AH, Karahan S. Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders: A randomized controlled trial. J Bodyw Mov Ther. 2013. Jul;17(3):302-8.

PRACTICEbuilding

Building Partnerships with Physicians when Treating Craniofacial Pain

by Dr. Mayoor Patel

I

t has been estimated that approximately 45 million Americans complain about headaches alone each year; almost 1 out of every 6 people. Pain referral patterns can result in misdiagnosis, potentially leading to unnecessary or ineffective treatment.

With such a large portion of the population not getting the right treatment for what are often debilitating disorders, there is an incredible need for dentists, trained in diagnosis of common pain complaints in the head and neck, to connect with other healthcare providers.

Often referred to as “The Great Imposter” due to the wide array of symptoms that may mimic other conditions, diagnosing and treating temporomandibular joint disorders (TMD) and craniofacial pain is an important responsibility of the dentist. Ranging from headaches to ear pain to jaw pain and even tooth or sinus pain, your patients can feel discomfort without being able to specify many details. At times, the cause is of dental origin but there are many other reasons to consider.

Assessing craniofacial pain is a team effort, with the patient’s Dentist, GP, ENT, Neurologist, Physiatrist, Physical Therapist, and Psychiatrist all potentially playing a role in diagnosis and treatment. A dentist must understand what physicians do in their diagnostic workups and treatments and when it’s necessary to refer out to truly understand their own role and fulfill the dentist’s duties in patient care. Although the majority of head and facial pain symptoms are benign, they can be a harbinger of a more serious underlying disease.

Establishing referral relationships across many physician specialties provides the

50 DSP | Spring 2015

dentist with needed resources. Additionally, just as the medical professionals you’ll be working with are billing medical insurance, most medical insurance covers craniofacial pain diagnosis and/or treatment, even when performed in a dental office. Your comfort with billing medical insurance and the fact that over 30 states have mandated coverage for craniomandibular or temporomandibular joint disorders is important to share with physicians you’ll be working with and will increase their confidence in making a referral.

What is Craniofacial Pain?

The field of craniofacial pain/orofacial pain treatment refers to pain associated with the hard and soft tissues of the head, face, and neck. This includes the diagnosis and management of complex acute and chronic craniofacial pain disorders which may be categorized as neuropathic, neurovascular, chronic regional pain syndrome, masticatory with interrelated cervical pain disorders, headache disorders, TMD, craniofacial sleep disorders, and other disorders causing persistent pain and dysfunction.1, 2 The potential for pain arising from and referred to the trigeminal receptive fields is why evaluation and management of orofacial pain requires collaboration among many fields of medicine.3 It is important for dentists to understand what their responsibilities in treatment are in order to effectively conduct their portion of care, while also developing working relationships with medical colleagues.

When it comes to aspects of craniofacial pain such as headaches, migraines and jaw pain, the underlying cause can often go un-

PRACTICEbuilding diagnosed, or even misdiagnosed. The general assumption is it’s “just a headache or some sort of pain.” Patients may feel that taking an analgesic to make the pain go away is all that is necessary. Without diagnosis, the cause cannot be addressed and clinically important time may pass without proper action.

By learning how to diagnose and treat craniofacial pain, dentists gain a great power to change their patients’ lives. With great power comes great responsibility for the proper diagnosis and management of pain in and around the mouth, face and neck.4 The complete dentist is cautious about assuming her/his treatment plan will always be the only treatment required.

Why Develop a Working Relationship with a Medical Professional?

Many patients will find themselves in a neurological, primary care, chiropractic, pain management or an ENT’s office, but that may not always be the best place to receive appropriate care. As the graphic shows symptoms can present in many other areas.

In many cases, medical practitioners and dentists are stumped by the vast crossover of symptoms their patients are experiencing.

For example, a patient may complain of TMJ pain, but is actually suffering from a disease or infection of the ear, nose or throat. It is also common for a patient to complain of ear pain when in fact the pain is related to an affected TMJ (see image). These patients may be in the

incorrect practice seeking treatment, or the clinician is frustrated that prescribed therapy based on the symptoms are not resolving the patient’s complaints.

I’ve stated that craniofacial pain may be caused by conditions other than dental in nature. Whether it is neurological or sinus related, you want your patients to get the best care

Dr. Mayoor Patel received his dental degree from the University of Tennessee in 1994. After graduation he completed a one-year residency in Advanced Education in General Dentistry (AEGD). In 2011 he completed a Masters in Science from Tufts University in the area of Craniofacial Pain and Dental Sleep Medicine. Dr. Patel has earned a Fellowship in the American Academy of Orofacial Pain, American Academy of Craniofacial Pain, the International College of Craniomandibular Orthopedics and the Academy of General Dentistry. He also became a Diplomate in the American Board of Dental Sleep Medicine, American Board of Orofacial Pain, American Board of Craniofacial Pain and American Board of Craniofacial Dental Sleep Medicine.

Presently, Dr. Patel serves as a board member with the Georgia Association of Sleep Professionals, the American Board of Craniofacial Dental Sleep Medicine and American Academy of Craniofacial Pain. He also has taken the role as examination chair for the American Board of Craniofacial Dental Sleep Medicine and American Board of Craniofacial Pain. He has also taken the role as Director of Clinical Education for Nierman Practice Management.

With extensive dental knowledge and expertise, Dr. Mayoor Patel has served as Director of Dental Sleep Medicine for FusionSleep from 2008-2014 and as Adjunct Faculty Member at Tufts University from 2011-2014. He presently is an Adjunct Faculty member with Georgia Regents University and The Atlanta School of Sleep Medicine.

Since 2003, Dr. Patel has limited his practice to the treatment of TMJ Disorders, Headaches, Facial Pain and Sleep Apnea. Additional contributions have been published textbook chapters, consumer book on treatment options for sleep apnea and various professional and consumer articles. He also holds patents on oral appliance for sleep apnea and other related products.

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PRACTICEbuilding available, and that means joining forces with other medical professionals. From neurologists and otolaryngologists to family practitioners, it is important to create a working relationship with each in order to discuss or refer for diagnosis and management of your patients when further assistance is needed.

How Do You Develop a Working Relationship?

By learning how to diagnose and treat craniofacial pain, dentists gain a great power to change their patients’ lives.

52 DSP | Spring 2015

In order to create this working relationship, it is important that you give physicians and their staff confidence that your practice will provide exceptional care for their patients. By speaking their language and sending standard medical SOAP format narratives that document your patients’ treatment, you demonstrate to physicians that your practice has established proper protocols.

Medical professionals prefer written communications about their patients. Typically, a brief narrative describing subjective findings, objective findings, assessments and the proposed treatment plan (SOAP) is the preferred method. At my office, we utilize DentalWriter™ software—it is our workhorse. For every patient examined, a letter is sent to their primary care doctor, dentist, and the referral source. Letters are only sent if patients provide us with a HIPAA release allowing us to share their information. Generally, our patients are happy to allow us to send such communications to the appropriate medical professionals and often this is the first time they’ve seen such a commitment to collaborative care.

Three letters will be sent: When we see a new patient, if treatment is initiated, and at completion of treatment. With every initial letter we will attach a one-page fact sheet that is a compilation of summarized abstracts from journals that the respective specialist may read. The abstracts are research papers showing the associated symptoms with TMD such as headaches, jaw pain, unexplained tooth pain, otalgia and so on. We have one for Primary Care Medicine, Neurology, ENT, Sleep Physicians and Dentistry. We include a sheet with every letter to the respective specialty in order to help educate the Physician Assistant (PA), Nurse Practitioner (NP) or the physician themselves of symptoms that mimic TMD and alert them to cases that they may not have seen success in.

When it comes time to refer a patient due to uncertainty or the need of a specialist to

help with diagnosis and management, picking up the phone works. Interestingly, I never have experienced a push back from the physicians when we asked about a patient that we would like to send over. Over time, your patients will help you learn important bedside manners that a physician exhibits when they may have seen them for their symptoms.

We keep a record of the physicians we have heard positive things about and try to utilize them for patients we may need to refer. We prefer to use medical professionals that are close to the patient’s work or home.

Additionally, I try and make it a point to go to the physician’s office to introduce myself. While there, I may also get a chance to speak or meet with the office manager or the referral coordinator. I find that face-to-face time with the NP and PA pays off better. Ultimately, the NP and PA see many patients for follow-up care, and by educating them on what we do, we can help with getting referrals. Conversely, I have yet to have a negative response when advising them that we have patients that may come to us first and may need their area of specialty to assist with diagnosis and management.

Another good way to develop a working relationship and to have physicians understand what you can offer their patients is an in-service to educate their medical team.

Once we have utilized a physician and have set up a lunch meeting, we will bring in lunch and present, in brief, all the high points of what a dentist such as myself can offer to their patients. The opportunity at hand allows face-to-face time for the medical professionals and their team to meet you and ask questions. Time is always valuable so keep your presentation short and to the point.

Join forces with other medical professionals to provide the best care for your patients.

Whether it is ear, dental or head related, a working relationship with the medical professionals in your community is essential in providing proper treatment and becoming a hero to your patients!

References: 1.

Bell WE: Orofacial Pain. Classification, diagnosis, management.

4th edition. Chicago:Year book medical publishers, 1989 2.

Simmons CH: Craniofacial Pain. A handbook for assessment, diagnosis and management. Chattanooga: Chroma inc, 2009 3. de Leeuw R: Orofacial Pain. Guidelines for assessment, diagnosis and management. 4th edition. Chicago: Quintessence Publishing, 2008 4.

Okeson JP: Bells oral and facial pain. 7th edition. Chicago: Quintessence Publishing, 2014

PRACTICEmanagement

by Dr. Richard Drake Diplomate, ABDSM

Start Screening your patients today!

E

ach week, millions of Americans enter dental offices to get their teeth cleaned or a tooth filled, and unbeknownst to them they have a disease that is literally sucking the life out of them every night. In a previous issue of DSP, my Dental Sleep Solutions partner, Dr. Gy Yatros, referred to Dental Sleep Medicine (DSM) as a mosaic. I would like to use another analogy and highlight the importance of a strong foundation for each of the four pillars of our field. Unless you have a defined protocol in place for each of these, you are not likely to succeed at making DSM a more integral part of your practice. I’ll classify these pillars as: 1. Screen 2. Test 3. Treat 4. Insurance

Are you screening your existing patient population for Sleep Disordered Breathing (SDB)? Once they are screened, do you have a defined, repeatable system in place to get them sleep tested? If you’re not, you’re doing your patients a great disservice, and you are leaving money on the table. We have been teaching dentists how to implement DSM into their practices for several years now and regularly hear novice dentists inquire about how they can acquire new DSM patients.

“Should I run a radio ad?”

“What about a billboard?”

The answer again is, “Start SCREENING your patients today!” Look no further than your own waiting room! You can put an Epworth Sleepiness Scale onto your letterhead and start the process of screening every adult patient who walks through your door tomorrow. You can use the STOP BANG or the DS3 Screener. Sounds simple, but it’s not, because you and your team have to be prepared to help your patients take the next step.

If they ask ‘What does the screening number mean?’ you have to know how to answer. You and your staff have to believe in what you’re doing, and that you’re doing it for the right DentalSleepPractice.com

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PRACTICEmanagement

You and your staff have to believe in what you’re doing

reasons. Staff members don’t want to feel like they are selling something. So educate yourself AND your staff.

I have a daughter in law who just loves to cook. And she’s quite the chef. With a little prodding, she revealed her secrets to me: You buy the best cookbook and you simply follow the instructions! Wow. What a concept.

Create a system, a cookbook, and follow the recipe.

Screening helps to identify at risk patients. Now you have to get the patient to acknowledge that he may indeed have a problem. Sometimes this is easy, and sometimes it is near impossible, but using learned verbal skills can prove quite valuable at getting the patient to move on to the next step, testing.

“Our screening process has identified you as being at high risk for sleep disordered breathing. It’s like a skin lesion that looks very, very suspicious of being cancerous. If I saw that and said you should get it biopsied you would agree. It’s just harder to see sleeping and breathing problems, but they still exist and you need to get tested.”

Make it easy for your patients to get a Sleep Test.

Back in the old days (since I’m an old guy and have been doing DSM for many years), the only sleep testing option I had was to refer the patient to the local sleep doctor who also owned the only sleep lab in town. I would refer ten patients to him a month, and he would call them and beg them to come in and get a sleep lab test done, but only about half would ever go. In-lab polysomnogram (PSGs) are not the only game in town anymore, thank goodness. We now have multiple companies who offer Home Sleep Testing (HST) services, and having an additional

Richard B. Drake, DDS, received his DDS degree from The University of Texas Health Science Center (UTHSCSA), Dental School in 1989. Thirteen years ago, after a fishing trip to the Amazon where he spent several nights in a tent with a champion snorer, he sold his general practice and now splits his time between patient care and helping dentists implement dental sleep medicine into their practice. He has treated thousands of patients with dental devices, yet his passion in this field continues to grow. He is the co-founder of Dental Sleep Solutions and DS3, a system to help dentists implement dental sleep medicine into their practices.

54 DSP | Spring 2015

service choice means that a greater percentage of the patients we identified through our screening process end up actually getting tested. Which test, a PSG or a HST, should you recommend for your patient? That’s a great question, and the American Academy of Sleep Medicine (AASM) has guidelines to help, but in the end, the one the patient’s insurance will pay for is likely the one the patient will utilize. We’re not here to debate the pros and cons of each sleep test; we just want our patients tested. Either test is good, but it is very important that you have the test interpreted by a Board Certified sleep physician who will make the diagnosis. Again, verbal skills play an important role in getting patients to the next step. Dental Sleep Solutions teaches our dentists to ask: “Would you prefer to do a sleep test in the local sleep lab or in your own home?” (Pause, for effect, since the next person who speaks loses.) Consider insurance and cost, of course, but get the patient to acknowledge that he may have a problem and that he needs a test. Then make the appropriate referral, and by this we mean create the referral form, fax it to the entity that will do the test, and create a task for yourself in DS3 to follow up with the patient three days later to make sure they have scheduled the sleep test. And finally, schedule the patient for a consultation four weeks later. Scheduling the patient creates accountability and puts a timeline on everything. Now, get a copy of the patient’s medical insurance card. (You’ll need this for later!) Task yourself for one week before the patient comes back for the consultation to collect and verify his insurance benefits.

Contrast this scenario with what most dentists typically do: identify an at-risk patient and recommend he get a sleep study. Then schedule him for his next six month prophy. Half a year later, do the same thing again since the patient never was tested. Insanity, remember: doing the same thing over and over hoping for a different result. Meanwhile, your patient’s health may be suffering every night the airway closes, over and over and over.

Summary

• Educate yourself AND your staff • Begin screening all adult patients • Have systems in place to get patients tested Stay tuned for next issue when we’ll highlight treatment and insurance.

TEAMfocus

I Stopped Snoring, but Now My Jaw Hurts!

by Glennine Varga, AAS, RDA, CTA

T

his is a remark often heard by team members in a dental sleep medicine practice, but it’s also a question. There are many factors that can affect the TM joints of patients in oral device therapy; muscle soreness, joint pain, repositioned condyles, changed bites, and sore teeth are on the list of complaints a patient may have. How do we handle this? What happens with medical insurance and what do we say to our patients?

TMD is an acronym for temporomandibular dysfunction, which includes muscles, joints, and occlusion. When patients are vague about explaining a TMD issue, it may be because it’s hard to pinpoint the problem.

No need to get concerned and panic – the patient will feel your fear. Instead, calmly help your patient identify and share their true concerns and brief your doctor so she/he is prepared to focus on diagnosis and solutions.

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The issue may have a simple solution like morning bite exercises.

Just like with OSA it is important to obtain a diagnosis. If you are in a practice that actively treats TMD patients chances are you have a protocol in place which could range from extensive history taking to CT scans. If you are in a practice that offers minimal to no TMD treatments chances are a referral would be made. In either case, communication and prevention are as fundamental as an informed consent and written homecare instructions.

A good defense is the best offense. Being upfront with patients on expectations prior to committing to treatment is everything. A strong informed consent should include information on possible side effects, what is expected of the patient and what would happen in the event of unusual symptoms or discomfort. Typically, if a problem should arise, an evaluation of the situation is needed to deter-

TEAMfocus mine action and will be handled separately from the oral device therapy. The informed consent should be explained to the patient in detail and make sure to give patients a copy and time to look over and understand before signing. If an informed consent is absent or does not include this information get with your doctor about revising it. Dr. Berley writes about this in his column this issue.

As great team members, we strive to support our doctors and patients to have the best experiences with therapy. Here are some suggestions that may help to reduce the number of TMD issues with oral device therapy. First, be observant while taking records for the fabrication of the device; for example, recording deflections of the jaw during protrusive measurements. If you are in charge of recording this information and you notice the jaw moving off to one side, make sure your doctor is well aware of this before taking a bite registration. Next, some practices allow patients to advance their own devices. In these situations it is critical patients know how to do it properly. Team members help make sure they do, with written instructions and hands-on practice to have patients demonstrate their understanding. Also, morning bite exercises are key in maintaining a stable bite. When the mandible is suspended in a forward position all night, synovial joint fluid can build up in the TM joints, jaw muscles can get sore and or stiff and patients may have a hard time “finding their bite”. These exercises are essential in maintaining centric occlusion and reducing possible bite changes in the future.

Patients might feel questions about these areas are ‘too simple’ to ask the doctor about; that puts the team member in the perfect place to help.

Patients sought your doctor’s help for sleep breathing problems, most of them without TMD concerns. Your initial assessment didn’t turn up any particular risk, but some patients return to the office with pain or another of the common TMD symptoms.

Now they have two problems: chronic sleep disordered breathing managed by your mandibular advancing device, and TMD. This second problem requires treatment. Is this separate from the original diagnosis? I think so! What do we say to patients who ask “I didn’t have jaw pain before your appliance, now you want to charge me for treating that too?” If your doctor has already evaluated

the situation and you are discussing finances, have the signed informed consent ready to remind the patient of what was explained, understood and agreed upon before starting treatment. Let the patient know the treatment charges are separate. Depending on the insurance policy, medical benefits may be available for TMD therapies. However, a proper diagnosis and diagnostic code should be selected when billing TMD to medical insurance and medical necessity will need to be established. Ultimately, it will be the decision of the claims processor or sent to a medical examiner for review. Typically it’s best to keep the therapies separate. However, there are always exceptions to this rule so team communication is critical for Great teams patients to hear a consistent message in support patients what can be a touchy situation and individual patients may be treated differently. to have the In conclusion, identify if your office best experiences. offers TMD therapies and what the diagnostic process is. Hopefully, TMD risk is assessed prior to starting therapy and a treatment plan can be given for both. If TMD symptoms arise after therapy begins it’s best to keep the treatments separate. Keep in mind it’s not fair for our doctors to provide two therapies for the cost of one.

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

Glennine Varga is a certified TMD assistant and educator with an AA of sciences. She is a certified TMD assistant with the American Academy of Craniofacial Pain.

She has been employed in dental education for over 18 years. Glennine is certified in radiology, electrodiagnostics, expanded duties dental assistant in the treatment of temporomandibular disorders. She has been a TMD/ Sleep Apnea trainer and speaker with emphasis on medical billing and documentation for over ten years and has trained the use of electrodiagnostic equipment for five years. Glennine is currently employed, full time, by IDEA Communications including OSA University. Glennine has trained and assisted hundreds of dental offices on practice management, TMD/Sleep Apnea concepts, medical billing and team training.

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PRACTICEmanagement

Rose’s Reimbursement Rules

Does New Legislation Mandate TMJ Treatment in your State?

by Rose Nierman

W

ould medical reimbursement help your practice increase both the number of TMJ Disorder (TMJD) cases you treat and the revenue per case? If so, you may be in luck because the Affordable Care Act (ACA), commonly known as Obamacare, has prompted close to 70% of US states to mandate this coverage!

With so much opportunity for reimbursement, I cringe when I hear about dental practices eating up patients’ dental insurance by billing the wrong insurer when the treatment may be medically necessary.

Prior to the Affordable Care Act (ACA), 20 States mandated treatment of TMD. My research has uncovered 34 states that either have coverage in their “Benchmark Plan” or have deemed “TMJ” to be an Essential Health Benefit (EHB). The ACA’s improvements for TMD coverage doesn’t stop there! Some of the states that had already mandated coverage have enhanced rules or have eliminated barriers such as dollar limitations, though a few states continue to allow such limits.

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TMD Billing Rules

• You’ll be asked by the medical insurer to demonstrate that TMD treatment is medically necessary. A SOAP type narrative report showing the patient’s subjective complaints, objective exam findings, assessment and plan is the most common format for medical necessity. Include the ICD diagnosis codes in your narrative report to corroborate medical necessity.

• Verify pre-authorization rules and precise coverage for each policy. Confirm every procedure code you expect to bill during a verification phone call and let the insurer know the expected length of treatment.

• Physical therapy procedures may require that a Registered Physical Therapist perform the services. I make it a rule to ask about this during the verification process.

• When the patient does not have out-ofnetwork benefits, request a GAP exception using the “network insufficiency rule.”

• Across the markets and plans examined, Durable Medical Equipment (DME) is an

PRACTICEmanagement Essential Health Benefit in 49 states. As a rule, sleep apnea appliances are categorized as DME and, for this reason, are covered! TMD appliances are considered DME by some commercial carriers but not by Medicare.

• Remember, even if your state does not mandate TMD, many insurance carriers cover exams, radiographs, TMJ orthotics or appliances and follow-up visits so it’s well worthwhile to verify each plan. You may also want to check into your state’s nondiscrimination statute regarding health care providers and if TMJ treatment legislation is pending.

TMJ Treatment State Examples of Coverage

Each state has a Benchmark Plan connected to the ACA that “sets the bar” for other health plans in your state. With up to 34 states having different mandates, we can’t list them all, but here are a few examples of some of the new state-specific Benchmark Plans. If your state didn’t make the example list, don’t worry, just contact us and we will help you understand where your state stands.

California: Covers TMJ surgical, diagnostic and medically necessary procedures:

Mississippi: The MS Benchmark Plan limits TMJ Surgery/Diagnostic Services and removable oral appliances for TMJ to $5,000 Lifetime Maximum Benefits.”

Georgia: TMJ treatment is an Essential Health Benefit. The policies I reviewed have coverage of “Treatment of temporomandibular joint syndrome (TMJ) or myofacial pain, including only removable appliances for TMJ repositioning and related surgery and diagnostic services.”

Illinois: State law mandates coverage as an Essential Health Benefit.

THE CALIFORNIA BENCHMARK PLAN - TMJ COVERED SERVICES: • • • •

Medical treatment such as cortisone injections, muscle relaxants, and pain medications Physical therapy Splint therapy Surgical/arthroscopic treatment of TMJ when conservative medical treatment has failed and surgery to reposition the upper or lower jaw.

Florida: Since 1996, Florida has required that surgical and diagnostic services related to the temporomandibular joint and the jawbone must be covered, when medically necessary. Now, payment for splints for Temporomandibular Joint (TMJ) Dysfunction is an Essential Health Benefit.

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, TMD/orofacial pain and Cross-Coding from dental to medical insurance. Rose’s systems and teachings have helped thousands of dentists grow their practices through the implementation and expansion of Dental Sleep Medicine, TMJ treatment and oral surgeries.

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Washington State: As an EHB, “TMJ Treatment covers abnormal range of motion or limitation of motion of the TMJ; arthritic problems with the TMJ; internal derangement or pain in the musculature associated with the TMJ.”

“Healing is a matter of time but it is also sometimes a matter of opportunity” - Hippocrates

In treating sleep patients, you will often uncover problems they have with TMD or using the device you provide will result in some jaw pain. Now you know that coverage might help you and your patient deal with this! Get prepared for this conversation and you’ll be ready to give better service to your patients.

For more information, feel free to contact me through http://www.dentalwriter.com/ for a TMJ Treatment Mandate Fact Sheet for your State.

LEGALledger

A

s you know by now, this issue is dedicated to TMD complications secondary to Oral Appliance Therapy. I have resisted writing on this subject because it is so complicated and difficult to adequately cover in a short article. However, upon request and hereby and forever under protest, I will attempt to cover this subject as efficiently as possible in the space I have available.

From a legal perspective, TMD dysfunction secondary to Oral Appliance Therapy is problematic given that some medical insurance companies restrict the fabrication of an Oral Appliance for the treatment of OSA if the patient has TMD. Additionally, if care is not taken when TMD dysfunction develops secondary to Oral Appliance Therapy, the treating dentist could find himself party to a malpractice action for damaging the temporomandibular joint.

“WARNING!” Temporomandibular Joint Dysfunction it is one of the listed complications in the 2005 AADSM Practice Parameters article.

Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005 An American Academy of Sleep Medicine Report 3.4.3 …….. “Oral appliances may aggravate temporomandibular joint disease and may cause dental misalignment and discomfort that are unique to each device.”

by Ken Berley, DDS, JD

It is very unfortunate from a legal perspective that TMD is listed as a known complication of OAT. By listing TMD as a complication of OAT in a practice parameters document all dentists practicing Dental Sleep Medicine are thereby placed on legal notice that worsening or aggravation of TMD is a “foreseeable” consequence of mandibular advancement therapy. Foreseeability creates a “Legal Duty” to protect the patient from developing the foreseeable complication and a legal requirement that we use all reasonable means to prevent the complication from occurring.

So the question is: “If your patient has ANY signs or symptoms of TMD at your initial exam, is it malpractice to provide Oral Appliance Therapy?” CAUTION! A jury could determine that YOU negligently breached the alleged “Standard of Care” for proceeding with OAT if the patient has TMD symptoms at intake.

“Would a reasonable and prudent practitioner, who is on notice that treatment DentalSleepPractice.com

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LEGALledger

It is very unfortunate from a legal perspective that TMD is listed as a known complication of OAT.

can exacerbate Temporomandibular Joint Dysfunction, proceed with MAD therapy?”

Obviously this would be a question for a jury to decide. Personally, I don’t want to be the dentist in court defending my actions because I provided treatment on a patient who had TMD symptoms at intake! So I refuse to take that risk!

Since the 2005 Practice Parameters places us on legal notice that our treatment with a mandibular advancement device can “aggravate temporomandibular joint disease,” if your patient has ANY TMD symptoms isn’t it the legally prudent course to refrain from treating these patients? The problem with this approach is that, from my observation, almost all OSA patients have some signs of TMD. Some definitions of TMD include ALL patients with any joint sounds. The last time I checked this may be 75% or more of the population. If we are forced to eliminate patients with ANY joint sounds, we would never treat any patients.

So how have I resolved this dilemma?

I insist that the patient assume the risk for his or her joint issues. As I said, I refuse to take the risk of TMD. In my practice, I document ALL TMD signs and symptoms. I do a complete history and I palpate all muscles of mastication and record tenderness. I do complete range of motion measurements and I document all joint sounds. I routinely palpate the origin of the lateral pterygoid intraorally and on the majority of OSA patients I discover this muscle to be inflamed. Obviously, my examination frequently uncovers symptoms of TMD. At that point, I discuss with the patient the fact that some dentists believe that patients with TMD symptoms are at a greater risk for joint pain and soreness when their OSA is treated using Man-

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

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dibular Advancement Devices. I explain that I personally believe that TMD symptoms are generally improved by MAD therapy and not made worse but because TMD is listed as a “complication” in our practice parameters, I cannot proceed with treatment unless they are willing to assume the risk that the Mandibular Advancement Device may cause problems with the Temporomandibular Joint.

I inform the patient that in my opinion they may have more initial joint tenderness than some patients, but these symptoms generally resolve with time, however, I cannot guarantee that will happen. Additionally, I remind the patient that if we don’t proceed with MAD therapy their only option may be CPAP or surgery. At that point I make a note in the patient’s record that the patient has been informed of the risk associated with treating his or her OSA in the presence of TMD symptoms and the patient has agreed to assume the risk. I then have the patient sign the record.

Legally if the patient has signed an informed consent that states that developing or worsening TMD symptoms is a possible complication with MAD therapy, then signs your record stating that he/she has been informed of this risk and forever assumes this risk and releases you of liability for this complication, you should be free to treat this patient. Having the patient assume this risk does not mean that the patient cannot sue, however, winning that suit would be very difficult and most plaintiff’s attorneys would not want to be involved.

The next problem associated with TMD is that some of the insurance companies prohibit Oral Appliance Therapy on patients with TMD signs or symptoms. For example: Arkansas Blue Cross and Blue Shield Coverage Policy Manual states: Intraoral appliances (tongue retaining devices or mandibular advancing/positioning devices) meets primary coverage criteria of effectiveness and is covered in patients with OSA under the following conditions: • OSA defined by an apnea/hypopnea index (AHI) of at least 15 per hour or an AHI of at least 5 events per hour in a patient with excessive daytime sleepiness or unexplained hypertension, AND • A trial with CPAP has failed or is contraindicated, AND • The device is prescribed by a treating physician, AND

LEGALledger • The device is custom-fitted by qualified dental personnel, AND • There is absence of temporomandibular dysfunction or periodontal disease.

What a mess! How much TMD is too much? What definition of TMD do we apply to disqualify patients due to the presence of this condition? Obviously this paragraph was written by someone who does not do TMD exams on all sleep apnea patients, because the majority of patients would be disqualified. Therefore, from a legal perspective, if we treat a patient with ANY symptoms of TMD, are we committing insurance fraud? This risk is real! If we document any signs of TMD we may be providing treatment to patients who do not qualify for insurance coverage. If we then file a medical insurance claim, we could be accused of fraud. As we all are aware, fighting a claim of insurance fraud is a nowin situation. The medical insurance company has every legal right to audit your records and demand any payments to be returned to the company. Additionally, if the insurance company can prove that you intentionally defrauded the company, criminal charges could be filed. If we don’t document TMD status in our intake examination we run the risk of being accused of damaging the temporomandibular joint during treatment if the patient develops clinically significant symptoms. In other words, if you don’t document the existing signs and symptoms that are present during your initial examination you leave yourself open to attack. If the patient suddenly develops significant TMD symptoms you then might be vulnerable in a malpractice suit alleging that you caused TMD dysfunction by over-titrating or excessively titrating your patient. So what do we do?

The first thought that comes to mind is a Class Action suit against all insurance companies that restrict care for patients with OSA, but that discussion is for my attorney friends. In my office, I document ALL TMD signs and symptoms. Then I decide if the TMD signs and symptoms uncovered in my examination necessitate a diagnosis of TMD dysfunction requiring treatment of the condition. In other words, how much TMD is too much? If the symptoms are not significantly serious enough to require treatment at the time of my intake exam, then it is my legal opinion that the TMD symptoms do not rise to the level that disqualifies the patient from OAT. Therefore, if the patient does not have a level of disease that requires treatment, they

are not disqualified under their insurance policy. Obviously, my opinion has not been tested in court, therefore, we do not have a legal precedent to guide our decisions.

“CAUTION!! Proceed at Your Own Risk!”

With that being said, I document TMD signs but I do not offer a diagnosis of TMD and I do not recommend any treatment. Therefore, if the patient has the TMD restriction in their Medical Insurance Policy, I place the following paragraph in my records: “The patient is aware that he/she may have some signs and symptoms of TMD disorder but Dr. Berley feels the symptoms do not rise to the level of a diagnosis of Temporomandibular Joint Dysfunction nor do the symptoms require treatment at this time. Therefore these symptoms in Dr. Berley’s opinion would not contraindicate oral appliance therapy.”

In conclusion, dentists practicing Dental Sleep Medicine must be aware of the risk associated with TMJ including malpractice and insurance fraud. The prudent practitioner will proceed with caution and develop a strategy to manage this risk.

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SLEEPhumor

...The Lighter Side of Sleep Apnea

64 DSP | Spring 2015